Delayed presentation of biopsy-proven eosinophilic myocarditis following COVID-19 mRNA vaccine

Myopericarditis associated with COVID-19 mRNA vaccines has been recognized as an uncommon adverse reaction, especially among young, healthy adult males. Eosinophilic myocarditis is a rare form of inflammation reflecting a hypersensitivity reaction following an inciting event commonly caused by drugs including vaccines. Eosinophilic myocarditis, a subtype of myocarditis, is characterized by eosinophilic myocardial infiltrates. It is usually accompanied by systemic eosinophilia in the form of a drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and is rarely associated with myocyte fibrosis and/or necrosis. In this report, we present a case of biopsy-proven eosinophilic myocarditis in a 24-year-old male patient, likely secondary to COVID-19 mRNA vaccination. To our knowledge, this is the first report to describe delayed eosinophilic myocarditis following the COVID-19 mRNA vaccine. Clinicians should be aware of possible delayed presentation to avoid associated morbidity.

Ten year real world experience with ultrafiltration for the management of acute decompensated heart failure

Background

Randomized controlled trials (RCT) of ultrafiltration (UF) have demonstrated conflicting results regarding its efficacy and safety.

Objective

We reviewed 10 years of data for adjustable UF during heart failure hospitalizations in a real world cohort.

Methods

We performed a retrospective, single center analysis of 335 consecutive patients treated with adjustable rate UF using the CHF Solutions Aquadex Flex Flo System from 2009 to 2019.

Results

Compared to previous RCTs investigating UF, our cohort was older, with worse renal impairment and more antecedent HF hospitalizations in the year preceding therapy. Mean fluid removal with UF was 14.6 l. Mean weight loss with UF was 15.6 lbs (range 0.2-57 lbs) and was sustained at 1-2 week follow-up. Mean creatinine change upon stopping UF, at discharge and follow-up (mean 30 days) was +0.11 mg/dl, +0.07 mg/dl and +0.11 mg/dl, respectively. HF rehospitalizations at 30 days, 90 days and 1 year were 12.4 %, 14.9 % and 27.3 % respectively. On average patients had 1.74 fewer hospitalizations for HF in the year following UF when compared to 12 months preceding UF. Major bleeding defined as requiring discontinuation of anticoagulation occurred in 3.6 % of patients.

Conclusions

Compared with previous UF trials, our study demonstrates that UF compares favorably for HF rehospitalizations, renal function response, and weight/volume loss. Importantly, our real world experience allowed for the adjustment of UF rate during therapy and we believe this is a major contributor to our favorable outcomes. In clinical practice, UF can be a safe and effective strategy for decongestion.

Caregiver Health-Related Quality of Life, Burden, and Patient Outcomes in Ambulatory Advanced Heart Failure: A Report From REVIVAL

Background Heart failure (HF) imposes significant burden on patients and caregivers. Longitudinal data on caregiver health-related quality of life (HRQOL) and burden in ambulatory advanced HF are limited. Methods and Results Ambulatory patients with advanced HF (n=400) and their participating caregivers (n=95) enrolled in REVIVAL (Registry Evaluation of Vital Information for VADs [Ventricular Assist Devices] in Ambulatory Life) were followed up for 24 months, or until patient death, left ventricular assist device implantation, heart transplantation, or loss to follow-up. Caregiver HRQOL (EuroQol Visual Analog Scale) and burden (Oberst Caregiving Burden Scale) did not change significantly from baseline to follow-up. At time of caregiver enrollment, better patient HRQOL by Kansas City Cardiomyopathy Questionnaire was associated with better caregiver HRQOL (P=0.007) and less burden by both time spent (P<0.0001) and difficulty (P=0.0007) of caregiving tasks. On longitudinal analyses adjusted for baseline values, better patient HRQOL (P=0.034) and being a married caregiver (P=0.016) were independently associated with better caregiver HRQOL. Patients with participating caregivers (versus without) were more likely to prefer left ventricular assist device therapy over time (odds ratio, 1.43; 95% CI, 1.03-1.99; P=0.034). Among patients with participating caregivers, those with nonmarried (versus married) caregivers were at higher composite risk of HF hospitalization, death, heart transplantation or left ventricular assist device implantation (hazard ratio, 2.99; 95% CI, 1.29-6.96; P=0.011). Conclusions Patient and caregiver characteristics may impact their HRQOL and other health outcomes over time. Understanding the patient-caregiver relationship may better inform medical decision making and outcomes in ambulatory advanced HF.

Impact of Body Mass Index on COVID-19-Related In-Hospital Outcomes and Mortality

BACKGROUND

Given the high prevalence of obesity around the globe, patients with coronavirus disease 2019 (COVID-19) are at an increased risk of devastating complications.

METHODS

A retrospective cohort study was performed to determine the association of basal metabolic index (body mass index (BMI)) with the need for invasive mechanical ventilation (IMV), dialysis, upgrade to an intensive care unit (ICU) and mortality. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aORs) with its 95% confidence interval (CI), respectively.

RESULTS

A total of 176 consecutive patients with confirmed COVID-19 diagnosis were included. The mean age was 62.2 years, with 51% being male patients. The mean BMI for non-surviving patients was significantly higher compared to patients surviving on the seventh day of hospitalization (35 vs. 30 kg/m2, P = 0.022). Similarly, patients requiring IMV had a higher BMI (33 vs. 29, P = 0.002) compared to non-intubated patients. The unadjusted OR for patients with a higher BMI requiring IMV (56% vs. 28%, OR: 3.3, 95% CI: 1.6 - 7.0, P = 0.002) and upgrade to ICU (46% vs. 28%, OR; 2.2, 1.07 - 4.6, P = 0.04) were significantly higher compared to patients with a lower BMI. Similarly, patients with a higher BMI had higher in-hospital mortality (21% vs. 9%, OR: 3.2, 95% CI: 1.3 - 8.2, P = 0.01) compared to patients with a normal BMI. Despite a numerical advantage in the lower BMI group, there was no significant difference between the two groups in terms of the need for dialysis (5% vs. 13%, OR: 3.8, 13% vs. 4%, 1.1 - 14.1, P = 0.07). aORs controlled for baseline comorbidities and medications mirrored the overall results, except for the need to upgrade to ICU.

CONCLUSIONS

In patients with confirmed COVID-19, morbid obesity serves as an independent risk factor of high in-hospital mortality and the need for IMV.

Effects of left ventricular assist device on pulmonary functions and pulmonary hemodynamics: A meta-analysis

BACKGROUND

Given current evidence, the effect of left ventricular assist device (LVAD) implantation on pulmonary function tests remains controversial.

AIM

To better understand the factors contributing to the changes seen on pulmonary function testing and the correlation with pulmonary hemodynamics after LVAD implantation.

METHODS

Electronic databases were queried to identify relevant articles. The summary effect size was estimated as a difference of overall means and standard deviation on a random-effects model.

RESULTS

A total of four studies comprising 219 patients were included. The overall mean forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusion lung capacity of carbon monoxide (DLCO) after LVAD implantation were significantly lower by 0.23 L (95%CI: 0.11-0.34, P = 00002), 0.18 L (95%CI: 0.03-0.34, P = 0.02), and 3.16 mmol/min (95%CI: 2.17-4.14, P < 0.00001), respectively. The net post-LVAD mean value of the cardiac index was significantly higher by 0.49 L/min/m² (95%CI: 0.31-0.66, P < 0.00001) compared to pre-LVAD value. The pulmonary capillary wedge pressure and pulmonary vascular resistance were significantly reduced after LVAD implantation by 8.56 mmHg (95%CI: 3.78-13.35, P = 0.0004), and 0.83 Woods U (95%CI: 0.11-1.55, P = 0.02), respectively. There was no significant difference observed in the right atrial pressure after LVAD implantation (0.61 mmHg, 95%CI: -2.00 to 3.32, P = 0.65). Overall findings appear to be driven by studies using HeartMateII devices.

CONCLUSION

LVAD implantation might be associated with a significant reduction of the spirometric measures, including FEV1, FVC, and DLCO, and an overall improvement of pulmonary hemodynamics.

Predictability of CRP and D-Dimer levels for in-hospital outcomes and mortality of COVID-19

Background

Systemic inflammation elicited by a cytokine storm is considered a hallmark of coronavirus disease 2019 (COVID-19). This study aims to assess the clinical utility of the C-reactive protein (CRP) and D-Dimer levels for predicting in-hospital outcomes in COVID-19.

Methods

A retrospective cohort study was performed to determine the association of CRP and D-Dimer with the need for invasive mechanical ventilation (IMV), dialysis, upgrade to an intensive care unit (ICU) and mortality. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aOR) with its 95% confidence interval (CI), respectively.

Results

A total of 176 patients with confirmed COVID-19 diagnosis were included. On presentation, the unadjusted odds for the need of IMV (OR 2.5, 95% CI 1.3-4.8, p = 0.012) and upgrade to ICU (OR 3.2, 95% CI 1.6-6.5, p = 0.002) were significantly higher for patients with CRP (>101 mg/dl). Similarly, the unadjusted odds of in-hospital mortality were significantly higher in patients with high CRP (>101 mg/dl) and high D-Dimer (>501 ng/ml), compared to corresponding low CRP (<100 mg/dl) and low D-Dimer (<500 ng/ml) groups on day-7 (OR 3.5, 95% CI 1.2-10.5, p = 0.03 and OR 10.0, 95% CI 1.2-77.9, p = 0.02), respectively. Both high D-Dimer (>501 ng/ml) and high CRP (>101 mg/dl) were associated with increased need for upgrade to the ICU and higher requirement for IMV on day-7 of hospitalization. A multivariate regression model mirrored the overall unadjusted trends except that adjusted odds for IMV were high in the high CRP group on day 7 (aOR 2.5, 95% CI 1.05-6.0, p = 0.04).

Conclusion

CRP value greater than 100 mg/dL and D-dimer levels higher than 500 ng/ml during hospitalization might predict higher odds of in-hospital mortality. Higher levels at presentation might indicate impending clinical deterioration and the need for IMV.

Safety and Efficacy of Hydroxychloroquine in COVID-19: A Systematic Review and Meta-Analysis

BACKGROUND

During the initial phases of the coronavirus disease 2019 (COVID-19) epidemic, there was an unfounded fervor surrounding the use of hydroxychloroquine (HCQ); however, recently, the Centers for Disease Control and Prevention (CDC) has recommended against routine use of HCQ outside of study protocols citing possible adverse outcomes.

METHODS

Multiple databases were searched to identify articles on COVID-19. An unadjusted odds ratio (OR) was used to calculate the safety and efficacy of HCQ on a random effect model.

RESULTS

Twelve studies comprising 3,912 patients (HCQ 2,512 and control 1400) were included. The odds of all-cause mortality (OR: 2.23, 95% confidence interval (CI): 1.58 - 3.13, P value < 0.00001) were significantly higher in patients on HCQ compared to patients on control agent. The response to therapy assessed by negative repeat polymerase chain reaction (PCR) (OR: 1.83, 95% CI: 0.50 - 6.75, P = 0.36), radiological resolution (OR: 1.98, 95% CI: 0.47 - 8.36, P value = 0.36) and the need for invasive mechanical ventilation (IMV) (OR: 1.21, 95% CI: 0.34 - 4.33, P value = 0.76) were identical between the two groups. Overall, four times higher odds of net adverse events (NAEs) were observed in the HCQ group (OR: 4.59, 95% CI 1.73 - 12.20, P value = 0.02). The measures for individual safety endpoints were also numerically lower in the control arm; however, none of these values reached the level of statistical significance.

CONCLUSIONS

HCQ might offer no benefits in terms of decreasing the viral load and radiological improvement in patients with COVID-19. HCQ appears to be associated with higher odds of all-cause mortality and NAEs.

Lymphocyte-to-C-Reactive Protein Ratio: A Novel Predictor of Adverse Outcomes in COVID-19

Background

Systemic inflammation elicited by a cytokine storm is considered a hallmark of coronavirus disease 2019 (COVID-19). This study aims to assess the validity and clinical utility of the lymphocyte-to-C-reactive protein (CRP) ratio (LCR), typically used for gastric carcinoma prognostication, versus the neutrophil-to-lymphocyte ratio (NLR) for predicting in-hospital outcomes in COVID-19.

Methods

A retrospective cohort study was performed to determine the association of LCR and NLR with the need for invasive mechanical ventilation (IMV), dialysis, upgrade to an intensive care unit (ICU) and mortality. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aORs) with its 95% confidence interval (CI), respectively.

Results

The mean age for NLR patients was 63.6 versus 61.6, and for LCR groups, it was 62.6 versus 63.7 years, respectively. The baseline comorbidities across all groups were comparable except that the higher LCR group had female predominance. The mean NLR was significantly higher for patients who died during hospitalization (19 vs. 7, P ≤ 0.001) and those requiring IMV (12 vs. 7, P = 0.01). Compared to alive patients, a significantly lower mean LCR was observed in patients who did not survive hospitalization (1,011 vs. 632, P = 0.04). For patients with a higher NLR (> 10), the unadjusted odds of mortality (odds ratios (ORs) 11.0, 3.6 - 33.0, P < 0.0001) and need for IMV (OR 3.3, 95% CI 1.4 - 7.7, P = 0.008) were significantly higher compared to patients with lower NLR. By contrast, for patients with lower LCR (< 100), the odds of in-hospital all-cause mortality were significantly higher compared to patients with a higher LCR (OR 0.2, 0.06 - 0.47, P = 0.001). The aORs controlled for baseline comorbidities and medications mirrored the overall results, indicating a genuinely significant correlation between these biomarkers and outcomes.

Conclusions

A high NLR and decreased LCR value predict higher odds of in-hospital mortality. A high LCR at presentation might indicate impending clinical deterioration and the need for IMV.

Outcomes of open mitral valve replacement versus Transcatheter mitral valve repair; insight from the National Inpatient Sample Database

BACKGROUND

Transcatheter mitral valve repair and replacement (TMVR) is a minimally invasive alternative to conventional open-heart mitral valve replacement (OMVR). The present study aims to compare the burden, demographics, cost, and complications of TMVR and OMVR.

METHODS

The United States National Inpatient Sample (US-NIS) for the year 2017 was queried to identify all cases of TMVR and OMVR. Categorical and continuous data were analyzed using Pearson chi-square and independent t-test analysis, respectively. An adjusted odds ratio (aOR) based on the ordinal logistic regression (OLR) model was calculated to determine the association between outcome variables.

RESULTS

Of 19,580 patients, 18,460 (94%) underwent OMVR and 1120 (6%) TMVR. Mean ages of patients were 63 ± 14 years (OMVR) and 67 ± 13 years (TMVR). Both cohorts were predominantly Caucasian (73% OMVR vs. 74.0% TMVR). The patients who underwent TMVR were more likely to belong to a household with an income in the highest quartile (26.1% vs. 22.0% for OMVR) versus the lowest quartile (22.1% vs. 27.8%). The average number of days from admission to TMVR was less compared to OMVR (2.63 days vs. 3.02 days, p = 0.015). In-hospital length of stay (LOS) was significantly lower for TMVR compared to OMVR (11.56 vs. 14.01 days, p=<0.0001). Adjusted in-hospital mortality taking into account comorbidities showed no significant difference between the two groups (OR 1.2, 0.93-1.68, p = 0.15).

CONCLUSION

Patients undergoing TMVR were older and more financially affluent. TMVR was more costly but was associated with a shorter hospital stay and similar mortality to OMVR.

Diagnostic Accuracy of Cardiac Magnetic Resonance Versus Fractional Flow Reserve: A Systematic Review and Meta-Analysis

Background

Fractional flow reserve (FFR) is considered the gold standard for diagnosis of coronary artery disease (CAD). Stress Cardiac magnetic resonance (SCMR) has been recently gaining traction as a non-invasive alternative to FFR.

Methods

Studies comparing the diagnostic accuracy of SCMR versus FFR were identified and analyzed using Review Manager (RevMan) 5.3 and Stata software.

Results

A total of 28 studies, comprising 2,387 patients, were included. The pooled sensitivity and specificity for SCMR were 86% and 86% at the patient level, and 82% and 88% at the vessel level, respectively. When the patient-level data were stratified based on the FFR thresholds, higher sensitivity and specificity (both 90%) were noted with the higher cutoff (0.75) and lower cutoff (0.8), respectively. At the vessel level, sensitivity and specificity at the lower FFR threshold were significantly higher at 88% and 89%, compared to the corresponding values for higher cutoff at 0.75. Similarly, meta-regression analysis of SCMR at higher (3T) resolution showed a higher sensitivity of 87% at the patient level and higher specificity of 90% at the vessel level. The highest sensitivity and specificity of SCMR (92% and 94%, respectively) were noted in studies with CAD prevalence greater than 60%.

Conclusions

SCMR has high diagnostic accuracy for CAD comparable to FFR at a spatial resolution of 3T and an FFR cut-off of 0.80. An increase in CAD prevalence further improved the specificity of SCMR.

Efficacy of antibacterial envelope in prevention of cardiovascular implantable electronic device infections in high-risk patients: A systematic review and meta-analysis

BACKGROUND

Limited evidence is available to determine the efficacy of an antibacterial enveloped (AE) cardiovascular implantable electronic device (CIED).

OBJECTIVE

To assess if the use of antibacterial enveloped devices in high-risk patients are associated with lower chances of major CIED infections and mortality compared to non-enveloped devices.

METHODS

A comprehensive literature search on multiple databases was performed. The relative odds ratio (OR) of major CIED infection and mortality was calculated using a random-effect model.

RESULTS

A total of six studies consisting of 11,897 patients, were included; 5844 with an AE-CIED and 6053 with conventional CIED. In the pooled cohort, patients with AE-CIED had a 66% lower odds of major CIED infection (OR 0.34, 0.13, 0.86, CI 95%, p = 0.02) compared to CIED. Propensity matched analysis showed a 71% lower odds of major infection in the AE-CIED group (OR 0.29, 95% CI 0.10-0.82, p = 0.02). Stratified analysis based on the type of study (retrospective vs. prospective) and duration of follow up (6 months vs. greater than six months) also showed numerically lower infection odds in the AE-CIED. Similarly, the relative odds of mortality were lower in patients with AE-CIED (OR 0.55, 95% CI 0.16-1.91, p = 0.34) compared to CIED patients; however, this difference was statistically non-significant.

CONCLUSION

In high-risk patients, AE-CIED might offer lower odds of CIED infections. It has numerically lower (45%) but statistically non-significant odds of mortality if used in conjunction with the standard infection prevention protocol. More large scale studies and long-term follow-ups are required to validate our findings.

Impact of Socioeconomic Factors on Patient Desire for Early LVAD Therapy Prior to Inotrope Dependence

BACKGROUND

Worsening heart failure (HF) and health-related quality of life (HRQOL) have been shown to impact the decision to proceed with left ventricular assist device (LVAD) implantation, but little is known about how socioeconomic factors influence expressed patient preference for LVAD.

METHODS AND RESULTS

Ambulatory patients with advanced systolic HF (n=353) reviewed written information about LVAD therapy and completed a brief survey to indicate whether they would want an LVAD to treat their current level of HF. Ordinal logistic regression analyses identified clinical and demographic predictors of LVAD preference. Higher New York Heart Association (NYHA) class, worse HRQOL measured by Kansas City Cardiomyopathy Questionnaire, lower education level, and lower income were significant univariable predictors of patients wanting an LVAD. In the multivariable model, higher NYHA class (OR [odds ratio]: 1.43, CI [confidence interval]: 1.08-1.90, P = .013) and lower income level (OR: 2.10, CI: 1.18 - 3.76, P = .012 for <$40,000 vs >$80,000) remained significantly associated with wanting an LVAD.

CONCLUSION

Among ambulatory patients with advanced systolic HF, treatment preference for LVAD was influenced by level of income independent of HF severity. Understanding the impact of socioeconomic factors on willingness to consider LVAD therapy may help tailor counseling towards individual needs.

Centralized, stepped, patient preference-based treatment for patients with post-acute coronary syndrome depression: CODIACS vanguard randomized controlled trial

IMPORTANCE

Controversy remains about whether depression can be successfully managed after acute coronary syndrome (ACS) and the costs and benefits of doing so.

OBJECTIVE

To determine the effects of providing post-ACS depression care on depressive symptoms and health care costs.

DESIGN

Multicenter randomized controlled trial.

SETTING

Patients were recruited from 2 private and 5 academic ambulatory centers across the United States.

PARTICIPANTS

A total of 150 patients with elevated depressive symptoms (Beck Depression Inventory [BDI] score ≥10) 2 to 6 months after an ACS, recruited between March 18, 2010, and January 9, 2012.

INTERVENTIONS

Patients were randomized to 6 months of centralized depression care (patient preference for problem-solving treatment given via telephone or the Internet, pharmacotherapy, both, or neither), stepped every 6 to 8 weeks (active treatment group; n = 73), or to locally determined depression care after physician notification about the patient's depressive symptoms (usual care group; n = 77).

MAIN OUTCOME MEASURES

Change in depressive symptoms during 6 months and total health care costs.

RESULTS

Depressive symptoms decreased significantly more in the active treatment group than in the usual care group (differential change between groups, -3.5 BDI points; 95% CI, -6.1 to -0.7; P = .01). Although mental health care estimated costs were higher for active treatment than for usual care, overall health care estimated costs were not significantly different (difference adjusting for confounding, -$325; 95% CI, -$2639 to $1989; P = .78).

CONCLUSIONS

For patients with post-ACS depression, active treatment had a substantial beneficial effect on depressive symptoms. This kind of depression care is feasible, effective, and may be cost-neutral within 6 months; therefore, it should be tested in a large phase 3 pragmatic trial.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01032018.

Design and baseline data from the vanguard of the Comparison of Depression Interventions after Acute Coronary Syndrome (CODIACS) randomized controlled trial

This paper describes the rationale and design of the vanguard for the Comparison of Depression Interventions after Acute Coronary Syndrome (CODIACS), a multicenter, randomized, controlled trial of a patient preference-based, stepped care protocol for persistent depressive symptoms after acute coronary syndrome (ACS). The overall aim of the vanguard phase was to determine whether the patient-preference, stepped care protocol, which is based on the intervention used in the recent Coronary Psychosocial Evaluation Studies (COPES) trial, was feasible in patients with recent ACS who were recruited from 5 geographically diverse sites. Innovative design features of this trial include randomization to either initial patient-preference of treatment or to a referred care arm in which the primary care provider decided upon care. Additionally, delivery of psychotherapy was accomplished by telephone, or webcam, depending upon patient preference. The vanguard phase provides estimates of eligibility and screening/enrollment ratios, patient acceptance of screening, and retention. In this report, we describe the innovative features and the baseline results of the vanguard phase of CODIACS. The data from this vanguard study will be used to finalize planning for a large, phase III clinical trial designed to evaluate the effect of treatment on depressive symptoms, coronary events, and death.

Incident and recurrent major depressive disorder and coronary artery disease severity in acute coronary syndrome patients

There is recent evidence that acute coronary syndrome (ACS) patients with first time incident major depressive disorder (MDD) and those with recurrent MDD represent different subtypes among individuals with ACS and comorbid depression. However, few studies have examined whether or not these subtypes differ in coronary artery disease (CAD) severity. We assessed whether those with incident MDD (in-hospital MDD and negative for history of MDD) or recurrent MDD (in-hospital MDD and a positive history of MDD) differ in angiographically documented CAD severity. Within 1 week of admission for ACS, 88 patients completed a clinical interview to assess current and past diagnosis of MDD. CAD severity was assessed in all patients by coronary angiography. A hierarchical regression analysis showed that neither in-hospital MDD status, nor history of MDD were significant predictors of CAD severity, but the interaction term between in-hospital MDD status and history of MDD was a significant predictor of CAD severity, after controlling for age, sex and ethnicity. Follow-up analyses showed that patients with first time, incident MDD had significantly more severe CAD compared to patients with recurrent MDD (p=0.043). To conclude, our study adds to the growing evidence that patients with incident MDD should be considered as a clinically distinct subtype from those with recurrent MDD. Possible mechanisms for differing CAD severity by angiogram between these two subtypes are proposed and implications for prognosis and treatment are discussed.

Standardizing the Comparison of Systolic Blood Pressure vs. Pulse Pressure for Predicting Coronary Heart Disease

Whether systolic blood pressure (SBP) or pulse pressure (PP) is more predictive of coronary heart disease remains controversial. The authors analyzed 6032 participants in the first National Health and Nutritional Examination Survey (NHANES I) followed up for an average of 16 years. Blood pressure was measured at baseline and coronary heart disease outcomes were determined from hospital or mortality records. Cox proportional hazard analyses were used to estimate the multivariate-adjusted relative risk (RR) for increases of 10 mm Hg or 1 SD in SBP and PP, and the RR associated with PP was greater than the RR associated with SBP when using an increase of 10 mm Hg. However, when using an increase of 1 SD, the RR associated with SBP was larger than for PP. Although both are predictors, the authors conclude that SBP has a larger RR than PP for coronary heart disease events.

Persistent depression affects adherence to secondary prevention behaviors after acute coronary syndromes

BACKGROUND

The persistence of depressive symptoms after hospitalization is a strong risk factor for mortality after acute coronary syndromes (ACS). Poor adherence to secondary prevention behaviors may be a mediator of the relationship between depression and increased mortality.

OBJECTIVE

To determine whether rates of adherence to risk reducing behaviors were affected by depressive status during hospitalization and 3 months later.

DESIGN

Prospective observational cohort study.

SETTING

Three university hospitals.

PARTICIPANTS

Five hundred and sixty patients were enrolled within 7 days after ACS. Of these, 492 (88%) patients completed 3-month follow-up.

MEASUREMENTS

We used the Beck Depression Inventory (BDI) to assess depressive symptoms in the hospital and 3 months after discharge. We assessed adherence to 5 risk-reducing behaviors by patient self-report at 3 months. We used chi2 analysis to compare differences in adherence among 3 groups: persistently nondepressed (BDI < 10 at hospitalization and 3 months); remittent depressed (BDI > or = 10 at hospitalization; < 10 at 3 months); and persistently depressed patients (BDI > or = 10 at hospitalization and 3 months).

RESULTS

Compared with persistently nondepressed, persistently depressed patients reported lower rates of adherence to quitting smoking (adjusted odds ratio [OR] 0.23, 95% confidence interval [95% CI] 0.05 to 0.97), taking medications (adjusted OR 0.50, 95% CI 0.27 to 0.95), exercising (adjusted OR 0.57, 95% CI 0.34 to 0.95), and attending cardiac rehabilitation (adjusted OR 0.5, 95% CI 0.27 to 0.91). There were no significant differences between remittent depressed and persistently nondepressed patients.

CONCLUSIONS

Persistently depressed patients were less likely to adhere to behaviors that reduce the risk of recurrent ACS. Differences in adherence to these behaviors may explain in part why depression predicts mortality after ACS.

Age-dependent associations between sleep-disordered breathing and hypertension: importance of discriminating between systolic/diastolic hypertension and isolated systolic hypertension in the Sleep Heart Health Study

BACKGROUND

Sleep-disordered breathing (SDB) is associated with hypertension in the middle-aged. The association is less clear in older persons. Most middle-aged hypertensives have systolic/diastolic hypertension, whereas isolated systolic hypertension (ISH) is common among persons over 60 years. Mechanistically, only systolic/diastolic hypertension is expected to be associated with SDB, but few studies of SDB and hypertension distinguish systolic/diastolic hypertension from ISH. Prior investigations may have underestimated an association between SDB and systolic/diastolic hypertension in the elderly by categorizing individuals with ISH as simply hypertensive.

METHODS AND RESULTS

We conducted cross-sectional analyses of 6120 participants in the Sleep Heart Health Study, stratified by age: 40 to 59 (n=2477) and > or =60 years. Outcome measures included apnea-hypopnea index (AHI; average number of apneas plus hypopneas per hour of sleep), systolic/diastolic hypertension (> or =140 and > or =90 mm Hg), and ISH (> or =140 and <90 mm Hg). With adjustment for covariates, ISH was not associated with SDB in either age category. In those aged<60 years, AHI was significantly associated with higher odds of systolic/diastolic hypertension (AHI 15 to 29.9, OR=2.38 [95% CI 1.30 to 4.38]; AHI > or =30, OR=2.24 [95% CI 1.10 to 4.54]). Among those aged > or =60 years, no adjusted association between AHI and systolic/diastolic hypertension was found.

CONCLUSIONS

SDB is associated with systolic/diastolic hypertension in those aged <60 years. No association was found between SDB and systolic/diastolic hypertension in those aged > or =60 years or between SDB and ISH in either age category. These findings have implications for SDB screening and treatment. Distinguishing between hypertensive subtypes reveals a stronger association between SDB and hypertension for those aged <60 years than previously reported.

A comparison of morning blood pressure surge in African Americans and whites

African Americans have twice the risk of suffering a stroke compared to whites, but the reasons for this disparity have yet to be elucidated. Recent data suggest that the morning blood pressure (BP) surge is an independent predictor of strokes. Whether African Americans and whites differ with respect to morning BP surge is unknown. African-American (n=183) and white (n=139) participants, age 18-65, were studied with 24-hour ambulatory BP monitoring. Morning surge was defined as morning BP minus the trough BP during sleep. The morning surge was significantly lower in African Americans than in whites (23 mm Hg vs. 27 mm Hg; both SEM=1.0; p=0.009). This relationship was no longer evident after adjusting for gender, age, and body mass index (23 mm Hg vs. 26 mm Hg; SE=1.0 and 1.1; p=nonsignificant). Morning BP surge is unlikely to account for differences in stroke incidence between African Americans and whites.

Negative impact of depression on outcomes in patients with coronary artery disease: mechanisms, treatment considerations, and future directions

Depressive symptoms are common in coronary artery disease (CAD) patients, and are associated with increased cardiac risk. Although an important relation exists between depression and CAD prognosis, the underlying pathophysiological mechanisms are poorly understood. Additionally, evidence including the recently published ENRICHD (Enhancing Recovery in Coronary Heart Disease Patients) trial suggests that depression treatments do not lower recurrent cardiac risk. The reason for the observed lack of benefit with depression treatment in CAD patients is unclear. In this review, we discuss the impact of depression in CAD patients, the possible mechanisms involved, the studies that have examined the effects of psychological and antidepressant therapies on recurrent cardiac events, and the direction that future research should take.

Depressive symptoms are independently predictive of carotid atherosclerosis

The investigators tested whether depressive symptoms were predictive of carotid atherosclerosis, a marker of coronary atherosclerosis. Healthy participants (n = 219) underwent the baseline assessment of cardiovascular risk factors, including self-reported depressive symptoms, and were assessed for carotid plaque at 10-year follow-up. Adjusting for baseline cardiovascular risk factors, participants with elevated depression scores at baseline were >2 times as likely as those with no depressive symptoms to have carotid plaque.

"Abdominal crunch"-induced rhabdomyolysis presenting as right upper quadrant pain

A young, active duty sailor presented with right upper quadrant abdominal pain. History, physical, and laboratory findings initially suggested cholecystitis or related disease. Further evaluation found myoglobinuria and a recently increased exercise program, leading to the diagnosis of exercise-induced right upper abdominal wall rhabdomyolysis. Although not a common cause of abdominal pain, this diagnosis should be considered in the patient with abdominal pain and a recently increased exercise program, particularly exercises of the abdominal wall such as "abdominal crunches."

Chronic post-traumatic headaches classified and compared with natural headaches

This study sought to determine whether chronic post-traumatic headaches are different from or identical to the naturally occurring headaches. The chronic post-traumatic headaches of 48 patients were classified, as if they were natural headaches, by the diagnostic criteria of the International Headache Society. Thirty-six patients' headaches (75%) were chronic tension-type headache, 10 (21%) were migraine without aura, and 2 (4%) were unclassifiable. The characteristics and accompaniments of the headaches within each diagnostic group were then compared to those in a control group with natural headaches of the same type. No notable differences between the post-traumatic and control groups were found. Hence, chronic post-traumatic headaches have no special features, but are symptomatically identical to either chronic tension-type headache or migraine without aura (in this series of patients). This identity suggests that post-traumatic headaches are generated by the same processes causing the natural headaches, not by intracranial derangement from head blows or jolts.

Continuous chronic tension-type headache unaffected by two hours of frontalis and trapezius relaxation

Fourteen patients with the continuous form of chronic tension-type headache maintained electromyographically documented relaxation of frontalis and trapezius muscles for two consecutive hours. The headache intensity of the group did not decrease from the beginning to the end of the recording session. This result is evidence against tonic muscle tension as the mechanism of this form of headache.

Headache caused by a single lesion of multiple sclerosis in the periaqueductal gray area

We report a severe acute headache that occurred in conjunction with a solitary fresh lesion of multiple sclerosis in the periaqueductal gray region of a 16-year-old girl. This unique natural event supports the recent proposition, based on observations of patients with implanted electrodes, that perturbations of the periaqueductal gray region can produce headache. It also suggests that headaches accompanying attacks of multiple sclerosis are due to disturbances in particular regions of the brain.

Arteriovenous malformations and migraine: case reports and an analysis of the relationship

Some patients with cerebral arteriovenous malformations (AVMs) suffer recurrent migrainous attacks which meet the official criteria for migraine. The relationship of these attacks to the malformations has been poorly substantiated. Instances where attacks disappeared following surgical extirpation of an AVM support a relationship, but several other reported surgical outcomes do not. Both patients presented here had surgical results seemingly antithetical to a relationship: the attacks persisted in the first patient and began in the second after removal of the AVM. Nevertheless, data assembled from the literature attests to a causal role for AVMs in the production of migrainous attacks, by showing an overwhelming correlation between the side of the cranium with the AVM and the side afflicted by unilateral headache. An equally good correlation exists for lateralized auras. The correlative and surgical data together show that migrainous attacks develop in relation to AVMs, but not within the malformation itself. Instead, the neighboring brain is probably the generative site.

Plasmapheresis alleviates neuropathy accompanying IgM anti-myelin-associated glycoprotein paraproteinemia

A patient with peripheral neuropathy accompanying a benign IgM anti-myelin-associated glycoprotein paraproteinemia has been treated successfully by plasmapheresis for over a year, and during this time, fluctuations in the patient's symptoms and signs have correlated with variations in the serum IgM level. These results suggest that plasmapheresis may be more beneficial for such neuropathies than indicated previously, and they add to the evidence implicating the paraprotein as the cause of the neuropathy.

Trauma-triggered migraine: an explanation for common neurological attacks after mild head injury. Review of the literature

This paper reviews the literature on complex temporary disturbances of brain function triggered by mild blows to the head in children, adolescents, and young adults. It consolidates the evidence by which these attacks have been identified as classical or complicated migraines, and provides a historical account of the descriptions and proffered explanations of these attacks. The clinical features and the electroencephalography, angiography, computerized tomography, and cerebrospinal fluid findings of trauma-induced migraine are presented and compared to those of spontaneous migraine. Ideas about the pathogenesis of this condition are related to current thinking on the neurological phenomena of migraine in general.

Transient global amnesia triggered by mild head trauma

In 9 patients, aged 11 to 28 years, minor head injury triggered an amnesic attack grossly disproportionate to the degree of trauma. During these attacks, patients were unable to form new memories for 2 to 24 hours, had extensive retrograde amnesia, voiced repetitive queries and were disorientated for time, but were otherwise intact neurologically. We suggest that these episodes were attacks of transient global amnesia triggered by the mild blows to the head. We also suggest that they constitute a previously unrecognized variety of traumatic migraine.

Death from cerebral hypoperfusion during nitroprusside treatment of acute angiotensin-dependent hypertension

A 37-year-old woman, while being treated with nitroprusside for acute hypertension due to an intramural renal artery hemorrhage, became blind on the fourth hospital day, comatose on the fifth, and brain dead on the seventh. Postmortem examination of her brain revealed border-zone infarcts in the parietal-occipital regions and cerebrellum of the sort associated with cerebral hypoperfusion due to hypotension. Yet her blood pressure had been lowered judiciously to a mean pressure in the vicinity of 110 to 120 mm Hg, and episodes of hypotension had been avoided. As possible explanations for this unusual complication, the roles of acute hyperangiotensinemia and nitroprusside administration are discussed.

Carpal tunnel syndrome following automobile collisions

Seven patients developed symptoms and signs of carpal tunnel syndrome after vehicles they were driving were involved in collisions. Nerve conduction studies showed median nerve impairment at the wrist in 4 patients and suggested it in the other three. The presence of carpal tunnel syndrome was confirmed in every patient by the relief of symptoms following surgical division of the volar carpal ligament. The findings suggest that injuries inflicted on nonneural structures of the carpal tunnel when the patient was gripping the steering wheel led to chronic compression of the median nerve within the tunnel.

Absence of cell-mediated cytotoxicity to muscle cultures in polymyositis

Blood mononuclear cells from 10 patients with polymyositis and 22 controls were incubated with fetal-rat muscle cultures. Polymyositis cells produced no significant cytotoxic effects in cultures as determined by visual inspection and measurement of the release from cultures of creatine phosphokinase and radioactive chromium. These negative results contrast with previous reports and raise the question of whether blood mononuclear cells from polymyositis patients are cytotoxic for muscle cultures.