bluuebunny/crossref_metadata_2025 huggingface dataset:
Total laparoscopic hysterectomy: The Brisbane learning curve
Authors: GARRETT Andrea J. , NASCIMENTO Marcelo Carraro , NICKLIN James L. , PERRIN Lewis C. , OBERMAIR Andreas
Published: January 2007

Background:  Total laparoscopic hysterectomy (TLH) is becoming more commonly used for gynaecological malignancies.

Aims:  To describe our experience with TLH since its introduction to our tertiary referral centre for gynaecological cancer in 2003.

Methods:  Retrospective analysis of the first 120 consecutive cases of TLH performed at our gynaecological cancer centre. Patients were divided into the first, second and third group of 40 patients. Operating time, estimated blood loss, hospital stay, conversion to laparotomy and intra‐ and postoperative morbidity were evaluated.

Results:  The three groups were similar with regard to baseline characteristics. For the entire group the mean hospital stay was 2.4 ± 1.4 days and eight of 120 patients (6.6%) required conversion to laparotomy. Operating time, estimated blood loss and intraoperative morbidity were similar among the three groups. Postoperative morbidity was highest (25%) in the middle one‐third of the patients (P = 0.022). The percentage of pelvic lymph node dissections increased from 2.5% in the first one‐third of patients to 27.5% in the final one‐third of patients (P = 0.003).

Conclusions:  TLH can be established safely in a tertiary gynaecological cancer referral centre.
Morbidity associated with vaginal hysterectomies in Queensland public teaching hospitals
Authors: BECKMANN Michael , NEPPE Cliff
Published: January 2007

Hysterectomies performed vaginally are associated with less perioperative risk than those performed abdominally but the risk is not negligible. There are little sizable and/or contemporary Australian data of adverse outcomes associated with vaginal hysterectomy available.

 A retrospective analysis was undertaken in each of five Queensland public teaching hospitals of the last 200 women in each centre who underwent a vaginal hysterectomy for benign reasons.

 Serious morbidity complicated 14.0% of vaginal hysterectomies, minor morbidity was associated with 24.0% of hysterectomies and, overall, 29.9% suffered any (ie serious or minor) morbidity. Following multivariate analysis there remained an association between serious perioperative morbidity and ASA ≥ 2 (relative risk (RR) 1.89 (1.37–2.61)) and omission of prophylactic antibiotics (RR 2.0 (1.45–2.78)). There also remained an association between any morbidity and use of antidepressants (RR 1.35 (1.07–1.72)), epilepsy (RR 2.00 (136–2.95)), preoperative hypoalbuminaemia (albumin ≤ 35 g/L RR 2.08 (1.33–3.24)) as well as ASA ≥ 2 (RR 1.24 (1.00–1.54)) and omission of prophylactic antibiotics (RR 1.45 (1.18–1.79)).
Lipid Management Reduces Cardiovascular Complications in Individuals With Diabetes and Prediabetes
Authors: Aparna Gosavi , Gregory Flaker , David Gardner
Published: January 2007

Patients with type 2 diabetes are known to have an elevated risk of cardiovascular morbidity and mortality. Prior to the development of hyperglycemia and type 2 diabetes, individuals undergo a prolonged prediabetic phase involving hyperglycemia and insulin resistance. This has been associated with increased cardiovascular risk and is considered a cardiovascular risk equivalent. It is well known that dyslipidemia is an important contributor to the development of coronary artery disease. Treating diabetes with lipid‐lowering agents reduces patients' cardiovascular risk. Preliminary studies have shown that similar benefits are seen even in persons with prediabetes. Hence, lipid‐lowering agents should be considered not only in patients with type 2 diabetes, but also in individuals with prediabetes and with elevated lipid levels.
Rationale for Intensive Statin Treatment in High‐Risk Patients
Authors: Peter H. Jones
Published: January 2007

Intensive lipid‐lowering therapy with 3‐hydroxy‐ 3‐methylglutaryl coenzyme A reductase inhibitors (statins) is now an established regimen for patients at high risk for cardiovascular events, regardless of baseline low‐density lipoprotein cholesterol levels. Treatment with statins to reduce low‐density lipoprotein cholesterol levels significantly below 100 mg/dL has been shown to further reduce the risk of cardiovascular morbidity and mortality in high‐risk patients and has provided the necessary data for an update to the National Cholesterol Education Program's Third Adult Treatment Panel (ATP III) guidelines. Intensive statin therapy is also well tolerated, with no increased risk of noncardiovascular adverse events and a low incidence of clinically significant liver or muscle enzyme abnormalities. Results of recent clinical and surrogate end point trials confirm that intensive lowering of low‐density lipoprotein cholesterol is beneficial and safe in a majority of high‐risk patients.
Ethnic Differences in Barriers and Referral to Cardiac Rehabilitation Among Women Hospitalized With Coronary Heart Disease
Authors: Mochari Heidi , Lee JiWon R. , Kligfield Paul , Mosca Lori
Published: January 2007

Important gender differences in cardiac rehabilitation utilization are well established, yet few studies have documented whether reported barriers and referrals vary by ethnicity. This is a cross‐sectional study to determine whether barriers and referrals to participation in cardiac rehabilitation differed by race/ethnicity in 304 women (52% ethnic minorities) hospitalized with coronary heart disease. Nearly all subjects (92%) strongly agreed that physician referral was important to participation in rehab, but only 22% of subjects reported physician instruction to attend. Whites were more likely than minorities to report instruction to attend cardiac rehabilitation, and minorities were more likely to report financial barriers when compared with whites. These disparities need to be addressed because minority women have a worse prognosis following hospitalization for coronary heart disease, and cardiac rehabilitation has been shown to improve survival.
Conventional, Emerging, Heredity, Lifestyle, and Psychosocial Coronary Risk Factors: Relationships to Subclinical Atherosclerosis
Authors: Taylor Allen J. , Arora Navin S. , Bindeman Jody , Bhattari Saroj , Feuerstein Irwin M. , O'Malley Patrick G.
Published: January 2007

The authors examined the relationship between calcified coronary atherosclerosis and an array of cardiovascular risk factors in sequential logistic models to determine the extent to which these markers overlap in their identification of patients at risk for developing coronary heart disease. The prevalence of coronary artery calcium using electron beam computed tomography was 19.4% in this cross‐sectional study of a prospective, consecutive, screening cohort of 1999 healthy United States Army personnel (aged 39–50 years). The proportion of the total variance of coronary artery calcium explained by sequential logistic models incorporating conventional, emerging, hereditary, lifestyle, and psychosocial cardiovascular risk variables increased progressively from 9.7% to 14.5%. The best‐fit logistic model for the prediction of coronary artery calcium identified age, male gender, Framingham risk score, total cholesterol, high‐density lipoprotein cholesterol, triglycerides, smoking, a family history of coronary heart disease, white race, physical inactivity, and lower depression scores as significant independent correlates of coronary artery calcium. These data indicate that the explanatory power of models for atherosclerosis can be significantly improved with the use of emerging, heredity, lifestyle, and psychosocial factors. The large residual variance, however, supports the potential of atherosclerosis imaging to incrementally and independently identify coronary heart disease risk.
Angiotensin‐Converting Enzyme Genotype and Adherence to Aerobic Exercise Training
Authors: Thompson Paul D. , Tsongalis Gregory J. , Ordovas Jose M. , Seip Richard L. , Bilbie Cherie , Miles Mary , Zoeller Robert , Visich Paul , Gordon Paul , Angelopoulos Theodore J. , Pescatello Linda , Moyna Niall
Published: January 2007

Angiotensin‐converting enzyme (ACE) has two common genetic variants: the insertion (I) and deletion (D) forms. ACE levels are greater in subjects with the D allele, and several studies suggest superior endurance performance in subjects with the I allele. The authors recently reported the results of a 6‐month exercise training protocol examining the effect of apolipoprotein E on the lipid response. The present report examines the relationship of ACE genotype and exercise adherence. DNA samples were available for 110 subjects: 14 I/I, 52 I/D, and 44 D/D. Baseline and change in maximal oxygen uptake, body mass index, skinfold thickness, and serum lipids did not differ by ACE genotype, but adherence to exercise training was higher in I carriers than in D homozygotes. These preliminary results suggest that ACE genotype affects exercise adherence and raises the possibility that superior endurance capacity in subjects with the I allele is related to a genetic propensity to adhere to an exercise regimen.
Beta Blockade in the Post‐Myocardial Infarction Setting: Pharmacologic Rationale and Clinical Evidence
Authors: Williams Randall E.
Published: January 2007

The use of β blockers reduces the risk of arrhythmias, reinfarction, and heart failure in both the immediate and long‐term periods after a myocardial infarction. Every patient should be prescribed a β blocker after a myocardial infarction unless there is a strong contraindication to therapy. Despite compelling evidence and recommendations, β blockers remain an underutilized therapy in the post‐myocardial infarction period. Evidence‐based recommendations for the choice of agent and the practical implementation of β blockers are reviewed.
“Flush‐Free Niacin”: Dietary Supplement May Be “Benefit‐Free”
Authors: Norris Robert B.
Published: January 2007

This report describes a patient with coronary artery disease who was instructed to take extended‐release niacin to treat low high‐density lipoprotein cholesterol and instead purchased “flush‐free niacin” available at the pharmacy. There was no significant change in his lipids. Once the patient switched to extended‐release niacin, the anticipated beneficial effects were seen. The article reviews the composition of flush‐free niacin, its purported and real lipid effects, and warns against the effects of misleading marketing.
Application of National Screening Criteria for Blood Pressure and Cholesterol to Perimenopausal Women: Prevalence of Hypertension and Hypercholesterolemia in the Study of Women's Health Across the Nation
Authors: Derby Carol A. , FitzGerald Gordon , Lasser Norman L. , Pasternak Richard C.
Published: January 2007

National screening guidelines for hypertension and cholesterol were applied to the multiethnic sample of perimenopausal women (N=1349) in the Study of Women's Health Across the Nation (SWAN). To reduce low‐density lipoprotein, lifestyle modification was indicated in 9.5% of patients and drug therapy in 5%. Chinese and Japanese women were least likely and African Americans were most likely to require interventions. Among all women, 27% were prehypertensive, 23% were hypertensive (blood pressure >140/90 mm Hg or treated), and 9.1% were untreated hypertensive. Untreated hypertension was lowest among Japanese and Chinese and highest among Hispanic and African‐American women. Among all hypertensives, 60.5% were treated and only 58.5% of those treated were controlled. Control rates were lowest among African Americans and Hispanics. In this relatively low‐risk population, a significant proportion of women with hypertension or hypercholesterolemia were either not treated, not treated adequately, or had borderline risk factors that would benefit from lifestyle interventions to prevent the need for future drug treatment.
Relationship Between Glycosylated Hemoglobin and Arterial Elasticity
Authors: Prisant L. Michael , Mehta Puja , Arora Vishal , Gentry Mindy , Waller Jennifer L.
Published: January 2007

Arterial elasticity is decreased in diabetes, but it is unclear whether there is a relationship between glycosylated hemoglobin (HbA1c) and arterial elasticity. To evaluate this question, 111 subjects with diabetes mellitus had HbA1c and arterial elasticity determined in an academic outpatient setting. Three measurements of arterial elasticity indices were obtained supine using the HDI/PulseWave CR‐2000 Research Cardiovascular Profiling System (Hypertension Diagnostics Inc., Eagan, MN). The study population was 49% black and 51% women. Population characteristics included age, 49.2 years; duration of diabetes, 12.1 years; HbA1c, 8.9%; large artery elasticity, 11.8 mL/mm Hg × 10; and small artery elasticity, 4.7 mL/mm Hg × 100. Age correlated with diminished large artery elasticity. Women had a lower large artery elasticity than men (10.6 vs. 13.3 mL/mm Hg × 10; p=0.0002). Decreasing small artery elasticity was associated with increasing age (p=0.0001), HbA1c (p=0.0184), and African‐American ethnicity (p=0.0306). Women had less small artery elasticity than men (3.8 vs. mL/mm Hg × 100; p=0.0001). Black diabetic patients had a reduced arterial elasticity compared with whites. Increasing HbA1c is associated with decreasing small artery elasticity, but not large artery elasticity. In diabetic patients, small artery elasticity is reduced to a greater extent in women than men and in blacks than whites.
The Skinny on High‐Protein, Low‐Carbohydrate Diets
Authors: Cunningham Wendy , Hyson Dianne
Published: January 2007

Short‐term studies of high‐protein, low‐carbohydrate diets have shown weight loss and improvements in plasma lipid profiles. Studies of greater than 6 months' duration, however, have failed to show continued benefit of high‐protein, low‐carbohydrate diets on weight loss and cardiovascular risk factors compared with conventional diets. Without concurrent weight loss and caloric restriction, these diets offer no additional benefit to lipids or body weight over other weight‐loss regimens. In fact, high‐protein, low‐carbohydrate diets may add additional risk to individuals with cardiovascular disease due to their high fat and cholesterol content combined with decreased intake of fruits, vegetables, whole grains, and other nutrients related to cardiovascular risk. In addition, high‐protein, low‐carbohydrate diets have been implicated in other risks, including impaired renal, bone, and gastrointestinal health.
Electron Beam Computed Tomography Screening and Heart Disease Risk Factor Modification
Authors: Sandwell Julie C. , Wingard Deborah L. , Laughlin Gail A. , Barrett‐Connor Elizabeth
Published: January 2007

The authors examined the effect of electron beam computed tomography screening on perceived risk, behavior change, and medical intervention among community‐dwelling adults with no history of heart disease. Participants were 184 men and 180 women aged 55 years and older who had electron beam computed tomography scans in 2000–2001 and responded to a questionnaire 6 months later. They were classified as low‐, medium‐, or high‐risk based on coronary artery calcification score, an indicator of coronary artery plaque burden. Overall, only 5% of participants were alarmed or quite worried about developing heart disease. Compared with those with lower risk, high‐risk participants were more likely to discuss scan results with a physician, undergo further cardiac testing, have a cholesterol test (all p<0.001), and begin cholesterol‐lowering medication (p<0.001), aspirin (p=0.009), and multivitamins (p=0.018). The authors conclude that electron beam computed tomography screening motivates initiation of measures to prevent clinical heart disease without causing undue alarm among older men and women.
Achievement of National Cholesterol Education Program Goals by Patients With Dyslipidemia in Rural Ambulatory Care Settings
Authors: Qayyum Rehan , Chattha Ashraf A. , Bhullar Navneet , Katsetos Manny , Schulman Peter
Published: January 2007

The Third Adult Treatment Panel (ATP III) of the National Cholesterol Education Program provides guidelines for managing dyslipidemia; however, studies from large centers find that most dyslipidemic patients fail to achieve management goals. Few data exist on lipid management in rural settings. To determine the proportion of rural dyslipidemic patients achieving ATP III goals, records of 461 patients were reviewed from 4 practices. Only 54% of the patients with dyslipidemia achieved ATP III goals. Patients with diabetes or with a family history of premature coronary heart disease were less likely to achieve ATP III goals (odds ratio 0.56; 95% confidence interval, 0.38–0.84 and odds ratio 0.42; 95% confidence interval, 0.25–0.71, respectively). Patients taking statins were more likely to achieve goals (odds ratio 3.23; 95% confidence interval, 2.13–4.89). These results indicate that a significant proportion of patients with dyslipidemia in rural practices do not achieve management goals. Strategies to improve lipid management in rural practices are needed.
Cocaine Use in an Urban Medical Population and the Development of Angiographically Significant Coronary Artery Disease
Authors: Patel Amar D. , Sola Srikanth , Caneer Patrick , Cheema Faiz A. , Gupta Divya , Helmy Tarek , Khan Bobby V.
Published: January 2007

Cocaine is a common drug of abuse in the United States. Although long‐term cocaine use has been associated with premature coronary artery disease (CAD), the relationship between cocaine use and the presence of angiographically significant CAD (≥70%) is not clear. A retrospective analysis of all patients who had undergone cardiac catheterization at an urban medical center over a 1‐year period was performed. Five hundred twelve patients were enrolled in the study; 84 (16.4%) had evidence of cocaine use, and 111 (21.7%) were admitted with a myocardial infarction. At the time of cardiac catheterization, 31 (36.9%) cocaine‐positive patients had ≥70% stenosis in at least one epicardial vessel, compared with 200 (46.7%) cocaine‐negative patients (p=0.09). Although a trend toward an association was noted on unadjusted analysis, after adjusting for CAD risk factors, cocaine use was not associated with angiographically significant CAD (odds ratio, 0.9; 95% confidence interval, 0.55–1.5; p=0.7).
Acute Myocardial Infarction and Acute Coronary Syndrome: Then and Now (1950–2005)
Authors: Malach Monte , Imperato Pascal James
Published: January 2007

Advances in the prevention, diagnosis, and treatment of acute myocardial infarction (AMI) and acute coronary syndrome (ACS) have been remarkable since the mid‐20th century. Even the clinical terminology used to describe some of the various components of ACS have undergone change, while the latter term itself represents a fairly recent addition to the medical lexicon. Although there have been dramatic changes in the diagnostic and therapeutic interventions used and impressive declines in morbidity and mortality, the differential diagnosis and complications of AMI and ACS remain as challenging now as they were a half century ago. This article presents in detail the medical understanding of AMI in the mid‐20th century and how physicians of that era managed it and its complications, and contrasts this with current evidence‐based knowledge and interventions.
Lower Is Better—The Contemporary Concept of Low‐Density Lipoprotein Lowering in the Preventive Management of Cardiovascular Risk: Does This Apply to All Patients?
Authors: Nixon J.V.
Published: January 2007

The number of multiple outcomes‐based clinical trials evaluating the use of statin drugs for lowering cardiovascular risk continues to grow, incorporating patients requiring primary and secondary preventive care. This review surveys the most recently published studies and identifies both the more extensive patient population that may benefit from primary preventive care and the concept of aggressive titration of the statin drug to improve the prognosis of the patient undergoing secondary preventive care. Data on the elderly patient, the female patient, and the diabetic patient are reviewed, as are the possible mechanisms of action of the statins in modifying cardiovascular risk. The pleiotropic effects and anti‐inflammatory capabilities of the drugs are also reviewed. Conclusions are drawn regarding the contemporary use of statins in the primary and secondary preventive management of patients to significantly reduce cardiovascular risk.
Pharmacist‐Led Cardiac Risk Reduction Model
Authors: Taveira Tracey H. , Wu Wen‐Chih , Martin Oanh J. , Schleinitz Mark D. , Friedmann Peter , Sharma Satish C.
Published: January 2007

The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist‐coordinated care model that incorporates the 4 major modifiable risk factors into a single treatment program. The authors aimed to assess the effectiveness of the CRRC model by comparing the Framingham point score before and after CRRC intervention. Retrospective data between 2001 and 2002 were analyzed for 375 veterans (age 65±10 years) with diabetes (88.8%) or coronary artery disease (44%) referred to the CRRC for intensive cardiac risk management. Total Framingham point score decreased from 14.5 at baseline to 13.6 after CRRC intervention (mean change 0.9±0.3). When considering only the patients not at target goals at baseline (n=200), significant improvements in guideline adherence was observed in low‐density lipoprotein cholesterol, systolic blood pressure, hemoglobin A1c, and smoking. The CRRC model reduces the risk of cardiovascular events as assessed by Framingham point score in patients with established coronary artery disease and/or diabetes.
The Acute Effect of Aerobic Exercise on Brachial Artery Endothelial Function in Renal Transplant Recipients
Authors: Cosio‐Lima Ludmila M. , Thompson Paul D. , Reynolds Katy L. , Headley Samuel A. , Winter Christa R. , Manos Tina , Lagasse Marie A. , Todorovich John R. , Germain Michael
Published: January 2007

This study compared the effect of a 30‐minute walk on brachial artery endothelial vasodilatation in kidney transplant (KT) recipients and healthy controls (HCs). Endothelial‐dependent vasodilatation was measured by ultrasound before and after exercise. The HCs experienced a significant increase in vasodilatation after exercise 1 minute postocclusion when compared with the KT recipients (22%±13% vs 3%±4%; V<.05). Also, the HCs had a significantly higher vasodilatation from pretreadmill walk to post‐treadmill walk (1 minute postocclusion) when compared with KT recipients (from 3%±6% to 22%±13% vs 1%±3% to 3%±4%; V<.05). This acute vasodilatory response observed in the HCs may be related to the immediate release of nitric oxide and the combined response to shear stress and exercise. The KT recipients had several coronary artery disease risk factors that may have adversely affected endothelial function.
Gender Differences in Adhering to National Guidelines in a Community Lipid Clinic
Authors: Shammas Nicolas W. , Lemke Jon H. , Deckert Judi , Toth Peter P. , McKinney Dawn , Dippel Eric J.
Published: January 2007

The aggressive treatment of hypercholesterolemia improves morbidity and mortality in patients with a history of cardiovascular disease irrespective of gender. Electronically tracked data on 4324 patients enrolled in a community lipid clinic were analyzed for gender differences in lipid values and adherence to national guidelines in lipid management. Women were older, more likely to be diabetic and/or hypertensive, and have a family history of coronary heart disease. Women also had higher initial total cholesterol, low‐density lipoprotein, and triglyceride levels and were more likely to be at goal at entry for high‐density lipoprotein. Men were more likely to have coronary heart disease and lower high‐density lipoprotein and were more likely to be at goal at entry for triglyceride level. There were no gender differences in low‐density lipoprotein at goal at entry or rate of current smoking. All lipid parameters appeared better with age, irrespective of gender. More men than women reached goal for their low‐density lipoprotein (61.5% vs 51.7%) and triglyceride (36.9% vs 25.1%) levels, whereas more women than men reached goal for their high‐density lipoprotein (33.1% vs 22.2%). The authors conclude that there are significant gender differences in lipid values at entry to a community lipid clinic and in achieving National Cholesterol Education Program targets following the initiation of therapy. A possible gender‐independent survivorship effect exists for low‐density lipoprotein and high‐density lipoprotein.
Lipoprotein‐Associated Phospholipase A2: Review and Recommendation of a Clinical Cut Point for Adults
Authors: Lanman Richard B. , Wolfert Robert L. , Fleming James K. , Jaffe Allan S. , Roberts William L. , Warnick G. Russell , McConnell Joseph P.
Published: January 2007

Recently, several epidemiologic studies have demonstrated an association between plasma lipoprotein‐associated phospholipase A2 (Lp‐PLA2) concentration and risk of subsequent cardiovascular events. Several major commercial and reference laboratories across the United States are now offering Lp‐PLA2 testing for clinical use to evaluate cardiovascular risk and as a guide to intensity of therapy in individuals at intermediate risk for developing coronary heart disease. Each laboratory has established its own cut points, or “decision values,” for Lp‐PLA2, which vary from the 50th to the 95th percentile values of individual populations tested at each site. Uniform reporting of cut points has not been achieved. The purpose of this manuscript is to recommend appropriate decision values for Lp‐PLA2, endorsed by a consensus panel of laboratorians and clinicians from the major laboratories where the test is performed. These coauthors possess considerable experience with assessment of cardiovascular risk marker decision values in general and are familiar with the validation of the Lp‐PLA2 immunoassay and the Lp‐PLA2 clinical studies conducted thus far. An ideal risk marker, studied in an ideal population, might yield a consistent cut point associated with a sudden increase in cardiovascular risk. While acknowledging that additional studies will be required to test and refine the recommended decision value, this article reviews the most current information with which to provide guidance to practicing clinicians regarding Lp‐PLA2 levels. Since several studies have demonstrated increased risk associated with the second and third tertiles vs. the first tertile for Lp‐PLA2 the 50th percentile cut point (235 ng/mL) is recommended as a conservative cut point associated with increased risk for cardiovascular disease. This cut point is not proposed as a treatment target, but rather as a level above which clinicians should consider a patient to be at higher risk for cardiovascular events, independent of established risk factors, high‐ and low‐density lipoprotein cholesterol, and high‐sensitivity C‐reactive protein.
Trait Anger and Arterial Stiffness: Results From the Atherosclerosis Risk in Communities (ARIC) Study
Authors: Williams Janice E. , Din‐Dzietham Rebecca , Szklo Moyses
Published: January 2007

The cross‐sectional association between trait anger and stiffness of the left common carotid artery was examined in 10,285 black or white men or women, 48–67 years of age, from the Atherosclerosis Risk in Communities (ARIC) study cohort. Trait anger was assessed using the 10‐item Spielberger Trait Anger Scale. Arterial stiffness was assessed by pulsatile arterial diameter change (PADC) derived from echo‐tracking ultrasound methods; the smaller the PADC, the stiffer the common carotid artery. In men, trait anger was significantly associated with PADC, independent of the established cardiovascular disease risk factors (p=0.04). PADC decreased from the first (lowest anger group) to the second quintile of anger, but there was no progressive decrease thereafter. Also observed was a 13‐ìm (95% confidence interval [CI], 1–25) difference in the magnitude of PADC from the lowest to the uppermost quintile of anger (PADC [standard error], 421 [4] ìm vs. 408 [5] ìm). In women, the association was marginally significant (p=0.07). The low‐high difference in the magnitude of PADC (PADC [standard error], 397 [3] ìm vs. 406 [4] ìm) was inverse (−9 ìm 95% CI, −19 to 2). Conclusions indicate that very high trait anger is associated with arterial stiffness in men.
Implantable Cardioverter–Defibrillators: A New Preventive Medical Option
Authors: Glatter Kathryn A. , Young J. Nilas , McElvany Matthew D.
Published: January 2007

Implantable cardioverter‐defibrillator (ICD or defibrillator) therapy has revolutionized the fields of cardiology and electrophysiology. Hundreds of thousands of patients at risk for sudden cardiac death receive them each year. The devices are not much larger than a pacemaker, and they have full pacemaker capabilities in addition to being able to shock patients out of life‐threatening ventricular arrhythmias. The Multicenter Automatic Defibrillator Implantation Trial (MADIT) in 1996 was a landmark trial that showed for the first time a mortality benefit of ICD therapy over medications in patients at high risk for sudden death. Multicenter Automatic Defibrillator Implantation Trial II, published in 2002, extended these results to all patients with ischemic heart failure with depressed heart function. Candidates for ICD implantation include most patients with an ejection fraction of <30%, especially those with coronary artery disease. More work needs to be done to define those patients with nonischemic cardiomyopathies who will benefit from ICDs and biventricular pacing for heart failure.
Lipid Profile Correlates With Glycemic Control in Young Patients With Type 1 Diabetes Mellitus
Authors: Ladeia Ana Marice , Adan Luis , Couto‐Silva Ana Claudia , Hiltner Ângela , Guimarães Armênio C.
Published: January 2007

Data on dyslipidemia in type 1 diabetes is scarce. The authors aimed to evaluate the lipid profile in patients with type 1 diabetes and its correlation to glycemic control. Ninety‐four subjects (53.2% males), aged 15.4±4.7 (3.6–21.9 years), with disease duration of 5.0±3.6 years (0.3–17 years) were evaluated for heart rate, blood pressure, height, and weight. Laboratory data included total cholesterol (TC), high‐density lipoprotein (HDL), low‐density lipoprotein (LDL), triglycerides (TGs), glycemia, glycosylated hemoglobin (HbA1c), creatinine, thyroid‐stimulating hormone, antithyroid antibodies, and 24‐hour microalbuminuria. Correlations were performed by the Spearman rank correlation test, and the significance level was <0.05. Mean values were TC, 168.6±46.6 mg/d; HDL, 43.1±15.3 mg/dL; LDL, 110.9±40.6 mg/dL; TGs, 78.3±48.6 mg/dL; glycemia, 204.6±116.7 mg/dL; and HbA1c, 11.2%±2.9%. High TC (43.9% vs. 10.7%; p<0.002) and LDL (51.5% vs. 10.7%; p<0.01) were more prevalent in patients 19 years and younger (n=66). HbA1c correlated with TC (r=0.30; p=0.004), LDL (r=0.28; p=0.008), TG (r=0.31; p=0.003), and TG/HDL ratio (r=0.25; p=0.01). Duration of diabetes correlated with LDL (r=0.21; p=0.04) and insulin daily doses with TG (r=0.23; p=0.04) and body mass index expressed as z scores (r=–0.28; p=0.007). There was a high prevalence of hypercholesterolemia (54.6%) in these diabetic patients, and lipid fraction levels were correlated with HbA1c. Good management of diabetes seems to be of paramount importance in controlling dyslipidemia.
Intracardiac Devices for Stroke Prevention
Authors: Nageh Thuraia , Meier Bernhard
Published: January 2007

Stroke is a significant cause of serious disability and death worldwide. A substantial proportion of strokes are related to an underlying cardiac embolic source, most commonly in association with atrial arrhythmias (fibrillation/flutter). Atrial fibrillation is considered a major risk factor for stroke. Although long‐term prophylactic oral anticoagulation has been shown to be very effective in reducing stroke in patients with atrial fibrillation, it has a number of major limitations and is not feasible in all patients. In such cases, the use of percutaneously (transvenous) implanted left atrial appendage occlusive devices or surgical appendage obliteration is being explored. Similarly, the presence of a patent foramen ovale, especially in the presence of an atrial septal aneurysm, is now recognized as an important potential mediator of paradoxical cardiogenic embolism. Percutaneous patent foramen ovale closure is becoming increasingly established as a safe and effective means of preventing recurrent strokes in the presence of a patent foramen ovale. In this account, the authors discuss the intracardiac devices and techniques available and the relative merits of their use for stroke prevention.
Antioxidant Vitamin Intake and Subclinical Coronary Atherosclerosis
Authors: Hatzigeorgiou Christos , Taylor Allen J. , Feuerstein Irwin M. , Bautista Leonelo , O'Malley Patrick G.
Published: January 2007

Numerous studies have evaluated the association between antioxidants and coronary atherosclerosis but have been limited by its study among individuals with advanced atherosclerosis. The authors studied 865 consecutive patients, 39–45 years of age, without known coronary artery disease and presenting for a periodic physical examination. Antioxidant intake was assessed with the Block Dietary Questionnaire, and coronary atherosclerosis was identified by measuring coronary artery calcification using electron beam computed tomography. The mean age was 42 (±2), 83% were male, and the prevalence of coronary artery calcification was 20%. Vitamin supplements were used by 56% of the participants, and the mean (±SD) daily intake (dietary plus supplemental) of vitamins A, C, and E were 1683 μg (±1245), 371 mg (±375), and 97 mg (±165), respectively. There was no significant correlation between coronary artery calcification score and individual vitamin or total antioxidant vitamin intake, even after adjusting for traditional cardiac risk factors. The highest quartile of vitamin E was positively associated with calcification (odds ratio=1.77; 95% confidence interval, 1.02–3.06). Antioxidant vitamin intake is not significantly related to coronary artery calcification, implying that there is no effect on the development of early coronary atherosclerosis. High doses of vitamin E may confer an increased risk of calcified atherosclerosis.
Optimal Vascular Protection: A Case for Combination Antihypertensive Therapy
Authors: Vogel Robert A
Published: January 2007

Endothelial dysfunction is an important factor in the pathogenesis of atherosclerosis, hypertension, and heart failure. The endothelium mediates vascular tone, structure, and function by the release and regulation of multiple vasoactive substances that promote or inhibit vasodilation, vasoconstriction, cell growth, and other mechanisms. The effect of antihypertensive drugs on endothelial function may be an important indicator of their ability to reduce risks for cardiovascular morbidity and mortality. Endothelium‐dependent vasodilation induced by various antihypertensive drugs is accurately measured with high‐resolution ultrasound of flow‐mediated dilation of the brachial artery. Calcium channel blockers and angiotensin‐converting enzyme inhibitors have been shown to reverse endothelial dysfunction. The benefits of angiotensin‐converting enzyme inhibitors and calcium channel blockers on the endothelium are believed to derive from their effects on nitric oxide production and antioxidant effects, possibly independent of blood pressure reduction. Due to their complementary mechanisms of action, it has been hypothesized that the combination of an angiotensin‐converting enzyme inhibitor and a calcium channel blocker will provide superior cardiovascular protection, in part by producing an additive effect of increased nitric oxide availability, when compared with either agent alone.
Overview of B‐Type Natriuretic Peptide as a Blood Test
Authors: McCullough Peter A. , Mueller Christian , Yancy Clyde W.
Published: January 2007

A roundtable discussion was convened in December 2005 to discuss current and future applications of blood B‐type natriuretic peptide testing in the diagnosis and treatment of cardiovascular disease. Dr. Peter McCullough, consulting cardiologist and Chief of the Division of Preventive Medicine at William Beaumont Hospital in Royal Oak, MI, chaired the discussion. Dr. Christian Mueller, consultant cardiologist and active researcher in the area of cardiac natriuretic peptides at the Department of Internal Medicine, University Hospital, Basel, Switzerland; and Dr. Clyde Yancy, Associate Dean for Medical Affairs at the University of Texas Southwestern Medical Center, Dallas, TX, participated in the discussion.
Assigning Patients With Heart Failure to Observation Status: B‐Type Natriuretic Peptide, Ejection Fraction, or Physician Judgment
Authors: Ugwu Ostidimma , Chrysochoou George , Ashok Manjule , Waxler Jennifer , Shine Daniel
Published: January 2007

It is of clinical and financial importance to identify those heart failure patients who are likely to improve rapidly. The authors evaluated, as predictors of short‐term resolution, three clinical variables often used to predict long‐term outcome. Consenting patients admitted to the emergency department with dyspnea were examined daily until resolution (symptom reversion to baseline absent worsening clinical signs or x‐ray). The authors then compared hours to resolution of heart failure with serum B‐type natriuretic peptide (BNP), ejection fraction (EF), and admitting physician prediction. They calculated negative and positive predictive values for EF, BNP, and physician opinion using quintile and published severity standards as cutoffs (for EF and BNP). Among 85 patients, BNP <400 pg/mL and <1000 pg/mL had poor positive predictive values (34% and 22%, respectively), as did EF (21%) and physician opinion (16%–21%, depending on physician confidence). Combining tests did not improve prediction. These results do not support the use of BNP, EF, or clinical assessment in triaging heart failure patients to short‐stay status
Cardiac Resynchronization Therapy: A Practical Guide for Device Optimization, Part I
Authors: Trupp Robin J.
Published: January 2007

This is the first part of a two‐part series on strategies for optimizing the delivery of cardiac resynchronization therapy (CRT), focusing on device‐related aspects. There is overwhelming evidence from prospective randomized controlled trials providing consistent and concordant support for CRT in patients with symptomatic heart failure and ventricular dyssynchrony. CRT has consistently improved quality of life, cardiac structure and function, and survival in the majority of patients enrolled in these trials. No longer a consideration for select individuals with heart failure, the 2005 American College of Cardiology/American Heart Association Guidelines for Managing Adults with Chronic Heart Failure now consider CRT a class IA recommendation for stage C patients (QRS duration ≥120 milliseconds, left ventricular ejection fraction ≤35%) who remain symptomatic despite optimal medical therapy. However, not everyone experiences clinical improvement from CRT. This article discusses measures that should be considered to ensure proper functioning of a CRT device. A subsequent article will present strategies to optimize patients' responses to CRT.
Application of Continuous Positive Airway Pressure in Hypoxemic Acute Respiratory Failure Associated With Diastolic Dysfunction in Pregnancy
Authors: Hutter Deborah A. , Berkowitz Robert , Davis S. Edward , Ashtyani Hormoz
Published: January 2007

Diastolic heart failure with hypoxemia is a dangerous condition in pregnancy for both the mother and the fetus. Continuous positive airway pressure may help to decrease afterload and reduce venous return and ventricular filling, but its use in diastolic dysfunction has not yet been established. The authors report a case of a patient with pregnancy‐induced hypertension and oligohydramnios who developed acute decompensated diastolic heart failure. The addition of continuous positive airway pressure, diuretics, and neurohormonal‐blocking agents lead to a dramatic clinical and physiologic improvement. The authors recommend consideration of the use of positive pressure ventilation in these patients.
Heart Failure and Diabetes: Collateral Benefit of Chronic Disease Management
Authors: Ware Molly G. , Flavell Carol M. , Lewis Eldrin F. , Nohria Anju , Warner‐Stevenson Lynne , Givertz Michael M.
Published: January 2007

To test the hypothesis that a focus on heart failure (HF) care may be associated with inadequate diabetes care, the authors screened 78 patients (aged 64±11 years; 69% male) with diabetes enrolled in an HF disease management program for diabetes care as recommended by the American Diabetes Association (ADA). Ninety‐five percent of patients had hemoglobin A1c levels measured within 12 months, and 71% monitored their glucose at least once daily. Most patients received counseling regarding diabetic diet and exercise, and approximately 80% reported receiving regular eye and foot examinations. Mean hemoglobin A1c level was 7.8±1.9%. There was no relationship between hemoglobin A1c levels and New York Heart Association class or history of HF hospitalizations. Contrary to the authors' hypothesis, patients in an HF disease management program demonstrated levels of diabetic care close to ADA goals. “Collateral benefit” of HF disease management may contribute to improved patient outcomes in diabetic patients with HF.
Anemia and Cost in Medicare Patients With Congestive Heart Failure
Authors: Solid Craig A. , Foley Robert N. , Gilbertson David T. , Collins Allan J.
Published: January 2007

The objective of this study was to examine the total cost to Medicare associated with the presence of anemia in congestive heart failure (CHF) patients. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify anemia, CHF, and comorbid conditions in 2002, and total Medicare costs were calculated for 2003. The mean patient age was 77.8 years. Anemia, present in 32% of CHF patients, was associated with older age, female sex, non‐white race, and increasing burden of comorbidity. The total per‐member‐per‐month cost in 2003 was $1781.01 among CHF patients with anemia in the preceding year compared with $1142.38 for CHF patients without anemia, a ratio of 1.56 (95% confidence interval, 1.5589–1.5592). When adjustment was made for baseline demographic factors and comorbid conditions, the corresponding ratio was 1.25 (95% confidence interval, 1.2546–1.2548). Anemia, a common association of CHF in elderly patients, is an antecedent association of increased societal medical expenditure.
Reversible Attenuation of the ECG Voltage Due to Peripheral Edema Associated With Treatment With a COX‐2 Inhibitor
Authors: Madias John E. , Madias Nicolaos E.
Published: January 2007

A 74‐year‐old man developed peripheral edema as a side effect of the cyclooxygense‐2 selective receptor inhibitor rofecoxib, which he had been taking for severe chronic arthritis. Discontinuation of rofecoxib led to augmentation of electrocardiographic (ECG) voltage and loss of weight gain (and reversibility of peripheral edema), which correlated well (r=0.82; p=0.0002). Other good correlations of the weight and other ECG variables and intercorrelations of ECG parameters underscore the multiple reversible influences peripheral edema has on the ECG. This case highlights an enhanced role of the ECG in monitoring patient therapy with other than strictly cardiovascular drugs. Recently, a syndrome pertaining to the influence of peripheral edema on the ECG was described; its mechanism is via the transforming effect of the body volume conductor on the surface transfer of the heart's potentials. The objective of this report is to describe a patient who developed peripheral edema as a side effect of a cyclooxygenase‐2 selective receptor inhibitor.
Heart Failure, Myocardial Stunning, and Troponin: A Key Regulator of the Cardiac Myofilament
Authors: Murphy Anne M.
Published: January 2007

This review discusses post‐translational modifications of myofilament regulatory proteins, particularly troponin, associated with heart failure and myocardial stunning—two common disease processes. Altered phosphorylation, partial proteolysis and, possibly, oxidative damage to myofilament proteins may result in abnormalities in both systolic and diastolic function. At a molecular level, these changes may lead to abnormalities in crossbridge cycling and tension development and result in inefficiencies in utilization of energy. Understanding these alterations may lead to new targeted therapies.
Managing the Post‐Left Ventricular Assist Device Patient
Authors: Klodell Charles T. , Staples Edward D. , Aranda Juan M. , Schofield Richard S. , Hill James A. , Pauly Daniel F. , Beaver Thomas M.
Published: January 2007

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.
Ambulatory Hemodynamic Monitoring From an Implanted Device: Components of Continuous 24‐Hour Pressures That Correlate to Supine Resting Conditions and Acute Right Heart Catheterization
Authors: Adamson Philip B. , Kjellström Barbro , Braunschweig Frieder , Magalski Anthony , Linde Cecilia , Kolodiezj Alan , Cremers Bodo , Bennett Tom ,   for the Chronicle Investigators
Published: January 2007

Information from an implantable hemodynamic monitoring system (IHM) aids in management of patients with heart failure. This study identified which components of 24‐hour IHM data best estimate resting conditions. Thirty‐two patients with heart failure received an IHM in the right ventricular (RV) outflow tract. RV hemodynamics were divided into seven components of a 24‐hour recording and were compared with resting supine values. Ambulatory pressures approximating rest were then compared with acute invasive catheterization values. Resting RV pressures from the IHM averaged 41±16/10±6 mm Hg and estimated pulmonary artery diastolic pressure was 21±8 mm Hg. Nighttime (midnight to 4 a.m.) minimum pressures from the IHM best approximated supine resting conditions. RV and pulmonary artery pressures during catheterization were higher than the nighttime minimum, although RV diastolic pressure was not statistically different. Minimum RV and pulmonary artery pressures during nighttime approximate observed resting conditions; invasive catheterization pressures are higher than IHM resting values.
Diagnosis and Management of Stage A Heart Failure
Authors: Shenoy Mohan , Chapman Carrie B. , Nawaz M. Zaim , Sweitzer NancyK.
Published: January 2007

Reduction of the monetary and societal costs of the heart failure epidemic can best be achieved by prevention of new heart failure cases. To effectively prevent heart failure, patients at risk must be identified and treated. The American College of Cardiology/American Heart Association Guidelines for Evaluation and Management of Chronic Heart Failure in the Adult define the stage A heart failure patient as one with identified risk factors for heart failure, particularly coronary heart disease, hypertension, and diabetes, but no evidence of cardiovascular damage. In this review, the authors discuss the commonly recognized, as well as some less commonly recognized, risk factors that define the stage A patient. The authors also discuss data demonstrating that risk factor modification can reduce heart failure incidence. Given the size of the population at risk, through increased awareness of heart failure risk and aggressive treatment, health care providers can critically impact this public health concern.