Interrelations between albuminuria, electrocardiographic left atrial abnormality, and incident atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort.

BACKGROUND: The objective of the study was to examine the joint associations of albuminuria and electrocardiographic left atrial abnormality (ECG-LAA) with incident atrial fibrillation (AF) and whether this relationship varies by race. METHODS: This analysis included 6670 participants free of clinical cardiovascular disease (CVD), including atrial fibrillation (AF), from the Multi-Ethnic Study of Atherosclerosis. ECG-LAA was defined as P-wave terminal force in V1 [PTFV1] >5000 µV × ms. Albuminuria was defined as urine albumin-creatinine ratio (UACR) ≥30 mg/g. Incident AF events through 2015 were ascertained from hospital discharge records and study-scheduled electrocardiograms. Cox proportional hazard models were used to examine the association of "no albuminuria + no ECG-LAA (reference)", "isolated albuminuria", "isolated ECG-LAA" and "albuminuria + ECG-LAA" with incident AF. RESULTS: Over a median follow-up of 13.8 years, 979 incident cases of AF occurred. In adjusted models, the concomitant presence of ECG-LAA and albuminuria was associated with a higher risk of AF than either ECG-LAA or albuminuria in isolation (HR (95% CI): 2.43 (1.65-3.58), 1.33 (1.05-1.69), and 1.55 (1.27-1.88), respectively (interaction p-value = 0.50). Effect modification by race was observed with a 4-fold greater AF risk in Black participants with albuminuria + ECG-LAA (HR (95%CI): 4.37 (2.38-8.01) but no significant association in White participants (HR (95% CI) 0.60 (0.19-1.92) respectively; (interaction p-value for race x albuminuria-ECG-LAA combination = 0.05). CONCLUSIONS: Concomitant presence of ECG-LAA and albuminuria confers a higher risk of AF compared to either one in isolation with a stronger association in Blacks than Whites.

Volitional pursed lips breathing in patients with stable chronic obstructive pulmonary disease improves exercise capacity.

Pursed lips breathing (PLB) is used by a proportion of patients with chronic obstructive pulmonary disease (COPD) to alleviate dyspnea. It is also commonly used in pulmonary rehabilitation. Data to support its use in patients who do not spontaneously adopt PLB are limited. We performed this study to assess the acute effects of PLB on exercise capacity in nonspontaneously PLB patients with stable COPD. We performed a randomized crossover study comparing 6-min walk test (6MWT) at baseline without PLB with 6WMT using volitional PLB. Spirometry, maximal inspiratory and expiratory mouth pressures, and diaphragmatic excursion during tidal and vital capacity breathing using B-mode ultrasonography were measured at baseline and after 10 min of PLB. A Visual Analog Scale (VAS) assessed subjective breathlessness at rest, after 6MWT and after 6MWT with PLB. p ≤ 0.01 was considered significant. Mean ± SD age of patients was 53.1 ± 7.4 years. Forced expiratory volume in 1 second was 1.1 ± 0.4 L/min (38.4 ± 13.2% predicted). Compared with spontaneous breathing, all but one patient with PLB showed a significant increment in 6MW distance (+34.9 ± 26.4 m; p = 0.002). There was a significant reduction in respiratory rate post 6MWT with PLB compared with spontaneous breathing (-4.4 ± 2.8 per minute; p = 0.003). There was no difference in VAS scores. There was a significant correlation between improvement in 6MWT distance and increase in diaphragmatic excursion during forced breathing. The improvement was greater in patients who had poorer baseline exercise performance. PLB has an acute benefit on exercise capacity. Sustained PLB or short bursts of PLB may improve exercise capacity in stable COPD.

Effect of tripod position on objective parameters of respiratory function in stable chronic obstructive pulmonary disease.

OBJECTIVE: To examine changes in respiratory dynamics in patients with chronic obstructive pulmonary disease (COPD) sitting leaning forward with hands supported on the knees (tripod position), a posture frequently assumed by patients in respiratory distress. METHODS: Spirometry, maximal inspiratory and expiratory pressures (MIP and MEP) generated at the mouth, and diaphragmatic excursion during tidal and vital capacity maneuver breathing measured by B-mode ultrasonography were studied in 13 patients with stable COPD in sitting, supine and tripod positions. RESULTS: Mean +/- SD age of patients was 52.2 +/- 6.8 years. Median disease duration was three years. There was no statistically significant difference in spirometry for sitting, supine and tripod positions (FEV1: 1.11 +/- 0.4L, 1.14 +/- 0.5L and 1.11 +/- 0.4L; p = 0.99), respectively, (FEV1/FVC: 49.2 +/- 11.0, 53.7 +/- 8.5 and 48.5 +/- 11.3, p = 0.37), mouth pressures (MIP: 102.9 +/- 28.9, 90.6 +/- 29.1 and 99.2 +/- 32.9 cm H2O, p = 0.61 and MEP: 100.8 +/- 29.9, 100.4 +/- 34.4 and 90.6 +/- 32.6 cm H2O, p = 0.74) and diaphragmatic movements during tidal (16.1 +/- 5.9, 20.1 +/- 6.8 and 16.6 +/- 6.2 mm, p = 0.22) and forced breathing (33.9 +/- 11.0, 43.1 +/- 19.6 and 37.4 +/- 17.1 mm, p = 0.35). CONCLUSION: Commonly measured indices of respiratory function were not different in the tripod compared to sitting and supine positions.

Derivation of a prognostic equation to predict in-hospital mortality and requirement of invasive mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease.

OBJECTIVE: Predicting in-hospital mortality and formulating a scoring system derived from predictors of mortality may aid prognostication. METHODS: One hundred and fifty-one consecutive patients admitted with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) were followed to discharge or death in hospital stay. Secondary variables studied were duration of hospital stay, and need for and duration of mechanical ventilation (MV). RESULTS: Mean (SD) age of patients was 60.5 (11.4) years; 65.6% were mechanically ventilated, and 25.2% died in hospital. Independent predictors of mortality at admission were serum creatinine (odds ratio [OR] 2.1, 95% Confidence intervals [CI] 1.03 to 4.30; p = 0.04), and serum sodium (OR 0.94, 95% CI 0.90 to 0.99; p = 0.03). An equation derived [Score = 8+ (0.74 x creatinine) = (0.015 x sodium)] to predict mortality, had an area under receiver operating characteristic (ROC) curve of 73%, with a cut-off of 6.74 having sensitivity, specificity, positive and negative predictive values for predicting death of 71%, 64%, 40% and 87%, respectively. Glasgow coma scale (GCS), partial pressure of oxygen in arterial blood (PaO2) and partial pressure of carbon dioxide in arterial blood (PaCO2) at admission independently predicted need for invasive ventilation. An equation derived [Score = 2.36+(0.02 x PaO2)+(0.05 x PaCO2)-(0.47 x GCS)] to predict need for MV, had an area under ROC curve of 85%, with a cut-off of 0.54 having sensitivity, specificity, positive and negative predictive values for predicting need for MV of 82%, 81%, 89% and 70%, respectively. CONCLUSIONS: Serum creatinine and sodium at admission are independent predictors of mortality for patients admitted with AECOPD. The equation derived from these two variables is a simple and useful method for predicting outcome.

Non-pharmacological management of hypertension.

Hypertension is a silent killer. Indians are racially predisposed to cardiovascular disease and the increasing burden of hypertension has only added to the problem. Economic constraints and the allure of additional benefits without adverse effects have made lifestyle modifications an attractive proposition in developing and developed countries alike. Blood pressure is a continuum and any increase above optimal confers additional independent risk of vascular disease, even in ranges previously considered normal. While antihypertensive agents have been used for those patients with blood pressure above the traditional cutoff, there has been increasing emphasis on the prevention and treatment of hypertension by non-pharmacological means, termed 'lifestyle modifications.' A MEDLINE search was done for relevant references with emphasis on original studies, randomized controlled trials and meta-analyses. Lifestyle modifications that effectively lower blood pressure are increased physical activity, weight loss, limited alcohol consumption, reduced sodium intake and the Dietary Approaches to Stop Hypertension diet. Lifestyle modification is recommended as initial therapy in stage 1 hypertension before initiation of drug therapy and as an adjunct to medication in persons already on drug therapy. In pre-hypertensives, it can reduce the incidence of hypertension and lower end-organ damage. It is emphasized that simple advice from physicians can have a positive influence on patients' motivation to make lifestyle changes.