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Lee MT, Mahtta D, Ramsey DJ, Liu J, Misra A, Nasir K, Samad Z, Itchhaporia D, Khan SU, Schofield RS, Ballantyne CM, Petersen LA, Virani SS. Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease. JAMA Cardiol 2021; 6:782-790. [PMID: 33881448 DOI: 10.1001/jamacardio.2021.0683] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance There is a paucity of data regarding secondary prevention care disparities in women with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), defined as an ASCVD event at 55 years or younger and 40 years or younger, respectively. Objective To evaluate sex-based differences in antiplatelet agents, any statin, high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD. Design, Setting, and Participants This was a cross-sectional, multicenter, nationwide VA health care system-based study with patients enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. The study assessed patients who had at least 1 primary care visit in the Veterans Affairs (VA) health care system from October 1, 2014, to September 30, 2015. Participants included 147 600 veteran patients with premature ASCVD, encompassing ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD). Exposures Women vs men with premature and extremely premature ASCVD. Main Outcomes and Measures Antiplatelet use, any statin use, HIS use, and statin adherence (proportion of days covered [PDC] ≥0.8). Results We identified 10 413 women and 137 187 men with premature ASCVD (age ≤55 years) and 1340 women and 8145 men with extremely premature (age ≤40 years) ASCVD. Among patients with premature and extremely premature ASCVD, women represented 7.1% and 14.1% of those groups, respectively. When compared with men, women with premature ASCVD had a higher proportion of African American patients (36.1% vs 23.8%) and lower proportions of Asian patients (0.5% vs 0.7%) and White patients (56.1% vs. 68.1%). In the extremely premature ASCVD group, women had a comparatively higher proportion of African American patients (36.8% vs 23.2%) and lower proportion of White patients (55.0% vs 67.8%) and Asian patients (1.3% vs 1.5%) than men. Among patients with premature IHD, women received less antiplatelet (adjusted odds ratio [AOR], 0.47, 95% CI, 0.45-0.50), any statin (AOR, 0.62; 95% CI, 0.59-0.66), and HIS (AOR, 0.63; 95% CI, 0.59-0.66) therapy and were less statin adherent (mean [SD] PDC, 0.68 [0.34] vs 0.73 [0.31]; β coefficient: -0.02; 95% CI, -0.03 to -0.01) compared with men. Similarly, women with premature ICVD and premature PAD received comparatively less antiplatelet agents, any statin, and HIS. Among patients with extremely premature ASCVD, women also received less antiplatelet therapy (AOR, 0.61; 95% CI, 0.53-0.70), any statin therapy (AOR,0.51; 95% CI, 0.44-0.58), and HIS therapy (AOR, 0.45; 95% CI, 0.37-0.54) than men. There were no sex-associated differences in statin adherence among patients with premature ICVD, premature PAD, or extremely premature ASCVD. Conclusions and Relevance This cross-sectional study revealed that women veterans with premature ASCVD and extremely premature ASCVD receive less optimal secondary prevention cardiovascular care in comparison with men. Women with premature ASCVD, particularly those with IHD, were also less statin adherent. Multidisciplinary and patient-centered interventions are needed to improve these disparities in women.
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Affiliation(s)
- Michelle T Lee
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Dhruv Mahtta
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David J Ramsey
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
| | - Jing Liu
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Arunima Misra
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Khurram Nasir
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Zainab Samad
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Dipti Itchhaporia
- Department of Medicine, Cardiology Division, Hoag Memorial Hospital, University of California at Irvine
| | - Safi U Khan
- Department of Medicine, West Virginia University, Morgantown
| | - Richard S Schofield
- Division of Cardiovascular Medicine, University of Florida, Gainesville.,Department of Veterans Affairs Medical Center, Gainesville, Florida
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Laura A Petersen
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Salim S Virani
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas.,Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Shah NR, Ahmed ST, Winchester DE, Ramsey DJ, Akeroyd JM, Wu WC, Waldo SW, Schofield RS, Ballantyne CM, Petersen LA, Virani SS. Facility-Level Variation in Stress Test Utilization in Veterans With Ischemic Heart Disease. JACC Cardiovasc Imaging 2019; 12:1292-1293. [PMID: 31005521 DOI: 10.1016/j.jcmg.2019.02.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 02/05/2019] [Accepted: 02/06/2019] [Indexed: 10/27/2022]
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Valle JA, Schofield RS, Waldo SW. Ensuring Optimal Adjustment for Determinations of Institutional Quality. JAMA Cardiol 2018; 3:1129-1130. [DOI: 10.1001/jamacardio.2018.3256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Javier A. Valle
- Rocky Mountain Regional Veterans Affairs Medical Center, Denver, Colorado
- Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) Program, Denver, Colorado
| | - Richard S. Schofield
- North Florida/South Georgia Veterans Health System, Gainesville
- VA Office of Subspecialty Care, National Cardiology Program, Washington, DC
| | - Stephen W. Waldo
- Rocky Mountain Regional Veterans Affairs Medical Center, Denver, Colorado
- Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) Program, Denver, Colorado
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Karimi A, Beaver TM, Hess PJ, Martin TD, Staples ED, Schofield RS, Hill JA, Aranda JM, Klodell CT. Close antiplatelet therapy monitoring and adjustment based upon thrombelastography may reduce late-onset bleeding in HeartMate II recipients. Interact Cardiovasc Thorac Surg 2014; 18:457-65. [PMID: 24421208 DOI: 10.1093/icvts/ivt546] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Bleeding is the most common complication of HeartMate II and is partially attributable to platelet dysfunction; however, antiplatelet therapy is arbitrary in most centres. We investigated how antiplatelet therapy adjustment with thrombelastography affects late-onset bleeding. METHODS Thrombelastography was used to adjust antiplatelet therapy in 57 HeartMate II recipients. Kaplan-Meier survival curves and Cox proportional hazard ratio model were used to identify predictors of late-onset bleeding in univariate and multivariate analysis. Finally, late-onset bleeding rate in our study was compared with the reported rates in other studies in the literature, all of which did not use any test to monitor or adjust antiplatelet therapy. RESULTS Mean follow-up was 347 days. Eighteen late-onset bleeding events occurred in 12 patients, a late-onset bleeding rate of 12/57 (21%) or 0.21 events/patient-year. The Kaplan-Meier survival curves demonstrated that late-onset bleeding was more common in the destination therapy cohort (P = 0.02), in patients older than 60 years (P = 0.04) and in females (P = 0.01), none of which was significant in multivariate analysis at a significance level of 0.05. To further investigate the higher bleeding rate in elderly patients, thrombelastography parameters were compared between younger and older patients at the age cut-off of 60 years which demonstrated a prothrombotic change the day after device implantation in younger patients that was absent in the elderly. There was also a trend towards higher requirement for antiplatelet therapy in younger patients while on device support, but the difference did not reach statistical significance. The average late-onset or gastrointestinal bleeding rate among seven comparable studies in the literature that did not use any monitoring test to adjust antiplatelet therapy was 0.49 events/patient-year. CONCLUSIONS Our study implicates that antiplatelet therapy adjustment with thrombelastography may reduce late-onset bleeding rate in HeartMate II recipients. Bleeding was more common in the elderly recipients and analysis of thrombelastography data suggests that a less aggressive antiplatelet therapy regimen could potentially lower bleeding rate in this vulnerable population.
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Affiliation(s)
- Ashkan Karimi
- Department of Medicine, University of Florida, Gainesville, FL, USA
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Anderson SD, Cleeton T, Malloy S, Jungklaus T, Perez J, Chapman D, Dangl M, Anderson T, Schmalfuss C, Schofield RS. Correlation between Disease-Specific Quality of Life Tools in Recently Hospitalized Heart Failure Patients. J Card Fail 2013. [DOI: 10.1016/j.cardfail.2013.06.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rose DK, Behrman AL, Nadeau SE, Martin AD, Schofield RS, Tilson JK, Cen SY, Lu X, Wu SS, Azen S, Duncan PW. Does exercise tolerance testing at 60 days poststroke predict rehabilitation performance? Arch Phys Med Rehabil 2013; 94:1223-9. [PMID: 23548545 DOI: 10.1016/j.apmr.2013.01.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 01/25/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To assess the relationship between exercise tolerance test (ETT) performance at 6 weeks poststroke and subsequent performance in a treadmill and overground locomotor training program (LTP). DESIGN Prospective cohort study. SETTING Exercise testing laboratory in either a primary care hospital or outpatient clinic. PARTICIPANTS Community-dwelling individuals (N=469), 54.9±19.0 days poststroke, enrolled in the Locomotor Experience Applied Post-Stroke randomized controlled trial. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES For participants randomly assigned to LTP, the number of sessions needed to attain the training goal of 20 minutes of treadmill stepping was determined. Regression analyses determined the contribution of ETT performance (cycling duration), age, and 6-minute walk test (6MWT) distance to attainment of the stepping duration goal. RESULTS Age, 6MWT, and ETT performance individually accounted for 10.74%, 10.82%, and 10.76%, respectively, of the variance in the number of sessions needed to attain 20 minutes of stepping. When age and 6MWT were included in the model, the additional contribution of ETT performance was rendered nonsignificant (P=.150). CONCLUSIONS To the extent that ETT performance can be viewed as a measure of cardiovascular fitness rather than neurologic impairment, cardiovascular fitness at the time of the ETT did not make a significant unique contribution to the number of sessions needed to achieve 20 minutes of stepping. The 6MWT, which involves less intensive exercise than the ETT and therefore is likely to be predominantly affected by neurologic impairment and muscular condition, appeared to account for as much variance as the ETT.
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Affiliation(s)
- Dorian K Rose
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA.
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Beitelshees AL, Aquilante CL, Allayee H, Langaee TY, Welder GJ, Schofield RS, Zineh I. CXCL5 polymorphisms are associated with variable blood pressure in cardiovascular disease-free adults. Hum Genomics 2012; 6:9. [PMID: 23245743 PMCID: PMC3505480 DOI: 10.1186/1479-7364-6-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 05/18/2012] [Indexed: 12/20/2022] Open
Abstract
Objective Leukocyte count has been associated with blood pressure, hypertension, and hypertensive complications. We hypothesized that polymorphisms in the CXCL5 gene, which encodes the neutrophilic chemokine ENA-78, are associated with blood pressure in cardiovascular disease (CVD)-free adults and that these polymorphisms are functional. Methods and results A total of 192 community-dwelling participants without CVD or risk equivalents were enrolled. Two CXCL5 polymorphisms (−156 G > C (rs352046) and 398 G > A (rs425535)) were tested for associations with blood pressure. Allele-specific mRNA expression in leukocytes was also measured to determine whether heterozygosity was associated with allelic expression imbalance. In −156 C variant carriers, systolic blood pressure (SBP) was 7 mmHg higher than in −156 G/G wild-type homozygotes (131 ± 17 vs. 124 ± 14 mmHg; P = 0.008). Similarly, diastolic blood pressure (DBP) was 4 mmHg higher in −156 C variant carriers (78 ± 11 vs. 74 ± 11 mmHg; P = 0.013). In multivariate analysis of SBP, age, sex, body mass index, and the −156 G > C polymorphism were identified as significant variables. Age, sex, and the −156 G > C SNP were further associated with DBP, along with white blood cells. Allelic expression imbalance and significantly higher circulating ENA-78 concentrations were noted for variant carriers. Conclusion CXCL5 gene polymorphisms are functional and associated with variable blood pressure in CVD-free individuals. The role of CXCL5 as a hypertension- and CVD-susceptibility gene should be further explored.
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Affiliation(s)
- Amber L Beitelshees
- Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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9
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Maska E, Dorman SM, Schofield RS. Coronary artery involvement in cardiac amyloidosis. Clin Res Cardiol 2011; 100:1045-6. [PMID: 21744170 DOI: 10.1007/s00392-011-0342-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 07/01/2011] [Indexed: 11/24/2022]
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Schofield RS, Schofield PM. The current status of percutaneous mitral valve repair. J Saudi Heart Assoc 2010; 22:111-4. [PMID: 23960602 DOI: 10.1016/j.jsha.2010.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Accepted: 04/28/2010] [Indexed: 11/29/2022] Open
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Mishkin JD, Saxonhouse SJ, Woo GW, Burkart TA, Miles WM, Conti JB, Schofield RS, Sears SF, Aranda JM. Appropriate Evaluation and Treatment of Heart Failure Patients After Implantable Cardioverter-Defibrillator Discharge. J Am Coll Cardiol 2009; 54:1993-2000. [DOI: 10.1016/j.jacc.2009.07.039] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 06/25/2009] [Accepted: 07/12/2009] [Indexed: 11/25/2022]
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Anderson SD, Maska E, Jungklaus T, Mullikin A, Boyer L, Reeder DN, Schmalfuss C, Schofield RS. Quality of Life Differences in Heart Failure Drug Combinations. J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Anderson SD, Maska E, Jungklaus T, Mullikin A, Boyer L, Reeder DN, Schmalfuss C, Schofield RS. Low Utilization of Aldosterone Antagonists (AA) and Digoxin upon Hospital Discharge in Veterans Consulted to a Two-Tiered Interventional, Multi-Disciplinary Heart Failure Disease Management Program (HFDMP). J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Schofield RS, Dorman SM, Aranda JM, Hill JA, Pauly DF, Klodell CT. Constrictive Pericarditis Presenting as a Calcified Anterior Cardiac Mass. Ann Thorac Surg 2009; 87:1597-9. [DOI: 10.1016/j.athoracsur.2008.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 09/28/2008] [Accepted: 10/03/2008] [Indexed: 11/27/2022]
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McLaughlin VV, Archer SL, Badesch DB, Barst RJ, Farber HW, Lindner JR, Mathier MA, McGoon MD, Park MH, Rosenson RS, Rubin LJ, Tapson VF, Varga J, Harrington RA, Anderson JL, Bates ER, Bridges CR, Eisenberg MJ, Ferrari VA, Grines CL, Hlatky MA, Jacobs AK, Kaul S, Lichtenberg RC, Lindner JR, Moliterno DJ, Mukherjee D, Pohost GM, Rosenson RS, Schofield RS, Shubrooks SJ, Stein JH, Tracy CM, Weitz HH, Wesley DJ. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association. Circulation 2009; 119:2250-94. [PMID: 19332472 DOI: 10.1161/circulationaha.109.192230] [Citation(s) in RCA: 745] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Puwanant S, Hamilton KK, Klodell CT, Hill JA, Schofield RS, Cleeton TS, Pauly DF, Aranda JM. Tricuspid annular motion as a predictor of severe right ventricular failure after left ventricular assist device implantation. J Heart Lung Transplant 2009; 27:1102-7. [PMID: 18926401 DOI: 10.1016/j.healun.2008.07.022] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 06/19/2008] [Accepted: 07/22/2008] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Right ventricular (RV) failure after left ventricular assist device (LVAD) implantation is associated with a high rate of morbidity and mortality. We sought to determine pre-operative right heart echocardiographic predictors of post-LVAD severe RV failure. METHODS RV failure, defined as the need for inotropic support or pulmonary vasodilators for >or=14 days post-operatively, was evaluated in 33 patients (age 54 +/- 13 years) with LVADs. Preoperative RV systolic and diastolic echocardiographic parameters, including RV fractional area change, tricuspid annular motion, right atrial volume index, RV index of myocardial performance, hepatic vein Doppler velocities, tricuspid regurgitation severity, and RV systolic pressures (RVSPs) in patients with and without RV failure were compared. RESULTS Of the 33 patients evaluated, 11 (33%) had post-LVAD RV failure (2 needed RVAD support). Patients with post-LVAD RV failure had significantly lower pre-operative tricuspid annular motion (8 +/- 4 vs 15 +/- 6 mm, p < 0.01) and higher RVSPs (60 +/- 14 vs 46 +/- 11 mm Hg, p = 0.02). In 13 patients (39%) with moderate tricuspid regurgitation, pre-operative tricuspid annular motion remained significantly reduced (6.0 +/- 0.5 vs 13.5 +/- 5.0 mm, p = 0.045). Other echocardiographic parameters were not significantly different between patients. Tricuspid annular motion of <7.5 mm provides 91% specificity and 46% sensitivity in predicting post-LVAD RV failure. CONCLUSION Tricuspid annular motion is a predictor of post-LVAD RV failure. Using tricuspid annular motion in addition to conventional criteria may aid in early identification of patients with prolonged inotropic support or severe RV failure and allow for better pre-operative planning.
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Affiliation(s)
- Sarinya Puwanant
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Florida, Gainesville, Florida, USA.
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Bhatt DL, Scheiman J, Abraham NS, Antman EM, Chan FKL, Furberg CD, Johnson DA, Mahaffey KW, Quigley EM, Harrington RA, Bates ER, Bridges CR, Eisenberg MJ, Ferrari VA, Hlatky MA, Kaul S, Lindner JR, Moliterno DJ, Mukherjee D, Schofield RS, Rosenson RS, Stein JH, Weitz HH, Wesley DJ. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2008; 52:1502-17. [PMID: 19017521 DOI: 10.1016/j.jacc.2008.08.002] [Citation(s) in RCA: 346] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Bhatt DL, Scheiman J, Abraham NS, Antman EM, Chan FKL, Furberg CD, Johnson DA, Mahaffey KW, Quigley EM, Harrington RA, Bates ER, Bridges CR, Eisenberg MJ, Ferrari VA, Hlatky MA, Kaul S, Lindner JR, Moliterno DJ, Mukherjee D, Schofield RS, Rosenson RS, Stein JH, Weitz HH, Wesley DJ. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. Am J Gastroenterol 2008; 103:2890-907. [PMID: 18853965 DOI: 10.1111/j.1572-0241.2008.02216.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Puwanant S, Hill JA, Klodell CT, Hamilton KK, Schofield RS, Cleeton TS, Pauly DF, Aranda JM. Clinical Significance of Mitral Regurgitation Following Left Ventricular Assist Device Implantation. J Card Fail 2008. [DOI: 10.1016/j.cardfail.2008.06.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Braith RW, Schofield RS, Hill JA, Casey DP, Pierce GL. Exercise training attenuates progressive decline in brachial artery reactivity in heart transplant recipients. J Heart Lung Transplant 2008; 27:52-9. [PMID: 18187087 DOI: 10.1016/j.healun.2007.09.032] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Revised: 08/09/2007] [Accepted: 09/30/2007] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Heart transplantation normalizes central hemodynamics, but endothelial dysfunction persists after transplantation. METHODS To investigate the effects of aerobic exercise on arterial function, oxidative stress, lipid profile, and sympathetic nervous system activity, 20 heart transplant recipients (age, 54.3 +/- 9.1 years; 17 men, 3 women) were randomly assigned to 12 weeks of supervised treadmill exercise (Trained; n = 10) or standard medical care (Control; n = 10). Supervised exercise was initiated at 8 weeks after transplant. Brachial artery reactivity was assessed using flow-mediated dilation. RESULTS The VO2 peak increased 26% in the Trained patients (15.4 +/- 4.3 vs 19.4 +/- 5.5 ml/kg/min; p < or = 0.05) but did not change in the Controls (16.2 +/- 5.2 vs 16.8 +/- 2.8 ml/kg/min; p > or = 0.05). Brachial artery flow-mediated dilation (10.1% +/- 6.1% vs 9.6% +/- 6.2%) and absolute brachial diameter (0.48 +/- 0.22 vs 0.42 +/- 0.24 mm) did not change in Trained patients, but brachial flow-mediated dilation (10.5% +/- 2.8% vs 7.9% +/- 5.1%) and the absolute change in brachial diameter (0.48 +/- 0.16 vs 0.36 +/- 0.24 mm) decreased significantly (p < or = 0.05) in the Control patients. Resting norepinephrine decreased significantly (p < or = 0.05) after training (0.32 +/- 0.19 vs 0.22 +/- 0.22 ng/ml), but there was a nonsignificant trend toward increased norepinephrine in the Controls (0.26 +/- 0.17 vs 0.53 +/- 0.41 ng/ml; p = 0.07). The lipid profile and marker of oxidative stress did not differ between the groups before or after the intervention. CONCLUSIONS To our knowledge, this is the first prospective, randomized study to investigate the effects of heart transplantation and aerobic exercise on peripheral artery function in the same cohort of heart transplant recipients. Brachial artery flow-mediated dilation increased early in the post-operative period. Aerobic exercise preserved but did not improve brachial artery flow-mediated dilation. Heart transplant recipients who did not participate in supervised exercise showed a progressive decline in brachial artery flow-mediated dilation.
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Affiliation(s)
- Randy W Braith
- Center for Exercise Science, Department of Applied Physiology and Kinesiology, College of Health and Human Performance, University of Florida, Gainesville, Florida 32611, USA.
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Aranda JM, McIntyre SE, Klodell CT, York KM, Dragstedt CA, Chaille PJ, Conti JB, Pauly DF, Hill JA, Schofield RS. Initial heart rate and systolic blood pressure predict outcomes in chronic heart failure patients who are evaluated for cardiac transplant. Clin Cardiol 2007; 30:282-7. [PMID: 17551963 PMCID: PMC6653378 DOI: 10.1002/clc.20080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Heart rate (HR) and systolic blood pressure (SBP) are currently not considered among common clinical indicators of prognosis in patients referred for heart transplant (Htx). We sought to determine whether an initial hemodynamic profile of HR and SBP could be used to predict outcomes in chronic heart failure patients evaluated for Htx. METHODS We analyzed the medical records of patients evaluated for Htx and obtained demographic and clinical data collected at the initial transplant clinic visit or inpatient encounter. We assigned patients to groups based on their HR and SBP. Groups were compared after follow-up for differences in freedom from death or Htx. RESULTS From 1999 to 2003, 400 consecutive patients were considered by the local Htx medical review board. The median duration of follow-up was 26 months (interquartile range 1 to 45 months). Patients with initial >or= 90 beats per minute (bpm) and initial SBP < 100 mmHg ((n = 34) had worse New York Heart Association functional class (p=0.02), lower cardiac output ((p =0.02 ), and greater hyponatremia (>0.001;). These patients were more likely to be hospitalized at the time of referral (p >0.001) and more likely to have experienced death or Htx during follow-up than patients with other hemodynamic profiles (p = 0.001). CONCLUSIONS A hemodynamic profile of HR and SBP can be used with other prognostic indicators to identify high-risk patients at the time of initial evaluation for Htx.
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Affiliation(s)
- Juan M Aranda
- University of Florida College of Medicine, Department of Medicine, Division of Cardiovascular Medicine, Gainesville, Florida, USA.
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Schofield RS, Pierce GL, Nichols WW, Klodell CT, Aranda JM, Pauly DF, Hill JA, Braith RW. Arterial-wave reflections are increased in heart failure patients with a left-ventricular assist device. Am J Hypertens 2007; 20:622-8. [PMID: 17531918 DOI: 10.1016/j.amjhyper.2006.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Revised: 11/12/2006] [Accepted: 12/24/2006] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Chronic heart failure (HF) is associated with increased central arterial pulse-wave reflections, which may contribute to increased myocardial oxygen demand. Although the treatment of HF via left-ventricular assist device (LVAD) placement has recently become widespread, the effects of LVAD therapy on central arterial pulse-wave reflections are unknown. METHODS Central aortic pulse-wave analysis was performed on patients with end-stage HF awaiting cardiac transplantation and on healthy age-matched controls using the SphygmoCor (Akor Medical, Sydney, Australia) system. Arterial pulse-wave data were compared between patients receiving LVAD support versus those receiving intravenous inotropic drugs and healthy control patients. RESULTS Five patients on LVAD support were compared with 10 patients on inotropic drugs and 10 healthy control patients. Aortic augmented pressure and the aortic augmentation index (AI(a)) were higher in LVAD patients compared with inotrope and control patients, despite similar brachial and aortic blood pressures between groups. The AI(a) was significantly higher in LVAD patients than in patients on inotropic drugs (28.2% +/- 10% v 7.9% +/- 9%, P < or = .01). Additionally, there was a significantly higher aortic systolic tension time index, an index of left-ventricular myocardial oxygen demand, in the LVAD group compared with the inotrope group (2655 +/- 298 mm Hg/sec/min v 1748 +/- 303 mm Hg/sec/min, P < .01). CONCLUSIONS Central arterial pressure-wave reflection is increased in end-stage HF patients on LVAD support compared with those on inotropic drugs, leading to an increase in aortic augmented pressure, AI(a), and systolic tension time index. The AI(a) is also higher in LVAD patients than in healthy controls. This increased central arterial-wave reflection places an additional hemodynamic load on the LVAD device and may have relevance to the medical management of patients after LVAD placement and to the longevity of the LVAD device itself.
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Lobmeyer MT, Gong Y, Terra SG, Beitelshees AL, Langaee TY, Pauly DF, Schofield RS, Hamilton KK, Herbert Patterson J, Adams KF, Hill JA, Aranda JM, Johnson JA. Synergistic polymorphisms of beta1 and alpha2C-adrenergic receptors and the influence on left ventricular ejection fraction response to beta-blocker therapy in heart failure. Pharmacogenet Genomics 2007; 17:277-82. [PMID: 17496726 DOI: 10.1097/fpc.0b013e3280105245] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Arg389Gly polymorphism (Arg389Gly) in the beta1-adrenergic receptor gene (ADRB1) has been associated with improvement in left-ventricular remodeling with beta-blocker treatment. One study of risk for heart failure suggested a synergistic effect of ADRB1 Arg389Gly with the insertion/deletion polymorphism in the alpha2C-adrenergic receptor gene (ADRA2C). We tested whether the ADRA2C insertion/deletion polymorphism was associated with beta-blocker response in heart failure, either alone or in combination with the ADRB1Arg389Gly polymorphism. METHODS Fifty-four beta-blocker naive heart failure patients underwent echocardiography before and after 5-6 months of metoprolol CR/XL therapy. Multivariant linear regression modeling was performed to assess the impact of genotypes and other variables on changes in left-ventricular function in response to metoprolol therapy. RESULTS Deletion carriers had a significantly greater negative chronotropic response. Predictors of the end of study ejection fraction were baseline ejection fraction, deletion carrier status and Arg389Arg genotype. Patients with Arg389Arg/Del-carrier status showed the greatest ejection fraction increase with metoprolol CR/XL. Adjusting for baseline ejection fraction, final S-metoprolol plasma concentration and race, final ejection fraction in patients with this genotype combination was significantly higher than all other genotype combination groups. CONCLUSION ADRB1 and ADRA2C polymorphisms synergistically influence the ejection fraction response to beta-blocker therapy of heart failure patients.
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MESH Headings
- Adrenergic beta-Antagonists/therapeutic use
- Aged
- Amino Acid Substitution
- DNA Primers/genetics
- Female
- Heart Failure/drug therapy
- Heart Failure/genetics
- Heart Failure/physiopathology
- Humans
- Male
- Middle Aged
- Pharmacogenetics
- Polymorphism, Genetic
- Polymorphism, Single Nucleotide
- Receptors, Adrenergic, alpha-2/genetics
- Receptors, Adrenergic, alpha-2/physiology
- Receptors, Adrenergic, beta-1/genetics
- Receptors, Adrenergic, beta-1/physiology
- Stroke Volume/drug effects
- Stroke Volume/genetics
- Stroke Volume/physiology
- Ventricular Function, Left/drug effects
- Ventricular Function, Left/genetics
- Ventricular Function, Left/physiology
- Ventricular Remodeling/drug effects
- Ventricular Remodeling/genetics
- Ventricular Remodeling/physiology
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Pierce GL, Schofield RS, Casey DP, Nichols WW, Hill JA, Braith RW. Arterial Wave Refection Properties Are Associated With C-Reactive Protein And Exercise Capacity In Heart Transplant Recipients. Med Sci Sports Exerc 2007. [DOI: 10.1249/01.mss.0000273620.63827.1a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Mensah GA, Grant AO, Pepine CJ, Baddour LM, Cooper LT, Dunbar SB, Froelicher ES, Greenlund KJ, Kaplan EL, Kloner RA, Labarthe DR, Luepker RV, Madjid M, Muller JE, O'Connor S, Ornato JP, Robertson RM, Roy MJ, Shah PK, Taubert KA, Wilson WR, Zheng ZJ, Harrington RA, Abrams J, Anderson JL, Bates ER, Eisenberg MJ, Grines CL, Hlatky MA, Lichtenberg RC, Lindner JR, Pohost GM, Schofield RS, Shubrooks SJ, Stein JH, Tracy CM, Vogel RA, Wesley DJ. ACCF/AHA/CDC Conference Report on Emerging Infectious Diseases and Biological Terrorism Threats. Circulation 2007; 115:1656-95. [PMID: 17372165 DOI: 10.1161/circulationaha.107.181939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- George A Mensah
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341-3717, USA
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Mensah GA, Grant AO, Pepine CJ, Baddour LM, Cooper LT, Dunbar SB, Froelicher ES, Greenlund KJ, Kaplan EL, Kloner RA, Labarthe DR, Luepker RV, Madjid M, Muller JE, O'Connor S, Ornato JP, Robertson RM, Roy MJ, Shah PK, Taubert KA, Wilson WR, Zheng ZJ, Harrington RA, Abrams J, Anderson JL, Bates ER, Eisenberg MJ, Grines CL, Hlatky MA, Lichtenberg RC, Lindner JR, Pohost GM, Schofield RS, Shubrooks SJ, Stein JH, Tracy CM, Vogel RA, Wesley DJ. ACCF/AHA/CDC Conference Report on Emerging Infectious Diseases and Biological Terrorism Threats⁎⁎The findings and conclusions in this report are those of the Conference participants and do not necessarily reflect the official position of the American College of Cardiology Foundation, the American Heart Association, and the Centers for Disease Control and Prevention. J Am Coll Cardiol 2007; 49:1373-412. [PMID: 17394977 DOI: 10.1016/j.jacc.2007.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schofield RS, Aranda JM, Shoemaker SB, Pauly DF, Hill JA, Klodell CT. Cardiac Transplantation in Patients With Anti-phospholipid Antibodies. J Heart Lung Transplant 2007; 26:299-301. [PMID: 17346636 DOI: 10.1016/j.healun.2007.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Revised: 12/16/2006] [Accepted: 01/07/2007] [Indexed: 11/18/2022] Open
Abstract
Patients with severe heart failure are known to have an increased incidence of thromboembolic events and frequently have a visible thrombus in the left ventricle. Thromboemboli in heart failure patients are usually attributed to the underlying heart failure, and alternative etiologies for thrombus formation are rarely sought. However, anti-phospholipid antibodies and other inherited or acquired clotting abnormalities may contribute to hypercoagulability in heart failure patients and can lead to a persistent high risk for clotting, even after heart transplantation has corrected the underlying heart failure. We report outcomes with heart transplantation in 3 young patients with anti-phospholipid antibodies and a history of pre-heart transplantation thromboembolic events, and demonstrate the importance of post-heart transplantation anti-coagulation in these patients.
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Welder GJ, Wessel TR, Arant CB, Schofield RS, Zineh I. Complementary and alternative medicine use among individuals participating in research: implications for research and practice. Pharmacotherapy 2007; 26:1794-801. [PMID: 17125440 DOI: 10.1592/phco.26.12.1794] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To determine the frequency and type of complementary and alternative medicine (CAM) use among healthy volunteers participating in research, and to investigate the potential for interactions between commonly used CAM modalities and various drugs. DESIGN Prospective evaluation. SETTING University general clinical research center. SUBJECTS Sixty healthy adults participating in an ongoing drug study. MEASUREMENTS AND MAIN RESULTS The clinical study database was queried to determine the use and type of existing and newly started CAM throughout the study period. Baseline characteristics were compared between users and nonusers of CAM to identify differences between them. Potential CAM-drug interactions were classified based on curated databases and primary literature sources. Of the 60 subjects enrolled, 30 (50%) used CAM during the study. Of these, 26 (87%) were using CAM at study entry. Baseline CAM users were on average 7 years older than nonusers (p=0.03) and had high-density lipoprotein cholesterol concentrations 10 mg/dl higher than those of nonusers (p=0.04). The group using CAM had more women and nonsmokers than the other group. Several potential CAM-drug interactions were identified. CONCLUSION Because of high rates of CAM use (50% of the subjects were using biologically based CAM) and the many potential CAM-drug interactions, CAM use should be rigorously addressed in clinical practice and research. Failure to capture this information may have clinical repercussions through pharmacokinetic and pharmacodynamic interference of clinical response and clinical trial results. Clinicians and researchers may be able to identify those most likely to use CAM by their baseline characteristics; this would help target those patients and research subjects for more thorough assessment and follow-up.
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Affiliation(s)
- Gregory J Welder
- Department of Pharmacy Practice and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida 32610, USA.
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Greenland P, Bonow RO, Brundage BH, Budoff MJ, Eisenberg MJ, Grundy SM, Lauer MS, Post WS, Raggi P, Redberg RF, Rodgers GP, Shaw LJ, Taylor AJ, Weintraub WS, Harrington RA, Abrams J, Anderson JL, Bates ER, Grines CL, Hlatky MA, Lichtenberg RC, Lindner JR, Pohost GM, Schofield RS, Shubrooks SJ, Stein JH, Tracy CM, Vogel RA, Wesley DJ. ACCF/AHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring by Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain. Circulation 2007; 115:402-26. [PMID: 17220398 DOI: 10.1161/circulationaha..107.181425] [Citation(s) in RCA: 361] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Greenland P, Bonow RO, Brundage BH, Budoff MJ, Eisenberg MJ, Grundy SM, Lauer MS, Post WS, Raggi P, Redberg RF, Rodgers GP, Shaw LJ, Taylor AJ, Weintraub WS, Harrington RA, Abrams J, Anderson JL, Bates ER, Grines CL, Hlatky MA, Lichtenberg RC, Lindner JR, Pohost GM, Schofield RS, Shubrooks SJ, Stein JH, Tracy CM, Vogel RA, Wesley DJ. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography). Circulation 2007. [PMID: 17220398 DOI: 10.1161/circulationaha.107.181425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Shin J, Lobmeyer MT, Gong Y, Zineh I, Langaee TY, Yarandi H, Schofield RS, Aranda JM, Hill JA, Pauly DF, Johnson JA. Relation of beta(2)-adrenoceptor haplotype to risk of death and heart transplantation in patients with heart failure. Am J Cardiol 2007; 99:250-5. [PMID: 17223428 DOI: 10.1016/j.amjcard.2006.08.020] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Revised: 08/01/2006] [Accepted: 08/01/2006] [Indexed: 11/21/2022]
Abstract
Heart failure (HF) is characterized by neurohormonal activation of the sympathetic nervous and renin-angiotensin systems. Genetic polymorphisms in these systems could alter the prognosis in HF. We hypothesized the genetic polymorphisms in the sympathetic nervous and renin-angiotensin systems are associated with adverse outcomes, defined as death or heart transplantation in patients with HF. A total of 227 patients with HF were enrolled from a tertiary care clinic and followed for outcomes for < or =4 years. Eight polymorphisms in 6 genes were genotyped: beta(1)-adrenergic receptor (ADRB1, S49G, R389G), beta(2)-adrenergic receptor (ADRB2, G16R, Q27E), alpha(2c)-adrenergic receptor (ADRA2C, insertion/deletion 322-325), angiotensinogen (AGT, M235T), angiotensin receptor type 1 (AGTR1, 1166A>C), and angiotensin-converting enzyme (ACE, insertion/deletion in intron 16). Most patients were treated according to consensus guidelines. Male gender (hazard ratio 2.24, 95% confidence interval 1.27 to 3.94), higher New York Heart Association functional class (hazard ratio 2.54, 95% confidence interval 1.84 to 3.52), and 2 copies of ADRB2 Arg16Gln27 haplotype (hazard ratio 1.91, 95% confidence interval 1.09 to 3.36) increased the risk of adverse outcomes. In contrast, a higher serum sodium level (hazard ratio 0.91, 95% confidence interval 0.86 to 0.97) and higher creatinine clearance (hazard ratio 0.99, 95% confidence interval 0.98 to 0.99) decreased the risk of adverse outcomes. None of the other genotypes/haplotypes were associated with adverse outcomes. In conclusion, ADRB2 Arg16Gln27 haplotype may significantly increase the risk of adverse outcomes in patients with HF receiving contemporary HF pharmacotherapy.
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Affiliation(s)
- Jaekyu Shin
- College of Pharmacy, Gainesville, Florida, USA
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Zineh I, Welder GJ, DeBella AE, Arant CB, Wessel TR, Schofield RS. Atorvastatin effect on circulating and leukocyte-produced CD40 ligand concentrations in people with normal cholesterol levels: a pilot study. Pharmacotherapy 2007; 26:1572-7. [PMID: 17064201 DOI: 10.1592/phco.26.11.1572] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To investigate whether atorvastatin decreases serum or leukocyte-produced CD40 ligand (CD40L) levels and whether these effects are dependent on reduction in low-density lipoprotein cholesterol (LDL) levels in people without overt dyslipidemia. DESIGN Prospective pilot study. SETTING University research center. SUBJECTS Twenty-five normocholesterolemic volunteers (mean age 32 +/- 11 yrs; 15 women, 10 men) without cardiovascular disease. INTERVENTION After a 2-week drug-free run-in period, subjects received atorvastatin 80 mg/day orally for 16 weeks. MEASUREMENTS AND MAIN RESULTS All lipoprotein level measurements were performed with the subject in the fasting state. The CD40L concentrations were measured by immunofluorescence detection in serum and leukocyte culture supernates after 24-hour incubation, and treatment effect was analyzed. Baseline mean +/- SD total cholesterol, LDL, high-density lipoprotein cholesterol, and triglyceride levels were 179 +/- 33, 97 +/- 29, 62 +/- 20, and 102 +/- 69 mg/dl, respectively. Mean changes in each of these levels, respectively, after 16 weeks of atorvastatin were -34%, -59%, +3%, and -23%. The median serum CD40L level was lower at 16 weeks (2.3 ng/ml, interquartile range [IQR] 1.2-5.0 ng/ml) than at baseline (3.0 ng/ml, IQR 2.1-3.7 ng/ml), but the change was not significant (p=0.24). However, atorvastatin significantly lowered CD40L produced from leukocytes by 57% (21 pg/mg of protein [IQR 10-38 pg/mg] vs 49 pg/mg [IQR 21-149 pg/mg], p=0.045). Effects were independent of reduction in cholesterol levels. CONCLUSION Although atorvastatin did not significantly lower serum CD40L levels, significant reduction in leukocyte production was seen independent of degree of LDL reduction. These pilot data suggest a potential benefit in normocholesterolemic individuals that should be further investigated, and that leukocyte CD40L concentrations should be considered in the drug response.
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Affiliation(s)
- Issam Zineh
- Department of Pharmacy Practice and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida 32610, USA.
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Klodell CT, Morey TE, Lobato EB, Aranda JM, Staples ED, Schofield RS, Hess PJ, Martin TD, Beaver TM. Effect of Sildenafil on Pulmonary Artery Pressure, Systemic Pressure, and Nitric Oxide Utilization in Patients With Left Ventricular Assist Devices. Ann Thorac Surg 2007; 83:68-71; discussion 71. [PMID: 17184632 DOI: 10.1016/j.athoracsur.2006.08.051] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Revised: 08/20/2006] [Accepted: 08/22/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary artery hypertension can complicate the early postoperative care of patients with left ventricular assist devices (LVADs). Inhaled nitric oxide (INO) is frequently used to manipulate pulmonary resistance after LVADs have been placed. We evaluated the effect of oral sildenafil therapy on pulmonary artery pressure, systemic pressure, and nitric oxide utilization. METHODS After Institutional Review Board approval, the records of 10 consecutive adult patients with LVADs and pulmonary hypertension who received sildenafil were reviewed. Demographics, surgical history, INO use, inotrope requirements, and hemodynamic response to oral sildenafil at multiple intervals were collected. Hemodynamic data were analyzed with a two-way analysis of variance of repeated measures with correction for multiple comparisons. RESULTS There were 8 men and 2 women with 6 Heartmate XVE LVADs and 4 Thoratec LVADs (both, Thoratec, Pleasanton, California). When weaning was attempted, 8 patients who received INO demonstrated rebound pulmonary hypertension or increased right heart dysfunction. All patients were on inotropic therapy with dobutamine and milrinone. Sildenafil produced a significant reduction in pulmonary artery systolic pressure within 90 minutes of oral administration (p = 0.042). Significant changes in systolic blood pressure, mean arterial pressure, systemic vascular resistance, and heart rate were not observed. All 8 patients receiving INO were weaned within 12 hours without recurrent pulmonary hypertension. All 10 patients were weaned from inotropic support within 72 hours. No patient suffered right-side heart failure requiring intervention. CONCLUSIONS Oral sildenafil represents a useful adjunctive therapy for patients with LVADs. In our series, it provided additional reduction of pulmonary artery pressure, and facilitated weaning from INO and inotropes without deleterious hemodynamic consequences.
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Affiliation(s)
- Charles T Klodell
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA.
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Aranda JM, Schofield RS, Leach D, Conti JB, Hill JA, Curtis AB. Ventricular dyssynchrony in dilated cardiomyopathy: the role of biventricular pacing in the treatment of congestive heart failure. Clin Cardiol 2006; 25:357-62. [PMID: 12173901 PMCID: PMC6654713 DOI: 10.1002/clc.4950250803] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Despite advances in pharmacologic therapy, the prognosis of patients with advanced congestive heart failure (CHF) remains poor. Many of these patients have cardiac conduction abnormalities, such as left bundle-branch block or interventricular conduction delays, that can lead to ventricular dyssynchrony (abnormal ventricular activation that results in decreased ventricular filling and abnormal ventricular wall motion). Biventricular pacing is an alternative, nonpharmacologic therapy under active investigation for the treatment of CHF. Resynchronization devices with transvenous leads in the right atrium, right ventricle, and left ventricle (via the coronary sinus) have been implanted in patients to provide atrial triggered biventricular pacing. The use of such devices has been associated with improvement in ejection fraction, dP/dt, stroke work, and functional class. The proposed mechanisms involved in improving ventricular function with biventricular pacing include improved septal contribution to ventricular ejection, increased diastolic filling times, and reduced mitral regurgitation. This article reviews the pathophysiology of ventricular dyssynchrony and examine insights from clinical trials that are evaluating cardiac resynchronization therapy for CHF.
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Affiliation(s)
- Juan M Aranda
- University of Florida Health Science Center, Division of Cardiovascular Medicine, Gainesville 32610-0277, USA.
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Affiliation(s)
- Richard S Schofield
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
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Braith RW, Schofield RS, Casey DP, Nichols WW, Hill JA, Pierce GL. Endurance Training Improves Endothelial Function and Buffers Sympathetic Nervous System Hyperactivity in Heart Transplant Recipients. Med Sci Sports Exerc 2006. [DOI: 10.1249/00005768-200605001-00975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Aquilante CL, Terra SG, Schofield RS, Pauly DF, Hatton PS, Binkley PF, Johnson JA. Sustained Restoration of Autonomic Balance With Long- but Not Short-Acting Metoprolol in Patients With Heart Failure. J Card Fail 2006; 12:171-6. [PMID: 16624680 DOI: 10.1016/j.cardfail.2005.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2005] [Revised: 12/16/2005] [Accepted: 12/22/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND The purpose of this study was to compare the effects of immediate-release (IR) metoprolol and extended-release (XL) metoprolol on measures of heart rate variability in chronic systolic heart failure patients. METHODS AND RESULTS Thirteen metoprolol-treated heart failure patients were randomized to a 2-way crossover study of equal daily doses of metoprolol IR and metoprolol XL, each administered for 3 weeks. After each 3-week interval, patients underwent 24-hour Holter and ambulatory blood pressure monitoring. Over the entire 24-hour period, the ratio of high to total variability (normalized measure of parasympathetic activity) was significantly greater (P < .05), the ratio of low to total variability (normalized measure of sympathetic activity) was significantly lower (P < .05), and the ratio of high to low variability (index of parasympathetic to sympathetic balance) was greater (P < .08) for metoprolol XL compared with metoprolol IR. Over the entire 24-hour period, both systolic and diastolic blood pressure were significantly lower for metoprolol XL compared with metoprolol IR (P < .0001, and .0005, respectively). CONCLUSION These data suggest that with twice daily dosing, metoprolol IR is inferior to metoprolol XL in its effects on heart rate variability, autonomic balance, and blood pressure in patients with heart failure.
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Affiliation(s)
- Christina L Aquilante
- Department of Pharmacy Practice, University of Florida College of Pharmacy, Gainesville, 32610, USA
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Zineh I, Aquilante CL, Langaee TY, Beitelshees AL, Arant CB, Wessel TR, Schofield RS. CXCL5 gene polymorphisms are related to systemic concentrations and leukocyte production of epithelial neutrophil-activating peptide (ENA-78). Cytokine 2006; 33:258-63. [PMID: 16567110 DOI: 10.1016/j.cyto.2006.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 01/04/2006] [Accepted: 02/02/2006] [Indexed: 11/22/2022]
Abstract
Data exist linking elevated epithelial neutrophil activating peptide (ENA-78) concentrations with myriad inflammatory conditions. ENA-78 is encoded by the CXCL5 gene which has recently been shown to be polymorphic in nature (rs352046 and rs425535). No functional data on these polymorphisms exist. We investigated whether CXCL5 polymorphisms are associated with differences in plasma ENA-78 concentrations or leukocyte production of ENA-78 from cultured leukocytes in relatively healthy adults. We genotyped 114 adults for the above polymorphisms. Variant alleles at both loci were highly linked (D'=1, r2=0.94). The rs352046 variant allele was associated with significantly higher ENA-78 plasma concentrations. A genotype effect was also demonstrated for this polymorphism and leukocyte production of ENA-78. Both polymorphisms were predicted to have functional consequences by in silico analyses, with the rs352046 polymorphism found to occur at a transcription factor binding site for myeloid zinc finger proteins and the rs425535 polymorphism found to be located in an exon splicing enhancer site. Our findings add to the strength of CXCL5 as candidate gene in future disease-gene and pharmacogenetic association studies.
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Affiliation(s)
- Issam Zineh
- University of Florida College of Pharmacy, Department of Pharmacy Practice, 1600 SW Archer Road., Room PG-06, PO Box 100486, Gainesville, FL 32610, USA.
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Zineh I, Luo X, Welder GJ, Debella AE, Wessel TR, Arant CB, Schofield RS, Chegini N. Modulatory Effects of Atorvastatin on Endothelial Cell–Derived Chemokines, Cytokines, and Angiogenic Factors. Pharmacotherapy 2006; 26:333-40. [PMID: 16503719 DOI: 10.1592/phco.26.3.333] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To investigate the immunomodulatory effects of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) by determining whether atorvastatin alters the production of specific endothelium-derived immunoactive proteins and whether its treatment effects depend on its concentration and/or inhibition of 3-hydroxy-3-methylglutaryl coenzyme A reductase. DESIGN In vitro study using a multiplexing method for protein measurement. SETTING University laboratory. MEASUREMENTS AND MAIN RESULTS Human umbilical vein endothelial cells were cultured to approximately 80% confluence and treated with atorvastatin 1-50 microM alone or with mevalonate for 24 hours. Untreated cells served as controls. Culture-conditioned media were removed and multiplex assayed for protein content of epithelial neutrophil-activating peptide-78, interleukin-8, monocyte chemotactic protein-1, interleukin-6, interleukin-10, fibroblast growth factor, and granulocyte colony stimulating factor. Atorvastatin significantly reduced the production of epithelial neutrophil-activating peptide-78, interleukin-6, interleukin-8, and monocyte chemotactic protein-1 (p<0.001 to p<0.05) in a concentration-dependent manner without affecting basal production of interleukin-10, fibroblast growth factor, and granulocyte colony stimulating factor. The treatment effects of atorvastatin were reversed with concurrent mevalonate therapy. CONCLUSION By inhibiting 3-hydroxy-3-methylglutaryl coenzyme A reductase, atorvastatin lowered concentrations of several inflammatory molecules derived from basal-state endothelial cells in a concentration-dependent manner. The in vivo importance of these immunomodulatory effects needs further investigation.
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Affiliation(s)
- Issam Zineh
- Department of Pharmacy Practice, College of Pharmacy, University of Florida, Gainesville, Florida 32610, USA.
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Ramachandruni S, Fillingim RB, McGorray SP, Schmalfuss CM, Cooper GR, Schofield RS, Sheps DS. Mental stress provokes ischemia in coronary artery disease subjects without exercise- or adenosine-induced ischemia. J Am Coll Cardiol 2006; 47:987-91. [PMID: 16516082 DOI: 10.1016/j.jacc.2005.10.051] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2005] [Revised: 08/08/2005] [Accepted: 10/17/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate the possibility that some patients with coronary artery disease (CAD) but negative exercise or chemical stress test results might have mental stress-induced ischemia. The study population consisted solely of those with negative test results. BACKGROUND Mental stress-induced ischemia has been reported in 20% to 70% of CAD subjects with exercise-induced ischemia. Because mechanisms of exercise and mental stress-induced ischemia may differ, we studied whether mental stress would produce ischemia in a proportion of subjects with CAD who have no inducible ischemia with exercise or pharmacologic tests. METHODS Twenty-one subjects (14 men, 7 women) with a mean age of 67 years and with a documented history of CAD were studied. All subjects had a recent negative nuclear stress test result (exercise or chemical). Subjects completed a speaking task involving role playing a difficult interpersonal situation. A total of 30 mCi 99mTc-sestamibi was injected at one minute into the speech, and imaging was started 40 min later. A resting image obtained within one week was compared with the stress image. Images were analyzed for number and severity of perfusion defects. The summed difference score based on the difference between summed stress and rest scores was calculated. Severity was assessed using a semiquantitative scoring method from zero to four. RESULTS Six of 21 (29%) subjects demonstrated reversible ischemia (summed difference score > or =3) with mental stress. No subject had chest pain or electrocardiographic changes during the stressor. Mean systolic and diastolic blood pressure and heart rate all increased between resting and times of peak stress. CONCLUSIONS Mental stress may produce ischemia in some subjects with CAD and negative exercise or chemical nuclear stress test results.
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Abstract
The implantation of ventricular assist devices allows the opportunity for patients with intractable heart failure to have improved quality and quantity of life. The devices may be implanted after failed attempts to wean from bypass, as a bridge to transplantation, or as destination therapy. Key issues following the implantation of assist devices include the prevention of right ventricular failure, appropriate pharmacologic management, prevention and management of infection, and detection and treatment of device dysfunction.
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Affiliation(s)
- Charles T Klodell
- Department of Surgery, University of Florida, Gainesville, FL 32610, USA.
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Woo GW, Schofield RS, Klodell CT, Pauly DF, Hill JA, Aranda JM. Atrial Fibrillation as a Cause of Left Ventricular Dysfunction After Cardiac Transplantation. J Heart Lung Transplant 2006; 25:131-3. [PMID: 16399543 DOI: 10.1016/j.healun.2005.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2005] [Revised: 06/17/2005] [Accepted: 06/24/2005] [Indexed: 10/25/2022] Open
Abstract
We report 3 cases of late-onset atrial fibrillation several years after cardiac transplantation, each involving left ventricular systolic dysfunction in the absence of cardiac rejection or cardiac allograft vasculopathy. Although the etiology of late-onset atrial fibrillation in cardiac transplant recipients is not clear, its presence in the absence of cardiac rejection or coronary allograft vasculopathy can result in left ventricular systolic dysfunction, and therefore should be considered in the differential diagnosis of cardiac allograft failure. The onset of atrial fibrillation years after a heart transplant is not necessarily an indication of rejection. Aggressive rate control and restoration of normal sinus rhythm may improve allograft function in such cases.
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Affiliation(s)
- Gregory W Woo
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
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Aranda JM, Woo GW, Schofield RS, Handberg EM, Hill JA, Curtis AB, Sears SF, Goff JS, Pauly DF, Conti JB. Management of Heart Failure After Cardiac Resynchronization Therapy. J Am Coll Cardiol 2005; 46:2193-8. [PMID: 16360045 DOI: 10.1016/j.jacc.2005.03.078] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2004] [Revised: 02/23/2005] [Accepted: 03/10/2005] [Indexed: 11/28/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an established adjunctive treatment for patients with systolic heart failure (HF) and ventricular dyssynchrony. The majority of recipients respond to CRT with improvements in quality of life, New York Heart Association functional class, 6-min walk test, and ventricular function. Management of HF after CRT may include up-titration of neurohormonal blockade and an exercise prescription through cardiac rehabilitation to further improve and sustain clinical outcomes. Diagnostic data provided by the CRT device may help to facilitate and optimize treatment. Initial nonresponder rates remain problematic. We suggest a simple step-by-step management and troubleshooting strategy that integrates device function with advanced HF therapy in patients who do not initially respond to CRT. This algorithm represents a new, comprehensive, collaborative approach between the HF and electrophysiology specialists to further improve and sustain outcomes in the field of CRT.
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Affiliation(s)
- Juan M Aranda
- Division of Cardiovascular Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, Florida, USA.
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Clark BM, Schofield RS. Dilated cardiomyopathy and acute liver injury associated with combined use of ephedra, gamma-hydroxybutyrate, and anabolic steroids. Pharmacotherapy 2005; 25:756-61. [PMID: 15899737 DOI: 10.1592/phco.25.5.756.63592] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Anabolic-androgenic steroids are synthetic derivatives of testosterone that some athletes have used to enhance muscle mass and improve their athletic performance. Ephedrine is a potent sympathomimetic agent that can lead to cardiomyopathy similar to that seen with catecholamine excess. Adverse cardiovascular events attributed to anabolic steroid and ephedra use, such as arrhythmias, myocardial infarction, cardiomyopathy, and sudden death, are rarely reported. Bodybuilders have used gamma-hydroxybutyrate, a potent secretagogue of growth hormone, to promote muscle development. Although dilated cardiomyopathy is a known complication of excess growth hormone levels, it has not been associated with use of gamma-hydroxybutyrate. A healthy 40-year-old man was admitted to our hospital for new-onset congestive heart failure and severe acute hepatitis that developed several months after he began using anabolic-androgenic steroids, ephedra, and gamma-hydroxybutyrate supplements. Analysis with an objective causality assessment scale revealed a probable adverse drug reaction between the patient's use of anabolic steroids, ephedra, and gamma-hydroxybutyrate and the development of his cardiomyopathy and acute liver injury.
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Affiliation(s)
- Brychan M Clark
- Department of Medicine, Wilford Hall USAF Medical Center, San Antonio, TX 78236, USA.
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Vogel JHK, Bolling SF, Costello RB, Guarneri EM, Krucoff MW, Longhurst JC, Olshansky B, Pelletier KR, Tracy CM, Vogel RA, Vogel RA, Abrams J, Anderson JL, Bates ER, Brodie BR, Grines CL, Danias PG, Gregoratos G, Hlatky MA, Hochman JS, Kaul S, Lichtenberg RC, Lindner JR, O'Rourke RA, Pohost GM, Schofield RS, Shubrooks SJ, Tracy CM, Winters WL. Integrating Complementary Medicine Into Cardiovascular Medicine. J Am Coll Cardiol 2005; 46:184-221. [PMID: 15992662 DOI: 10.1016/j.jacc.2005.05.031] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schofield RS, Kline SE, Schmalfuss CM, Carver HM, Aranda JM, Pauly DF, Hill JA, Neugaard BI, Chumbler NR. Early outcomes of a care coordination-enhanced telehome care program for elderly veterans with chronic heart failure. Telemed J E Health 2005; 11:20-7. [PMID: 15785217 DOI: 10.1089/tmj.2005.11.20] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Veterans with chronic heart failure (HF) are frequently elderly, have numerous comorbid chronic medical illnesses, frequent hospitalizations, and have high rates of cardiovascular events. Within the Veterans Health Administration (VHA), primary care providers are required to manage the majority of HF patients because access to cardiac specialty care within the VHA may be limited. We designed and implemented a care-coordinated, nurse-directed home telehealth management program for veterans with difficult-to-manage or new onset chronic systolic HF. An in-home telehealth message device was provided to the patient at enrollment, and patients received daily HF-specific education via the nurse coordinator and/or the device throughout their continuum of care. We collected demographic characteristics, clinical characteristics, and outcome data at the time of enrollment and at nearly 6 months after enrollment. A total of 92 patients were enrolled, with complete data available on 73. The mean patient age was 67 years, the mean left ventricular ejection fraction (LVEF) was 23%, and nearly all patients (99%) were men. After enrollment, significant improvements were found in blood pressure (129/73 to 119/69 mm Hg, p < 0.05), weight (196 to 192 pounds, p < 0.01), and shortness of breath rating (0-10 scale, 4.0 to 2.7, p = 0.02). Average daily doses of fosinopril (24 to 35 mg/d, p < 0.01) and metoprolol (84 to 94 mg/d, p = 0.05) were also improved. The total number of inpatient hospital days were reduced while on the home telehealth program (from 630 for the previous year to 122 for the duration of the program) with only 31% of the hospitalizations related to HF while on the program. Our nurse-directed, care coordinated home telehealth management program was associated with improved early outcomes in a group of elderly male veterans with chronic HF.
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Affiliation(s)
- Richard S Schofield
- Cardiology Section, Rehabilitation Outcomes Research Center, Department of Veterans Affairs Medical Center, Gainesville, Florida, USA.
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Terra SG, Hamilton KK, Pauly DF, Lee CR, Patterson JH, Adams KF, Schofield RS, Belgado BS, Hill JA, Aranda JM, Yarandi HN, Johnson JA. ??1-Adrenergic receptor polymorphisms and left ventricular remodeling changes in response to ??-blocker therapy. Pharmacogenet Genomics 2005; 15:227-34. [PMID: 15864115 DOI: 10.1097/01213011-200504000-00006] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Large variability exists in the improvement in left ventricular (LV) function from beta-blocker treatment. We hypothesized that polymorphisms at codon 389 (Arg389Gly) and 49 (Ser49Gly) in the beta1-adrenergic receptor (AR) gene were associated with LV reverse remodeling changes in response to beta-blocker therapy among heart failure patients. METHODS We prospectively enrolled 61 beta-blocker naive patients with systolic heart failure. Patients underwent baseline echocardiography followed by metoprolol CR/XL. The dose was doubled on a biweekly basis up to 200 mg/day or attainment of maximum tolerated dose. Echocardiography was repeated after the patient received the target or highest tolerated dose for 3 months. RESULTS Among patients with the Arg389Arg genotype, ejection fraction (EF) increased from 23+/-5 to 29+/-10 (P=0.008). Gly389 carriers did not demonstrate any significant change in EF (22+/-9 to 23+/-11; P=0.45). There was a significant between-group difference in EF by genotype (P=0.04). The Arg389Arg genotype was also associated with significantly greater reductions in LV end-diastolic and end-systolic diameters compared to Gly389 carriers. Patients with the Gly49 variant also had a significantly greater reduction in LV end-diastolic diameter compared to Ser49 homozygotes. Multiple regression analysis modeling revealed that the codon 389 polymorphism was a significant predictor of an improvement in EF and both codon 49 and 389 polymorphisms were significant predictors of final LV end-diastolic diameter. CONCLUSIONS Heart failure patients with the Arg389Arg genotype and Gly49 carriers had greater improvements in LV remodeling from beta-blocker treatment.
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Affiliation(s)
- Steven G Terra
- Department of Pharmacy Practice, University of Florida College of Pharmacy, Gainesville, FL 32610, USA
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Aranda JM, Woo GW, Conti JB, Schofield RS, Conti CR, Hill JA. Use of cardiac resynchronization therapy to optimize beta-blocker therapy in patients with heart failure and prolonged QRS duration. Am J Cardiol 2005; 95:889-91. [PMID: 15781026 DOI: 10.1016/j.amjcard.2004.12.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2004] [Revised: 12/06/2004] [Accepted: 12/06/2004] [Indexed: 11/18/2022]
Abstract
A retrospective analysis was performed on 52 patients with heart failure to determine the change in beta-blocker therapy after cardiac resynchronization therapy (CRT). After 6 months of CRT, the number of patients receiving beta-blocker therapy increased from 36 to 44, with improved clinical outcomes and larger beta-blocker doses, indicating that these 2 therapies may work together to improve outcomes by allowing the use of larger doses of beta blockers while correcting ventricular dyssynchrony.
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Affiliation(s)
- Juan M Aranda
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA.
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49
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Terra SG, Pauly DF, Lee CR, Patterson JH, Adams KF, Schofield RS, Belgado BS, Hamilton KK, Aranda JM, Hill JA, Yarandi HN, Walker JR, Phillips MS, Gelfand CA, Johnson JA. β-adrenergic Receptor Polymorphisms and Responses during Titration of Metoprolol Controlled Release/extended Release in Heart Failure*. Clin Pharmacol Ther 2005; 77:127-37. [PMID: 15735607 DOI: 10.1016/j.clpt.2004.10.006] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE beta-Blockers require careful initiation and titration when used in patients with heart failure. Some patients tolerate beta-blocker therapy initiation without difficulty, whereas in other patients this period presents clinical challenges. We tested the hypothesis that polymorphisms at codons 389 (Arg389Gly) and 49 (Ser49Gly) of the beta(1)-adrenergic receptor would be associated with differences in initial tolerability of beta-blocker therapy in patients with heart failure. We also tested whether polymorphisms in the beta(2)-adrenergic receptor, G-protein alpha s subunit (G(s)alpha), and cytochrome P450 (CYP) 2D6 genes or S-metoprolol plasma concentrations were associated with beta-blocker tolerability. METHODS Sixty-one beta-blocker-naive patients with systolic heart failure were prospectively enrolled. Patients began taking 12.5 to 25 mg metoprolol controlled release/extended release with titration every 2 weeks (as tolerated) to 200 mg/d or the maximum tolerated dose over a period of 8 to 10 weeks. Decompensation was the composite of death, heart failure hospitalization, increase in other heart failure medications, or need to discontinue metoprolol. End points were assessed during the titration period. RESULTS The overall rate of decompensation was not different between the codon 49 or 389 genotypes. However, a significantly greater percentage of patients with the Gly389 variant required increases in heart failure medications as compared with Arg389 homozygotes (48% versus 14%, respectively; P = .006). Similarly, patients with the Ser49 homozygous genotype were significantly more likely to require increases in concomitant heart failure therapy as compared with Gly49 carriers (41% versus 11%, respectively; P = .03). Neither CYP2D6 genotypes nor metoprolol pharmacokinetics differed between patients with and those without a decompensation event. There was no association between the beta(2)-adrenergic receptor or G(s)alpha polymorphisms with decompensated heart failure. CONCLUSIONS Patients with the Gly389 variant and Ser49Ser genotype were significantly more likely to require increases in heart failure medications during beta-blocker titration and thus may require more frequent follow-up during titration.
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MESH Headings
- Cytochrome P-450 CYP2D6/drug effects
- Cytochrome P-450 CYP2D6/genetics
- Cytochrome P-450 CYP2D6/metabolism
- Delayed-Action Preparations/administration & dosage
- Delayed-Action Preparations/pharmacokinetics
- Drug Administration Schedule
- Drug Resistance/drug effects
- Drug Resistance/genetics
- Exercise Tolerance/drug effects
- Exercise Tolerance/genetics
- GTP-Binding Protein alpha Subunits, Gs/drug effects
- GTP-Binding Protein alpha Subunits, Gs/genetics
- Genotype
- Heart Failure/diagnosis
- Heart Failure/drug therapy
- Humans
- Male
- Metoprolol/administration & dosage
- Metoprolol/pharmacokinetics
- Metoprolol/therapeutic use
- Middle Aged
- Pharmacogenetics/methods
- Phenotype
- Polymorphism, Genetic/drug effects
- Polymorphism, Genetic/genetics
- Polymorphism, Genetic/physiology
- Receptors, Adrenergic, beta/drug effects
- Receptors, Adrenergic, beta/genetics
- Receptors, Adrenergic, beta/physiology
- Time and Motion Studies
- Treatment Outcome
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Affiliation(s)
- Steven G Terra
- Department of Pharmacy Practice, University of Florida, Gainsville, FL 32610, USA
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Aranda JM, Beaver TM, Schofield RS, Leach DD, Staples ED, Kubo SH. 227 Predictors of hospital length of stay in a surgical approach to the failing heart: the ACORN cardiac support device randomized trial experience. J Card Fail 2004. [DOI: 10.1016/j.cardfail.2004.06.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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