Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B.

Background/Aim: Despite technological advances in diagnosis and treatment, in-hospital mortality with acute aortic dissection type B is still about 11%. The purpose of this study was to assess the risk factors for early and long-term adverse outcomes in patients with acute aortic dissection type B treated medically or with conventional open surgery. Methods: The present study included 104 consecutive patients with acute aortic dissection type B treated in our Center from January 1st, 1998 to January 1st, 2007. Patient demographic and clinical characteristics as well as in-hospital complications were reviewed. Univariate and multivariate testing was performed to identify the predictors of in-hospital (30-day) and late (within 9 years) mortality. Results: 92 (88.5%) patients were treated medically, while 12 (11.5%) patients with complicated acute aortic dissection type B were treated by open surgical repair. In-hospital complications occurred in 35.7% patients, the most often being acute renal failure (28%), hypotension/shock (24%), mesenteric ischemia (12%), and limb ischemia (8%). The in-hospital mortality rate was 15.7% and the 9-year mortality rate was 51.9%. Independent predictors of early mortality in patients with acute aortic dissection type B were uncontrolled hypertension (HR-20.69) and a dissecting aorta diameter >4.75 cm (HR-6.30). Independent predictors of late mortality were relapsing pain (HR-7.93), uncontrolled hypertension (HR-7.25), and a pathologic difference in arterial blood pressure (>20 mmHg) (HR-5.33). Conclusion: Knowledge of key risk factors may help with a better choice of treatment and mortality reduction in acute aortic dissection type B patients.

Alterations in Aerobic Exercise Performance and Gait Economy Following High-Intensity Dynamic Stepping Training in Persons With Subacute Stroke.

BACKGROUND AND PURPOSE: Impairments in metabolic capacity and economy (O2cost) are hallmark characteristics of locomotor dysfunction following stroke. High-intensity (aerobic) training has been shown to improve peak oxygen consumption in this population, with fewer reports of changes in O2cost. However, particularly in persons with subacute stroke, inconsistent gains in walking function are observed with minimal associations with gains in metabolic parameters. The purpose of this study was to evaluate changes in aerobic exercise performance in participants with subacute stroke following high-intensity variable stepping training as compared with conventional therapy. METHODS: A secondary analysis was performed on data from a randomized controlled trial comparing high-intensity training with conventional interventions, and from the pilot study that formed the basis for the randomized controlled trial. Participants 1 to 6 months poststroke received 40 or fewer sessions of high-intensity variable stepping training (n = 21) or conventional interventions (n = 12). Assessments were performed at baseline (BSL), posttraining, and 2- to 3-month follow-up and included changes in submaximal (Equation is included in full-text article.)O2 ((Equation is included in full-text article.)O2submax) and O2cost at fastest possible treadmill speeds and peak speeds at BSL testing. RESULTS: Significant improvements were observed in (Equation is included in full-text article.)O2submax with less consistent improvements in O2cost, although individual responses varied substantially. Combined changes in both (Equation is included in full-text article.)O2submax and (Equation is included in full-text article.)O2 at matched peak BSL speeds revealed stronger correlations to improvements in walking function as compared with either measure alone. DISCUSSION AND CONCLUSIONS: High-intensity stepping training may elicit significant improvements in (Equation is included in full-text article.)O2submax, whereas changes in both peak capacity and economy better reflect gains in walking function. Providing high-intensity training to improve locomotor and aerobic exercise performance may increase the efficiency of rehabilitation sessions.Video Abstract available for more insights from the authors (see Supplemental Digital Content, http://links.lww.com/JNPT/A142).

Personal health technology: A new era in cardiovascular disease prevention.

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide yet the majority of related risk factors are largely preventable (primary prevention [PP]) and effectively treatable (secondary prevention [SP]) with healthy lifestyle behaviors. The use of information and communication technology (ICT) offers a unique approach to personal health and CVD prevention, as these mediums are relatively affordable, approachable, and accessible. The purpose of this review is to provide an overview of ICT-driven personal health technologies and their potential role in promoting and supporting self-care behaviors for PP and SP of CVD. In this review, we focus on technological interventions that have been successful at supporting positive behavior change in order to determine which tools, resources, and methods are most appropriate for delivering interventions geared towards CVD prevention. We conducted a literature search from a range of sources including scholarly, peer-reviewed journal articles indexed in PubMed and CINAHL, gray literature, and reputable websites and other Internet-based media. A synthesis of existing literature indicates that the overall efficacy of ICT-driven personal health technologies is largely determined by: 1) the educational resources provided and the extent to which the relayed information is customized or individually tailored; and 2) the degree of self-monitoring and levels of personalized feedback or other interactions (e.g. interpersonal communications). We conclude that virtually all the technological tools and resources identified (e.g. Internet-based communications including websites, weblogs and wikis, mobile devices and applications, social media, and wearable monitors) can be strategically leveraged to enhance self-care behaviors for CVD risk reduction and SP but further research is needed to evaluate their efficacy, cost-effectiveness, and long-term maintainability.

Rehabilitation practice patterns for patients with heart failure: the South American perspective.

Heart failure (HF) is an important public health issue in South America. Economic impacts are substantial. Chagas heart disease is a prevalent HF etiology; it is caused by the protozoan Trypanosoma cruzi. Cardiac rehabilitation (CR) is an integral component of HF care. The benefits of CR in HF patients need to be assessed. The effectiveness and safety of CR delivery, such as home-based interventions, should be explored. Strategies to improve adherence in CR are imperative. We describe past and current CR trends for HF patients and discuss the future of this important intervention.

Pharmacologic and surgical interventions to improve functional capacity in heart failure.

Heart failure (HF) is a clinical syndrome of breathlessness, lower extremity swelling, fatigue, and exercise intolerance affecting a large portion of the population worldwide, and associated with premature death. Despite improvement in the management of HF, many patients remain unable to complete activities of daily living without experiencing exertional symptoms. Although prevention of death in patients with HF is imperative, treatment of symptoms and improving functional capacity are equally important goals. This article discusses treatments (medical and surgical) associated with improved functional capacity in HF.

Breathing exercises and inspiratory muscle training in heart failure.

Breathing exercises (BE) and inspiratory muscle training (IMT) have been demonstrated to improve ventilation and ventilation-to-perfusion matching, and to improve exercise, functional performance, and many pathophysiologic manifestations of heart failure (HF). This article provides an extensive review of BE and IMT in patients with HF and identifies several key areas in need of further investigation, including the role of expiratory muscle training, IMT targeted at various locations of inspiration (early, mid, or late inspiration), and alteration of the ratio of inspiratory time to total breath time, all of which have substantial potential to improve many pathophysiologic manifestations of HF.

Cardiac rehabilitation referral, attendance and mortality in women.

BACKGROUND: Cardiac rehabilitation (CR) reduces mortality in women and men with coronary artery disease (CAD). The objective of this study was to examine sex differences in long-term mortality, based on CR referral rates and attendance patterns in a large CAD population. DESIGN: This is a retrospective cohort study. METHODS: The Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) and Cardiac Wellness Institute of Calgary (CWIC) databases were used to obtain information on all patients. Rates of referral to and attendance at CR were compared by sex. Logistic regression models were constructed to assess whether sex predicted CR referral or completion. The association between referral, completion, and survival was assessed by sex using Cox proportional hazard models. RESULTS: 25,958 subjects (6374-24.6%-were women) with at least one vessel CAD were included. Females experienced reduced rates of CR referral (31.1% vs 42.2%, p < 0.0001) and completion (50.1 vs 60.4%, p < 0.0001). Adjusting for demographic and clinical characteristics, relative to men, CR referral was significantly lower in women (adjusted odds ratio (OR) 0.74, 95% CI 0.69, 0.79) as was CR completion (adjusted OR 0.73, 95% CI 0.66, 0.81). Women completing CR experienced the greatest reduction in mortality (HR 0.36, 95% CI 0.28, 0.45) with a relative benefit greater than men (HR 0.51, 95% CI 0.46, 0.56). CONCLUSION: This is the first large cohort study to demonstrate that referral to and attendance at CR is associated with a significant mortality reduction in women, comparatively better than that in men.

Cardiac rehabilitation and exercise therapy in the elderly: Should we invest in the aged?

Coronary heart disease (CHD) is the leading cause of death worldwide and becomes increasingly prevalent among patients aged 65 years and older. Elderly patients are at a higher risk for complications and accelerated physical deconditioning after a cardiovascular event, especially compared to their younger counterparts. The last few decades were privy to multiple studies that demonstrated the beneficial effects of cardiac rehabilitation (CR) and exercise therapy on mortality, exercise capacity, psychological risk factors, inflammation, and obesity among patients with CHD. Unfortunately, a significant portion of the available data in this field pertains to younger patients. A viable explanation is that older patients are grossly underrepresented in these programs for multiple reasons starting with the patient and extending to the physician. In this article, we will review the benefits of CR programs among the elderly, as well as some of the barriers that hinder their participation.

Enhanced interleukin-1 activity contributes to exercise intolerance in patients with systolic heart failure.

BACKGROUND: Heart failure (HF) is a complex clinical syndrome characterized by impaired cardiac function and poor exercise tolerance. Enhanced inflammation is associated with worsening outcomes in HF patients and may play a direct role in disease progression. Interleukin-1ß (IL-1ß) is a pro-inflammatory cytokine that becomes chronically elevated in HF and exerts putative negative inotropic effects. METHODS AND RESULTS: We developed a model of IL-1ß-induced left ventricular (LV) dysfunction in healthy mice that exhibited a 32% reduction in LV fractional shortening (P<0.001) and a 76% reduction in isoproterenol response (P<0.01) at 4 hours following a single dose of IL-1ß 3 mcg/kg. This phenotype was reproducible in mice injected with plasma from HF patients and fully preventable by pretreatment with IL-1 receptor antagonist (anakinra). This led to the design and conduct of a pilot clinical to test the effect of anakinra on cardiopulmonary exercise performance in patients with HF and evidence of elevated inflammatory signaling (n = 7). The median peak oxygen consumption (VO(2)) improved from 12.3 [10.0, 15.2] to 15.1 [13.7, 19.3] mL · kg(-1) · min(-1) (P = 0.016 vs. baseline) and median ventilator efficiency (V(E)/VCO(2) slope) improved from 28.1 [22.8, 31.7] to 24.9 [22.9, 28.3] (P = 0.031 vs. baseline). CONCLUSIONS: These findings suggest that IL-1ß activity contributes to poor exercise tolerance in patients with systolic HF and identifies IL-1ß blockade as a novel strategy for pharmacologic intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT01300650.

Research in the allied health professions: why fund it? A report of the ASAHP Research Committee.

Many professionals work closely with physicians and nurses to provide healthcare that is safe, patient-centered, efficient, equitable, timely, and effective. These professionals represent many and varied allied health disciplines. Each allied health professional is ethically accountable for bringing a theoretically-sound and evidence-based approach to problem-solving in healthcare delivery. Although allied health research is in its infancy, the breadth and depth of its potential contributions to effective healthcare research and its interprofessional application may be under-recognized, particularly by funding agencies. The purpose of this paper is to define allied health, clarify its theoretical and scientific foundation, emphasize the breadth of its application to evidence-based practice, and document its relevance to, and suitability for, funding through national organizations.

The utility of cardiopulmonary exercise testing to detect and track early-stage ischemic heart disease.

Evidence demonstrating the potential value of noninvasive cardiopulmonary exercise testing (CPET) to accurately detect exercise-induced myocardial ischemia is emerging. This case-based concept report describes CPET abnormalities in an asymptomatic at-risk man with suspected early-stage ischemic heart disease. When CPET was repeated 1 year after baseline assessment, his cardiovascular function had worsened, and an anti-atherosclerotic regimen was initiated. When the patient was retested after 3.3 years, the diminished left ventricular function had reversed with pharmacotherapy directed at decreasing cardiovascular events in patients with coronary artery disease. Thus, in addition to identifying appropriate patients in need of escalating therapy for atherosclerosis, CPET was useful in monitoring progression and reversal of abnormalities of the coronary circulation in a safe and cost-effective manner without the use of radiation. Serial CPET parameters may be useful to track changes marking the progression and/or regression of the underlying global ischemic burden.

Interleukin-1 blockade with anakinra to prevent adverse cardiac remodeling after acute myocardial infarction (Virginia Commonwealth University Anakinra Remodeling Trial [VCU-ART] Pilot study).

Acute myocardial infarction (AMI) initiates an intense inflammatory response in which interleukin-1 (IL-1) plays a central role. The IL-1 receptor antagonist is a naturally occurring antagonist, and anakinra is the recombinant form used to treat inflammatory diseases. The aim of the present pilot study was to test the safety and effects of IL-1 blockade with anakinra on left ventricular (LV) remodeling after AMI. Ten patients with ST-segment elevation AMI were randomized to either anakinra 100 mg/day subcutaneously for 14 days or placebo in a double-blind fashion. Two cardiac magnetic resonance (CMR) imaging and echocardiographic studies were performed during a 10- to 14-week period. The primary end point was the difference in the interval change in the LV end-systolic volume index (LVESVi) between the 2 groups on CMR imaging. The secondary end points included differences in the interval changes in the LV end-diastolic volume index, and C-reactive protein levels. A +2.0 ml/m(2) median increase (interquartile range +1.0, +11.5) in the LVESVi on CMR imaging was seen in the placebo group and a -3.2 ml/m(2) median decrease (interquartile range -4.5, -1.6) was seen in the anakinra group (p = 0.033). The median difference was 5.2 ml/m(2). On echocardiography, the median difference in the LVESVi change was 13.4 ml/m(2) (p = 0.006). Similar differences were observed in the LV end-diastolic volume index on CMR imaging (7.6 ml/m(2), p = 0.033) and echocardiography (9.4 ml/m(2), p = 0.008). The change in C-reactive protein levels between admission and 72 hours after admission correlated with the change in the LVESVi (R = +0.71, p = 0.022). In conclusion, in the present pilot study of patients with ST-segment elevation AMI, IL-1 blockade with anakinra was safe and favorably affected by LV remodeling. If confirmed in larger trials, IL-1 blockade might represent a novel therapeutic strategy to prevent heart failure after AMI.

A discordance in rosiglitazone mediated insulin sensitization and skeletal muscle mitochondrial content/activity in Type 2 diabetes mellitus.

Skeletal muscle mitochondrial dysfunction is hypothesized to contribute to the pathophysiology of insulin resistance and Type 2 diabetes. Whether thiazolidinedione therapy enhances skeletal muscle mitochondrial function as a component of its insulin-sensitizing effect is unknown. To test this, we evaluated skeletal muscle mitochondria and exercise capacity in Type 2 diabetic subjects with otherwise normal cardiopulmonary function in response to rosiglitazone therapy. Twenty-three subjects were treated for 12 wk and underwent pre- and posttherapy metabolic stress testing and skeletal muscle biopsies. Rosiglitazone significantly ameliorated fasting glucose, insulin, and free fatty acid levels but did not augment the subjects' maximal oxygen consumption (Vo(2max)) or their skeletal muscle mitochondrial copy number. The baseline Vo(2max) correlated strongly with muscle mitochondrial copy number (r = 0.56, P = 0.018, n = 17) and inversely with the duration of diabetes (r = -0.67, P = 0.004, n = 23). Despite the global lack of effect of rosiglitazone-mediated insulin sensitization on skeletal muscle mitochondria, subjects with the most preserved functional capacity demonstrated some plasticity in their mitochondria biology as evidenced by an upregulation of electron transfer chain proteins and in citrate synthase activity. This study demonstrates that the augmentation of skeletal muscle mitochondrial electron transfer chain content and/or bioenergetics is not a prerequisite for rosiglitazone-mediated improved insulin sensitivity. Moreover, in diabetic subjects, Vo(2max) reflects the duration of diabetes and skeletal muscle mitochondrial content. It remains to be determined whether longer-term insulin sensitization therapy with rosiglitazone will augment skeletal muscle mitochondrial bioenergetics in those diabetic subjects with relatively preserved basal aerobic capacity.

The prognostic value of ventilatory efficiency with beta-blocker therapy in heart failure.

PURPOSE: Beta-blockade (BB) has been shown to improve outcomes among patients with heart failure (HF). The impact this pharmacological approach has on the prognostic information gained from cardiopulmonary exercise testing (CPX) is, however, unclear. METHODS: Four hundred seventeen subjects diagnosed with HF underwent CPX. The numbers of subjects prescribed and not prescribed a BB agent were 167 and 250, respectively. Subjects were tracked for cardiac-related mortality after CPX. RESULTS: Values are reported for the no-BB versus the BB group throughout. Age (57.9 +/- 13.3 vs 55.6 +/- 12.5), peak VO2 (16.2 +/- 5.7 vs 16.5 +/- 5.5 mL x kg(-1) x min(-1)), VE/VCO2 slope (34.2 +/- 9.0 vs 33.2 +/- 7.4), and peak RER (1.07 +/- 0.16 vs 1.05 +/- 0.14) were similar between groups (P > 0.05). Multivariate Cox regression analysis revealed that the VE/VCO2 slope was the superior predictor of death in both groups (chi-square: 71.9, P < 0.001; and 18.4, P < 0.001). The optimal threshold values for VE/VCO2 slope in the no-BB and BB groups were 36.0 and 34.3, respectively. CONCLUSIONS: The results of the present study indicate that BB does not alter the prognostic value/characteristics of the VE/VCO2 slope. Findings from previous investigations examining the prognostic significance of CPX predominantly using HF groups not receiving a BB agent may, therefore, still be applicable in modern-day clinical practice.