Evaluation of a postdischarge coronary artery disease management program.

OBJECTIVES: We conducted a demonstration project to assess the value of a nurse practitioner (NP) based coronary artery disease management (CAD-DM) program for patients with an acute coronary syndrome (ACS) or percutaneous coronary intervention. METHODS: Patients were recruited to attend three 1-h monthly visits. The intervention included assessment of clinical symptoms and guideline-based treatments; education regarding CAD/ACS; review of nutrition, exercise, and appropriate referrals; and recognition of significant symptoms and emergency response. RESULTS: Two hundred thirteen (84.5%) completed the program. Physician approval for patient participation was 99%. Average age was 63 ± 11 years, 70% were male, and 89% white. At baseline, 61% (n = 133) had one or more cardiopulmonary symptoms, which declined to 30% at 12 weeks, p < .001. Sixty-nine percent attended cardiac rehabilitation or an exercise consult. Compared to the initial assessment, an additional 20% were at low-density lipoprotein cholesterol < 70 mg/dL (p = .04), an additional 35% met exercise goals (p < .0001), and there was an improvement in the mental (baseline 49.7 vs. 12 weeks 53, p = .0015) and physical components (44 vs. 48, p = .002) of the SF-12 health survey. CONCLUSION: This NP-based CAD-DM program was well received and participants demonstrated improvement in physical and mental health, and increased compliance with recommended lifestyle changes.

Left ventricular stroke volume quantification by contrast echocardiography - comparison of linear and flow-based methods to cardiac magnetic resonance.

BACKGROUND: Echocardiography (echo)-quantified LV stroke volume (SV) is widely used to assess systolic performance after acute myocardial infarction (AMI). This study compared 2 common echo approaches - predicated on flow (Doppler) and linear chamber dimensions (Teichholz) - to volumetric SV and global infarct parameters quantified by cardiac magnetic resonance (CMR). METHODS: Multimodality imaging was performed as part of a post-AMI registry. For echo, SV was measured by Doppler and Teichholz methods. Cine-CMR was used for volumetric SV and LVEF quantification, and delayed-enhancement (DE) CMR for infarct size. RESULTS: Overall, 142 patients underwent same day echo and CMR. On echo, mean SV by Teichholz (78 ± 17 mL) was slightly higher than Doppler (75 ± 16 mL; Δ = 3 ± 13 mL; P = 0.02). Compared to SV on CMR (78 ± 18 mL), mean difference by Teichholz (Δ = -0.2 ± 14; P = 0.89) was slightly smaller than Doppler (Δ = -3 ± 14; P = 0.02), but limits of agreement were similar between CMR and echo methods (Teichholz: -28, 27 mL, Doppler: -31, 24 mL). For Teichholz, differences with CMR SV were greatest among patients with anteroseptal or lateral wall hypokinesis (P < 0.05). For Doppler, differences were associated with aortic valve abnormalities or root dilation (P = 0.01). SV by both echo methods decreased stepwise in relation to global LV injury as assessed by CMR-quantified LVEF and infarct size (P < 0.01). CONCLUSIONS: Teichholz and Doppler calculated SV yield similar magnitude of agreement with CMR. Teichholz differences with CMR increase with septal or lateral wall contractile dysfunction, whereas Doppler yields increased offsets in patients with aortic remodeling.

Left ventricular architecture and survival in African-Americans free of coronary heart disease (from the Atherosclerosis Risk in Communities [ARIC] study).

Published studies of the prognostic value of left ventricular (LV) hypertrophy and LV geometric pattern in African-Americans were based on referred or hospitalized patients with hypertension or coronary heart disease. All-cause mortality rates and survival associated with LV geometric pattern were determined using echocardiography in a population-based sample of middle-aged and elderly African-American men and women. During the third (1993 to 1995) visit of the ARIC Study, echocardiography was performed at the Jackson, Mississippi, field center on the cohort of 2,445 African-Americans aged 49 to 75 years. M-Mode LV echocardiographic measurements were available for 1,722 persons. Mortality data were available through December 31, 2003. During the follow-up period (median 8.8 years, maximum 10.4), 160 deaths were identified. In men, multivariable-adjusted hazard ratios for all-cause mortality (compared with men with normal LV geometry) were 1.75 (95% confidence interval [CI] 0.71 to 4.33) in those with concentric LV hypertrophy, 0.38 (95% CI 0.08 to 1.88) in those with eccentric LV hypertrophy, and 0.79 (95% CI 0.41 to 1.54) in those with concentric remodeling. In women, multivariable-adjusted hazard ratios for all-cause mortality (compared with women with normal LV geometry) were 1.17 (95% CI 0.48 to 2.84) in those with concentric LV hypertrophy, 1.23 (95% CI 0.46 to 3.28) in those with eccentric LV hypertrophy, and 1.17 (95% CI 0.60 to 2.28) in those with concentric remodeling. In conclusion, in this population-based cohort of middle-aged and elderly African-Americans free of coronary heart disease, adjustment for baseline differences in cardiovascular disease risk factors and LV mass greatly attenuated the strength of the association between LV pattern and all-cause mortality risk in women. In men, an association between concentric LV hypertrophy and mortality risk remained.