Effects of allergic airway inflammation and chronic intermittent hypoxia on systemic blood pressure.

Asthma and obstructive sleep apnea (OSA) are highly prevalent chronic conditions, and both are associated with systemic hypertension. Additionally, asthma and OSA reciprocally interact, mutually exacerbating each other. In this study, we tested the effect of allergen-induced lower airway inflammation and concurrent chronic intermittent hypoxia (CIH) on systemic blood pressure (BP), pulmonary function, and proinflammatory cytokines, in a rat model. Brown Norway rats were exposed to 43 days of normoxia (NORM) or CIH, concurrent with weekly house dust mite (HDM) challenges. BP was measured 1 day after the last HDM challenge. On day 44, pulmonary function was tested, and blood for Th-2 and Th-1 cytokine levels was collected. HDM significantly increased mean (P = 0.002), systolic (P = 0.003), and diastolic (P = 0.004) BP compared with saline-challenged controls. Higher mean BP significantly correlated to increased total respiratory system resistance (R2 = 0.266, P = 0.002), driven by an association with parenchymal tissue dampening (R2 = 0.166, P = 0.016). HDM relative to saline-challenged controls increased the expression of serum IL-6 (P = 0.008), but no relationships of systemic BP with IL-6 or any other cytokines were found. CIH did not alter the allergen-induced responses on BP, although it tended to increase the expression of serum IL-6 (P = 0.06) and monocyte chemoattractant protein-1 (MCP-1, P = 0.09), regardless of HDM challenge. Chronic allergen-induced airway inflammation results in systemic hypertension that is correlated to the degree of distal airway obstruction induced by the allergen. These effects do not appear to be explained by the associated systemic inflammation.

The Clinical Impact of Imaging Surveillance and Clinic Visit Frequency after Acute Aortic Dissection.

BACKGROUND: Guidelines recommend frequent follow-up after acute aortic dissection (AAD), but optimal rates of follow-up are not clear. METHODS: We examined rates of imaging and clinic visits in 267 individuals surviving AAD during recommended intervals (≤1, > 1-3, > 3-6, > 6-12 months, then annually), frequency of adverse imaging findings, and the relationship between follow-up and mortality. RESULTS: Type A and B AAD were noted in 46 and 54% of patients, respectively. Mean follow-up was 54.7 ± 13.3 months, with 52 deaths. Adverse imaging findings peaked at 6 to 12 months (5.6%), but rarely resulted in an intervention (3.4% peak at 6-12 months). Compared with those with less frequent imaging, patients with imaging for 33 to 66% of intervals (p = 0.22) or ≥66% of intervals (p = 0.77) had similar adjusted survival. In comparison to patients with fewer clinic visits, those with visits in 33 to 66% of intervals experienced lower adjusted mortality (hazards ratio: 0.47, 95% confidence interval: 0.23-0.97, p = 0.04), with no difference seen in those with ≥66% (vs. < 33%) interval visits (p = 0.47). Imaging at 6 to 12 months (vs. none) was associated with decreased adjusted mortality (hazards ratio: 0.50, 95% confidence interval: 0.27-0.91, p = 0.02), while imaging during other intervals, or clinic visits during any specific intervals, was not associated with a difference in mortality (p > 0.05 for each). CONCLUSIONS: Adverse imaging findings following AAD are common, but rarely require prompt intervention. Patients with the lowest and highest rates of clinic visits experienced increased mortality. While the overall rate of surveillance imaging did not correlate with mortality, adverse imaging findings and related interventions peaked at 6 to 12 months after AAD, and imaging during this time was associated with improved survival.

Device and non-device-guided slow breathing to reduce blood pressure: A systematic review and meta-analysis.

OBJECTIVES: Interest is increasing in nonpharmacological interventions to treat blood pressure in hypertensive and prehypertensive patients at low cardiac risk. This meta-analysis of randomized controlled trials assesses the impact of device-guided and non-device-guided (pranayama) slow breathing on blood pressure reduction in these patient populations. METHODS: We searched PubMed, EMBASE, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Web of Science, BIOSIS (Biological Abstracts) Citation Index and Alt HealthWatch for studies meeting these inclusion criteria: randomized controlled trial or first phase of a randomized cross-over study; subjects with hypertension, prehypertension or on antihypertensive medication; intervention consisting of slow breathing at ≤10 breaths/minute for ≥5 min on ≥3 days/week; total intervention duration of ≥4 weeks; follow-up for ≥4 weeks; and a control group. Data were extracted by two authors independently, the Cochrane Risk of Bias Tool assessed bias risk, and data were pooled using the DerSimonian and Laird random effects model. Main outcomes included changes in systolic (SBP) and/or diastolic blood pressure (DBP), heart rate (HR), and/or decreased antihypertensive medication. RESULTS: Of 103 citations eligible for full-text review, 17 studies were included in the meta-analysis. Overall, slow breathing decreased SBP by -5.62 mmHg [-7.86, -3.38] and DBP by -2.97 mmHg [-4.28, -1.66]. Heterogeneity was high for all analyses. CONCLUSIONS: Slow breathing showed a modest reduction in blood pressure. It may be a reasonable first treatment for low-risk hypertensive and prehypertensive patients who are reluctant to start medication.

Peripherally Embolizing Aortic Thrombus: The Work-Up, Management, and Outcome of Primary Aortic Thrombus.

BACKGROUND: Primary aortic thrombus is an uncommon entity and not frequently reported in the literature. Herein, we discuss the presentation and management of a patient with a primary thoracic mural thrombus. CASE SUMMARY: A 46-year-old female with past medical history of tobacco dependence presented for low-grade fever and sudden onset, severe right upper quadrant abdominal pain with associated nausea and vomiting. Computed tomography (CT) revealed an intraluminal polypoid filling defect arising from the isthmus of the aorta projecting into the proximal descending aorta and findings consistent with infarction of the spleen and right kidney. Infectious, autoimmune, hematologic, and oncologic work-up were all unyielding. The patient was started on heparin and later transitioned to apixaban 5 mg twice a day and 81 mg of aspirin daily. She was also counseled regarding smoking cessation. Two months follow-up CT revealed resolution of the thrombus. Patient had no further thromboembolic complications. DISCUSSION: We present a unique case of primary aortic thrombus. To our knowledge, this is the first reported case managed successfully with a NOAC. This diagnosis is one of exclusion and through work-up should be completed. Our aim is to raise awareness of this condition and successful management with apixaban in low-risk patients.

Impact of a novel protocol for atrial fibrillation management in outpatient gastrointestinal endoscopic procedures: a retrospective cohort study.

BACKGROUND: Atrial fibrillation (AF) may result in procedure cancellations and emergency department (ED) referrals for patients presenting for outpatient GI endoscopic procedures. Such cancellations and referrals delay patient care and can lead to inefficient use of resources. METHODS: All consecutive patients presenting in AF for a colonoscopy or upper endoscopy to the University of Wisconsin Digestive Health Center between October 2013 and September 2014 were defined as the pre-intervention group (Group 1). In 2015, a protocol was initiated for peri-procedural management of patients presenting in AF, new onset or previously known. All consecutive patients after initiation of the protocol from October 2015 to September 2016 were analyzed as the post intervention group (Group 2). Patients with heart failure, hypotension, or chest pain were excluded from the protocol. RESULTS: One hundred nine and 141 patients were included in Groups 1 and Group 2, respectively. Following protocol initiation, patients were less likely to present to the ED (6.4% Group 1 vs. 1.4% Group 2, RR 0.22, p = 0.04). There was also a trend towards a reduction in procedure cancelations (5.5% Group 1 vs. 1.4% Group 2, RR 0.26, p = 0.08). All attempted procedures were completed and there were no complications in the intervention group. CONCLUSIONS: Implementation of a standardized protocol for management of atrial fibrillation in patients presenting for outpatient gastrointestinal endoscopic procedures resulted in a significant decrease in emergency department visits with an additional trend toward decreased procedural cancellations without an increased risk of complications.

Medication adherence patterns in aortic dissection survivors.

BACKGROUND & OBJECTIVES: Beta-blockers have been shown to improve survival in both type A and type B acute aortic dissection (AAD) patients. Calcium channel blockers have been shown to selectively improve survival only in type B AAD patients. There is a lack of data on medication adherence in AAD survivors. The purpose of this study was to assess medication adherence in patients who survived an AAD. METHODS: This was a cross-sectional survey-based study of individuals from a single medical centre which was part of the larger International Registry of Acute Aortic Dissection (IRAD). Patients with type A or B AAD who survived to discharge were included in this study. Individuals who were deceased based on the results of an online Social Security Death Index were excluded from the study. Data were obtained from both a survey and also from abstraction from the local academic institution's IRAD registry. A survey packet was sent to patients. One section of this survey was dedicated to assessing medication adherence using the 4-item Morisky scale. RESULTS: Eighty two completed surveys were returned; 74 patients completed the section of the survey pertaining to medication adherence (response rate 38%). Morisky score was ≥1.0 for 27 (36%) patients and 0 for 47 (64%) patients. Thirty three patients reported yes to 'forget to take medications' and eight reported yes to 'careless with medications.' Medication non-adherence (defined as a score of ≥1.0 on Morisky) was associated with increased follow up recurrence of chest pain at one year of follow up. Only two patients stopped their antihypertensive on their own and did not cite a reason for doing this. INTERPRETATION & CONCLUSIONS: The medication adherence rate for patients who survived an AAD was 64 per cent at a median (Q1, Q3) of 7.1 yr (5.6, 11.5) after discharge, as per the Morisky scale. The clinicians should educate their patients on the importance of antihypertensive therapy and assess for forgetfulness and carelessness at each clinic visit, as well as understand patients' beliefs about drug therapy, all of which have been shown to increase medication adherence.

Hypertension control after an initial cardiac event among Medicare patients with diabetes mellitus: A multidisciplinary group practice observational study.

Patients with diabetes mellitus and cardiovascular disease have a high risk of mortality and/or recurrent cardiovascular events. Hypertension control is critical for secondary prevention of cardiovascular events. The objective was to determine rates and predictors of achieving hypertension control among Medicare patients with diabetes and uncontrolled hypertension after hospital discharge for an initial cardiac event. A retrospective analysis of linked electronic health record and Medicare data was performed. The primary outcome was hypertension control within 1 year after hospital discharge for an initial cardiac event. Cox proportional hazard models assessed sociodemographics, medications, utilization, and comorbidities as predictors of control. Medicare patients with diabetes were more likely to achieve hypertension control when prescribed beta-blockers at discharge or with a history of more specialty visits. Adults ≥ 80 were more likely to achieve control with diuretics. These findings demonstrate the importance of implementing guideline-directed multidisciplinary care in this complex and high-risk population.

Comparison of Outcomes of Atrial Fibrillation in Patients With Reduced Versus Preserved Left Ventricular Ejection Fraction.

Patients with newly diagnosed atrial fibrillation (AF) and a rapid ventricular response may present with a reduced left ventricular ejection fraction (LVEF). We compared long-term outcomes of these patients with those with preserved LVEF. This retrospective cohort study included 385 consecutive adults with newly diagnosed AF with rapid ventricular response, presenting to a single medical center from January 2006 to August 2014. Patients with a history of coronary artery disease or known cardiomyopathy were excluded. Patients were divided into 2 groups: those with an LVEF ≤55% (n = 147) (REF) and those with an LVEF >55% (n = 238) (PEF). Echocardiographic parameters, all-cause mortality, cardiovascular mortality, and stroke rates were compared between both groups at baseline and a minimum of 1-year follow-up. The mean age of patients was 68 ± 1.1 in REF versus 60 ± 7.4 in PEF (p = 0.39). There were no significant differences in baseline co-morbidities between both groups. The mean LVEF during the index admission was 47.7 ± 0.8% in REF versus 65.5 ± 0.3% in PEF. The average duration of follow-up was 2.8 years. Patients with REF had higher all-cause mortality (32.7% REF vs 20.6% PEF, odds ratio 2.17, p = 0.008). Patients with REF had higher rates of subsequent clinic or ER visits for AF with a rapid ventricular response (32% REF vs 22.7% PEF, p = 0.044). The incidence of stroke was similar between both groups (17% REF vs 18.9% PEF, p = 0.639). Of the patients with REF, 64% had subsequent EF recovery and had similar outcomes compared with patients with PEF. Baseline LV end-diastolic diameter predicted all-cause mortality (odds ratio 1.14, p = 0.003) in the REF group. None of the echocardiographic parameters predicted EF recovery. In conclusion, in patients with new AF with rapid ventricular response, REF was associated with higher long-term all-cause mortality. Those with subsequent LVEF recovery after medical therapy appear to have a similar prognosis compared with those with initial PEF.

The pathophysiologic mechanisms associated with hypotensive susceptibility.

INTRODUCTION: Patients with vasovagal syncope (VVS) and positive tilt table test (TTT) were not found to benefit from pacing in the ISSUE-3 trial despite the presence of spontaneous asystole during monitoring. "Hypotensive susceptibility" unmasked by TTT was reported as a possible explanation. The purpose of this study was to assess the pathophysiologic mechanisms associated with hypotensive susceptibility. METHODS: 366 consecutive patients with the diagnosis of VVS who also had TTT were identified. Baroreflex gain (BRG) in addition to blood pressure (BP) and heart rate (HR) responses during the first 20 min of TTT were analyzed and compared between patients with positive TTT (n = 275, 75 %) and negative TTT (n = 91, 25 %). RESULTS: The mean BRG was similar between the groups (12.5 ± 6.3 versus 12.4 ± 6.3 ms/mmHg, p = 0.72); however, an age-dependent decrease was noted (17.6 ± 4.8, 15.0 ± 6.0, 10.6 ± 4.2, 10.3 ± 6.4 and 9.9 ± 8.5 ms/mmHg for patients <21, 21-40, 41-60, 61-80 and >80 years old, respectively; p < 0.001). In addition, we saw a main effect of age on the type of response with a greater prevalence of a vasodepressor response in older subjects (p < 0.001). During the first 20 min of TTT, BP was similar in patients with tilt-positive VVS when compared with patients with tilt-negative VVS; however, HR was significantly lower. CONCLUSION: BRG is similar in tilt-positive VVS patients when compared with tilt-negative VVS patients. An age-dependent decrease in BRG was noted with a higher prevalence of a vasodepressor response seen in older patients. The clinical significance of the blunted HR response in tilt-positive VVS remains to be determined.

Atherosclerosis and Nanotechnology: Diagnostic and Therapeutic Applications.

Over the past several decades, tremendous advances have been made in the understanding, diagnosis, and treatment of coronary artery disease (CAD). However, with shifting demographics and evolving risk factors we now face new challenges that must be met in order to further advance are management of patients with CAD. In parallel with advances in our mechanistic appreciation of CAD and atherosclerosis, nanotechnology approaches have greatly expanded, offering the potential for significant improvements in our diagnostic and therapeutic management of CAD. To realize this potential we must go beyond to recognize new frontiers including knowledge gaps between understanding atherosclerosis to the translation of targeted molecular tools. This review highlights nanotechnology applications for imaging and therapeutic advancements in CAD.

The Role of the Baroreflex in Tilt Table Testing: Outcome and Type of Response.

OBJECTIVES: The purpose of this study was to better understand the role of the baroreflex in tilt-induced vasovagal syncope (VVS). BACKGROUND: The role of the baroreflex in tilt-induced VVS remains controversial. The authors hypothesized that: 1) patients with positive tilt table test (TTT) results have greater baroreflex gain (BRG) compared with patients with negative TTT results; and 2) patients with tilt-induced asystole have greater BRG compared with patients without asystole. METHODS: Using the sequence method, BRG measurements were obtained in 438 consecutive patients undergoing TTT. Two hundred sixty-eight patients (61%) had positive TTT results (mean age 50 ± 21 years; 34% men), and 170 patients (39%) had negative TTT results (mean age 48 ± 21 years; 35% men). RESULTS: Mean BRG was significantly higher in patients with positive TTT results compared with those with negative TTT results (12.9 ± 6.0 ms/mm Hg vs. 11.5 ± 6.0 ms/mm Hg; p = 0.01). Among the 268 patients with positive TTT results, 23 (9%) had more than 3 s of asystole (mean age 37 ± 17; 30% men), and 245 patients had a mixed vasodepressor or cardioinhibitory response without asystole (mean age 51 ± 17 years; 34% men). Mean BRG was greater in patients with tilt-induced asystole (>3 s) compared with patients without asystole (15.3 ± 5.9 ms/mm Hg vs. 12.7 ± 5.9 ms/mm Hg; p = 0.03). CONCLUSIONS: The results of this study demonstrate that baseline BRG was higher in patients with positive TTT results compared with those with negative TTT results, with greater values noted in patients with tilt-induced asystole (>3 s) compared with those without asystole.

Slow breathing and cardiovascular disease.

Cardiovascular disease is the leading cause of death for both men and women worldwide. Much emphasis has been placed on the primary and secondary prevention of cardiovascular disease. While depression and anxiety increase the risk of developing cardiovascular disease, cardiovascular disease also increases the risk of developing anxiety and depression. Thus, promoting optimal mental health may be important for both primary and secondary prevention of cardiovascular disease. Like lowering blood pressure, lipids, and body weight, lowering anger and hostility and improving depression and anxiety may also be an important intervention in preventive cardiology. As we strive to further improve cardiovascular outcomes, the next bridge to cross may be one of offering patients nonpharmacologic means for combating daily mental stress and promoting mental health, such as yoga and pranayama. Indeed, the best preventive cardiovascular medicine may be a blend of both Western and Eastern medicine.

Exercise and Physical Activity for the Post-Aortic Dissection Patient: The Clinician's Conundrum.

Despite the paucity of evidence, it is often presumed, and is physiologically plausible, that sudden, acute elevations in blood pressure may transiently increase the risk of recurrent aortic dissection (AD) or rupture in patients with a prior AD, because a post-dissection aorta is almost invariably dilated and may thus experience greater associated wall stress as compared with a nondilated aorta. Few data are available regarding the specific types and intensities of exercise that may be both safe and beneficial for this escalating patient population. The purpose of this editorial/commentary is to further explore this conundrum for clinicians caring for and counseling AD survivors. Moderate-intensity cardiovascular activity may be cardioprotective in this patient cohort. It is likely that severe physical activity restrictions may reduce functional capacity and quality of life in post-AD patients and thus be harmful, underscoring the importance of further exploring the role of physical activity and/or structured exercise in this at-risk patient population.

Survivors of Aortic Dissection: Activity, Mental Health, and Sexual Function.

BACKGROUND: Currently no research exists assessing lifestyle modifications and emotional state of acute aortic dissection (AAD) survivors. We sought to assess activity, mental health, and sexual function in AAD survivors. HYPOTHESIS: Physical and sexual activity will decrease in AAD survivors compared to pre-dissection. Incidence of anxiety and depression will be significant after AAD. METHODS: A cross sectional survey was mailed to 197 subjects from a single academic medical center (part of larger IRAD database). Subjects were ≥18 years of age surviving a type A or B AAD between 1996 and 2011. 82 surveys were returned (overall response rate 42%). RESULTS: Mean age ± SD was 59.5 ± 13.7 years, with 54.9% type A and 43.9% type B patients. Walking remained the most prevalent form of physical activity (49 (60%) pre-dissection and 47 (57%) post-dissection). Physical inactivity increased from 14 (17%) before AAD to 20 (24%) after AAD; sexual activity decreased from 31 (38%) to 9 (11%) mostly due to fear. Most patients (66.7%) were not exerting themselves physically or emotionally at AAD onset. Systolic blood pressure (SBP) at 36 months post-discharge for patients engaging in ≥2 sessions of aerobic activity/week was 126.67 ± 10.30 vs. 141.10 ± 11.87 (p-value 0.012) in those who did not. Self-reported new-onset depression after AAD was 32% and also 32% for new-onset anxiety. CONCLUSIONS: Alterations in lifestyle and emotional state are frequent in AAD survivors. Clinicians should screen for unfounded fears or beliefs after dissection that may reduce function and/or quality of life for AAD survivors.