Implementation of a virtual international cardiology curriculum to address the deficit of cardiovascular education in Haiti: a pilot study.

BACKGROUND: Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide, conferring a disparate burden on low-income and middle-income countries (LMICs). Haiti represents a resource-constrained setting, limited by a paucity of resources and trained cardiovascular professionals equipped to address the increasing burden of CVD. OBJECTIVE: Here, we describe the creation of a comprehensive cardiology curriculum delivered through a virtual classroom. The curriculum was created to augment cardiovascular education in LMICs such as Haiti. METHODS: Over one academic year (May 2019-2020), International Cardiology Curriculum Accessible by Remote Distance Learning-Haiti consisted of biweekly, live-streamed, synchronous didactic lectures, seminars and case presentations broadcasted to 16 internal medicine (IM) residents at Hôpital Universitaire de Mirebalais, one of only four IM training programmes in Haiti. The virtual classroom was created using commercially available videoconferencing and data-sharing platforms. Prelecture and postlecture surveys and an end of the year survey were administered to assess the impact of the curriculum. RESULTS: Participant performance analysis revealed that 80% of the curriculum demonstrated a positive trend in knowledge acquisition postintervention. Based on the end of the year evaluation, 94% of participants reported that the curriculum was educational and relevant to medical practice in Haiti and 100% reported that the curriculum was good to excellent. Additionally, the curriculum was cited as an effective means of maintaining trainee education during the COVID-19 pandemic. CONCLUSION: This international medical education pilot study demonstrates the feasibility of augmenting cardiology education in LMICs by creating a virtual curriculum made possible by local partnerships, internet access and technology.

CT perfusion: ready for prime time.

Advancements in computed tomography (CT) technology have revolutionized clinical practice, particularly regarding the noninvasive assessment of coronary artery disease (CAD). The versatility of cardiac CT has rendered multiple applications including assessment of cardiac structure and function, myocardial viability, and coronary anatomy. The merits of cardiac computed tomography angiography (CTA) have been proven for the detection, and particularly the exclusion, of CAD. However, CTA becomes limited in the presence of significant CAD. Its inability to consistently identify lesion-associated ischemia may necessitate additional radionuclide myocardial perfusion imaging. Myocardial computed tomography perfusion imaging (CTP) has emerged as a useful and convenient method to immediately assess myocardial ischemia. In this review, we discuss the current state of CTP including available technology, its performance to date from current literature, and future challenges to this field.

Selective use of coronary calcification measurements in an expanded intermediate risk group.

Risk assessment is an imperative initial step in the clinical management of cardiovascular risk factors. On the basis of the estimation of the 10-year absolute risk of manifesting coronary heart disease (myocardial infarction or coronary heart disease death), risk categories are conventionally divided into low, intermediate, and high. The most widely used quantitative risk assessment algorithm, the Framingham risk score for hard events, is based on traditional risk factors, but it does not fully account for all available cardiovascular risk factors. Current national guidelines defining coronary heart disease risk categories based on the Framingham risk score may inaccurately assign persons with a high burden of subclinical coronary atherosclerosis to a low-risk group (<10% risk), failing to predict the true risk of a cardiovascular event. Coronary artery calcification as a measure of subclinical atherosclerosis has already established itself as a useful adjunct for refining the broad intermediate risk category of adults, leading to more decisive management strategies. In a point-counterpoint format this article argues for the improved accuracy of coronary calcium scoring in predicting the risk of future cardiac events in persons with a low Framingham risk score (including women and different ethnic groups). To better incorporate recent scientific findings into cardiovascular assessment and to refine stratification in those with a low Framingham risk score, we therefore propose a timely algorithm supporting coronary calcium screening in a selected group of low-risk persons.

Association of lactate with blood pressure before and after rapid weight loss.

BACKGROUND: The mechanism linking obesity with its downstream complications is poorly understood. Accumulating evidence suggests that insufficient oxidative capacity plays a central role in the development of insulin resistance and, perhaps, hypertension. METHODS: To investigate this hypothesis, we measured lactate, a marker of the gap between energy expenditure and oxidative capacity, in 40 obese subjects with the metabolic syndrome (Ob-MS), 40 obese subjects without the metabolic syndrome (Ob), and 20 lean controls (LCs). The 40 Ob-MS participants were then entered into a 12-20 week very low-calorie diet (VLCD) intervention. The change in lactate and a number of other metabolic factors including blood pressure were subsequently assessed. RESULTS: At baseline, median lactate levels were significantly higher in both the Ob (36.4 mg/dl) and Ob-MS (34.7 mg/dl) groups when compared to LCs (17.4 mg/dl; P < 0.001). After the VLCD intervention, Ob-MS subjects lost 14.7 kg on average, corresponding to a 5.0 kg/m(2) decrease in body mass index (BMI). Lactate levels fell from 41.3 to 28.7 mg/dl, a 31% reduction (P = 0.006). Even after adjustment for BMI change, change in lactate was strongly associated with change in diastolic blood pressure (DBP) (P = 0.007) and mean arterial pressure (P = 0.014), but not with systolic blood pressure (SBP) (P = 0.20) or other obesity-related traits. CONCLUSIONS: Baseline and longitudinal associations between lactate and DBP suggest that insufficient oxidative capacity may play a role in obesity-related hypertension.

Treatment of hypercholesterolemia with ezetimibe in cardiac transplant recipients.

The purpose of this study was to examine the efficacy and tolerability of ezetimibe in cardiac transplant recipients who were intolerant of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) or unable to reach target lipid levels with statin therapy. After treatment with ezetimibe (n = 16), mean total and low-density lipoprotein cholesterol levels decreased significantly (228 +/- 40 mg/dl to 197 +/- 48 mg/dl, p = 0.003; and 149 +/- 34 mg/dl to 117 +/- 39 mg/dl, p < 0.001, respectively). One patient required a reduction in ezetimibe dose owing to myalgias; no other adverse events occurred. This initial experience indicates that ezetimibe is well tolerated in cardiac transplant recipients and is effective in reducing total and low-density lipoprotein cholesterol levels.

The safety of rosuvastatin as used in common clinical practice: a postmarketing analysis.

BACKGROUND: Statins are currently the mainstay of dyslipidemia management for the primary and secondary prevention of cardiovascular disease. Controversial concerns about the safety of the newly marketed statin rosuvastatin have been raised on the basis of premarketing studies and a few postmarketing reports. METHODS AND RESULTS: We reviewed rosuvastatin-associated adverse events reported to the US Food and Drug Administration over its first year of marketing. On the basis of prescription data obtained from IMS Health, rates of adverse event reports (AERs) per million prescriptions were calculated. Rates of rosuvastatin-associated AERs over its first year of marketing were compared with those seen with atorvastatin, simvastatin, and pravastatin over the concurrent timeframe and during their respective first years of marketing. Comparison was also made to the first year of marketing of cerivastatin. The primary analysis examined the composite end point of AERs of rhabdomyolysis, proteinuria, nephropathy, or renal failure. With either timeframe comparison, rosuvastatin was significantly more likely to be associated with the composite end point of rhabdomyolysis, proteinuria, nephropathy, or renal failure AERs. Reported cases of rhabdomyolysis, proteinuria, or renal failure tended to occur early after the initiation of therapy and at relatively modest doses of rosuvastatin. The increased rate of rosuvastatin-associated AERs relative to other widely used statins was also observed in secondary analyses when other categories of AERs were examined, including adverse events with serious outcomes, liver toxicity, and muscle toxicity without rhabdomyolysis. CONCLUSIONS: The present analysis supports concerns about the relative safety of rosuvastatin at the range of doses used in common clinical practice in the general population.