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Socioeconomically disadvantaged patients are at an increased risk for adverse heart failure (HF) outcomes based upon nonadherence to medications and diet. Physicians are also suboptimally adherent to prescribing evidence-based therapy for HF.Congestive Heart Failure Adherence Redesign Trial (CHART) (NCT01698242) is a multicenter, bilevel, cluster randomized behavioral efficacy trial designed to assess the impact of intervening simultaneously on physicians and their socioeconomically disadvantaged patients (annual income$30,000) having HF with reduced ejection fraction. Treatment arm physicians received individualized feedback on their adherence to prescribing evidence-based therapy. Their patients received weekly home visits from community health workers aimed at promoting understanding of HF and integrating adherence into daily life. Control arm physicians received regular updates on advances in HF management, and patients received monthly HF educational tip sheets produced by the American Heart Association. The primary outcome was all-cause hospital days over 30 months.A total of 72 physicians (treatment, 35; control, 37) and their 320 patients (treatment, 157; control, 163) were recruited within 2 years. Randomization of physicians with all of their patients being assigned to the same arm was feasible and did not compromise the comparability of patients by arm. Using 5 recruiting hospitals located within disadvantaged neighborhoods produced a cohort that was primarily African American and representative of low-income urban patients with HF with reduced ejection fraction.CHART will determine the value of intervening on low adherence simultaneously in physicians and their socioeconomically disadvantaged patients in reducing all-cause hospitalization days.

Traumatic events and posttraumatic stress disorder (PTSD) are associated with increased risk for cardiopulmonary disease (CPD) in veterans, men, and primarily White populations. Less is known about trauma, PTSD, and CPD burden among low-income, racial minority residents who are at elevated risk for trauma and PTSD. It was hypothesized that traumatic events and PTSD would be significantly associated with CPD burden among low-income, racial minority residents.We evaluated cross-sectional relationships between traumatic events, PTSD, depression, and CPD burden in 251 low-income, urban, primarily Black adults diagnosed with heart failure. Data were analyzed using bivariate analyses, logistic and linear regression.Forty-three percent endorsed at least one traumatic event. Twenty-one percent endorsed two or more traumatic events. In logistic regression analyses, traumatic events were associated with increased prevalence of coronary artery disease (adjusted odds=1.33, p.05), hypertension (adjusted odds=1.28, p.05), chronic obstructive pulmonary disease (adjusted odds=1.52, p.01), and cardiac arrest (adjusted odds=1.27, p.05). PTSD was also related to increased risk for chronic obstructive pulmonary disease (adjusted odds=1.22, p.05) and was associated with earlier onset of heart failure (β=-.13, p.05).The study utilizes cross-sectional, self-report data.Findings support the link between traumatic events, PTSD, and CPD burden in low-income, primarily Black patients with heart failure. Depression appears to be less closely linked to CPD burden, despite receiving significant attention in the literature. The accumulation of traumatic events may exacerbate CPD burden among urban, low-income, racial minority residents with heart failure; findings highlight the importance of PTSD screening.

Posttraumatic stress disorder (PTSD) and Major Depressive Disorder (MDD) are associated with high disease burden. Pathways by which PTSD and MDD contribute to disease burden are not understood.Path analysis was used to examine pathways between PTSD symptoms, MDD symptoms, and disease burden among 251 low-income heart failure patients.In Model 1, we explored the independent relationship between PTSD and MDD symptoms on disease burden. In Model 2, we examined the association of PTSD symptoms and disease burden on MDD symptoms. We also examined indirect associations of PTSD symptoms on MDD symptoms, mediated by disease burden, and of PTSD symptoms on disease burden mediated by MDD symptoms.Disease burden correlated with PTSD symptoms (r = .41; p.001) and MDD symptoms (r = .43; p.001) symptoms. Both models fit the data well and displayed comparable fit. MDD symptoms did not mediate the association of PTSD symptoms with disease burden. Disease burden did mediate the relationship between PTSD symptoms and MDD symptoms.Results support the importance of detection of PTSD in individuals with disease. Results also provide preliminary models for testing longitudinal data in future studies.

This article was migrated. The article was marked as recommended. BackgroundPhysicians are typically appointed to leadership roles within health care organizations on the basis of individual accomplishments in research, education, and/or clinical care. However, these types of achievements seldom provide the requisite management capabilities to lead within health organizations. In this manuscript, we described our initial experience in developing an in-house program to provide current and aspiring physician leaders with the managerial capabilities to enhance the quality of health care delivery within their respective organization. MethodsIn a partnership established between a Medical School and a Business School, we designed two series of weekend workshops to provide current and aspiring physician leaders with the financial capabilities to assist them in their future healthcare leadership careers. This course was then expanded to a Management Principles for Physician workshop with open enrollment to physicians at all levels. Baseline demographics and participant evaluations of each course were recorded. In the open enrollment Management Principles for Physician workshop, we examined the relationship between participant background and their course evaluations as well as their areas of interest for further training.ResultsAll 3 workshops received excellent evaluations by participants. The positive impact of the open enrollment program, based on participants' self-evaluations, was the highest in female physicians, as well as early to mid-career physicians. Additionally, physicians who do not currently hold leadership positions and those who are leading at Divisional levels were the most interested in further training in finance.ConclusionIn summary, this series of workshops demonstrated the feasibility of an in-house physician leadership program and yielded important information for the design of future leadership development curriculum.

Heart failure (HF) is associated with poor health-related quality of life (HRQOL). The purpose of our study is to determine the effect of a self-management intervention on HRQOL domains across time, overall, and in prespecified demographic, clinical, and psychosocial subgroups of HF patients. HART was a single-center, multi-hospital randomized trial. Patients (n = 902) were randomized either to a self-management intervention with provision of HF educational information or an enhanced education control group which received the same HF educational materials. HRQOL was measured by the Quality of Life Index, Cardiac Version, modified, and the Medical Outcomes Study 36-item Short-Form Health Survey physical functioning scale. Analyses included descriptive statistics and mixed-effects regression models. In general, overall, study participants’ HRQOL improved over time. However, no significant differences in HRQOL domain were detected between treatment groups at baseline or across time (p > 0.05). Subgroup analyses demonstrated no differences by treatment arm for change in HRQOL from baseline to 3 years later. We conclude that in our cohort of patients, the self-management intervention had no benefit over enhanced education in improving domains of HRQOL and HRQOL for specified HF subgroups.

It is unknown whether the standardized intravenous aminophylline administration following regadenoson-stress can prevent the gastrointestinal and other adverse effects associated with regadenoson.In a randomized, double-blinded, placebo-controlled clinical trial we compared the frequency and severity of regadenoson adverse effects in those who received 75 mg of intravenous aminophylline versus a matching placebo administered 2 minutes after regadenoson or 90 seconds post-radioisotope injection.248 patients [44.8% women, mean age 62.2 (± 13.3) years] were randomized to receive aminophylline (124) or placebo (124). In the aminophylline arm, there was 50% reduction in the incidence of the primary endpoint of diarrhea and abdominal discomfort [11 (8.9%) vs 22 (17.7%), P = .04] and 70% reduction in the incidence of diarrhea [4 (3.2%) vs 13 (10.5%), P = .02]. Additionally, aminophylline use was associated with 34% reduction in the secondary endpoint of any regadenoson adverse effects [55 (44.4%) vs 83 (66.9%), P.001] and 71% reduction in headache [9 (7.3%) vs 31 (25%), P.001]. The stress protocol was better tolerated in the aminophylline group (P = .007). The quantitative summed difference score was similar in both study groups (P = .92). There were no excess adverse events in the aminophylline arm.This trial supports the routine administration of IV-aminophylline to reduce the frequency and severity of adverse effects associated with regadenoson-stress.

The Heart Failure Adherence and Retention Trial (HART) provided an opportunity to determine adherence to evidence-based guidelines (EBG) in patients with heart failure (HF). Ten hospitals were the source of 692 patients with HF (EF

Background Practice guidelines for non–ST-segment elevation acute coronary syndromes (NSTE ACS) recommend early invasive management (cardiac catheterization and revascularization within 48 hours of hospital presentation) for high-risk patients, but interhospital transfer is necessary to provide rapid access to revascularization procedures for patients who present to community hospitals without revascularization capabilities. Methods We analyzed patterns and factors associated with interhospital transfer among 19,238 patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) from 124 community hospitals without revascularization capabilities in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines quality improvement initiative from January 2001 through June 2004. Results Less than half of the patients (46.3%) admitted to community hospitals were transferred to tertiary hospitals, and fewer (20%) were transferred early (within 48 hours of presentation). Early transfer rates increased by 16% over 10 quarters in patients with a predicted low or moderate risk of inhospital mortality, compared with 5% in high-risk patients. By the last quarter of the analysis, 41.4% of low-risk patients were transferred early versus 12.5% of high-risk patients. Factors significantly associated with early transfer included younger age, lack of prior heart failure, cardiology inpatient care, and ischemic ST-segment electrocardiographic changes. Among patients who were not transferred, 29% had no further risk stratification performed with stress testing, ejection fraction measurement, or diagnostic cardiac catheterization (at hospitals with catheterization laboratories). Conclusions Most patients with NSTE ACS presenting to community hospitals without revascularization capabilities are not rapidly transferred to tertiary hospitals, and lower-risk patients appear to be preferentially transferred early. Further investigation is needed to determine if improved risk-based triage at community hospitals can optimize transfer decision making for high-risk patients with NSTE ACS.

Background: Women have worse morbidity, mortality, and health-related quality-of-life outcomes associated with coronary artery disease (CAD) compared with men. This may be related to underutilization of drug therapies, such as aspirin, β-blockers, angiotensin-converting enzyme (ACE) inhibitors, or statins. No studies have sought to describe the relationship of gender with adverse reactions to drug therapy (ADRs) for CAD in clinical practice. Objective: The aim of this study was to determine the prevalence of ADRs associated with common CAD drug therapies in women and men in clinical practice. Methods: In a cohort of consecutive outpatients with CAD, detailed chart abstraction was performed to determine the use of aspirin, β-blocker, ACE inhibitor, and statin therapy, as well as the ADRs reported for these treatments. Baseline clinical characteristics were also determined to identify the independent association of gender with use of standard drug treatments for CAD. Results: Consecutive patients with CAD (153 men, 151 women) were included in the study. Women and men were observed to have a similar prevalence of cardiac risk factors and comorbidities, except that men had significantly higher prevalence of atrial fibrillation (30 [19.6%] men vs 15 [9.9%] women; P = 0.03) and significantly lower mean (SD) high-density lipoprotein cholesterol concentrations (45 [16] mg/dL for men vs 55 [19] mg/dL for women; P < 0.001). No significant differences were observed between the sexes in the prevalence of ADRs; however, significantly fewer women than men were treated with statins (118 [78.1%] vs 139 [90.8%], respectively; P = 0.003). After adjusting for clinical characteristics, women were also found to be less likely than men to receive aspirin (odds ratio [OR] = 0.164; 95% CI, 0.083–0.322; P = 0.001) and β-blockers (OR = 0.184; 95% CI, 0.096-0.351; P = 0.001). Conclusions: Women and men experienced a similar prevalence of ADRs in the treatment of CAD; however, women were significantly less likely to be treated with aspirin, β-blockers, and statins than were their male counterparts. To optimize care for women with CAD, further study is needed to identify the cause of this gender disparity in therapeutic drug use.

To curb the epidemic of obesity in the United States, revised Medicare policy allows support for efficacious obesity treatments. This review summarizes the evidence from rigorous randomized trials (9 lifestyle trials, 5 drug trials, and 2 surgical trials) on the efficacy and risk- benefit profile of lifestyle, drug, and surgical interventions aimed at promoting sustained (= 2 years) reductions in weight. Both lifestyle and drug interventions consistently produced an approximate 7-lb (3.2-kg) weight loss that was sustained for 2 years and was associated with improvements in diabetes, blood pressure, and/or cardiovascular risk factors. Surgical interventions have a less solid empirical base but offer promise for the promotion of significant and sustained weight reduction posttreatment in the morbidly obese but with possible significant short-term side effects. In summary, there is strong and consistent support from rigorous randomized trials that lifestyle or drug interventions result in modest weight loss with minimal risks but disproportionate clinical benefit. Combinations of lifestyle, drug, and, where appropriate, surgical interventions may be the most efficacious approach to achieving sustained weight loss for the widest diversity of patients.

It would be useful to have an inexpensive, noninvasive point-of-care test for early detection of asymptomatic heart disease. This study used impedance cardiography (ICG) in a new way to assess heart function that did not use stroke volume or cardiac output. There is a model of the ICG dZ/dt waveform that may be used as a template to represent normal heart function. The hypothesis was that a dZ/dt waveform which deviates from that template should indicate heart dysfunction and therefore heart disease. The objective was to assess the accuracy of this new ICG approach, using echocardiography as the standard. Thirty-four outpatients undergoing echocardiographic testing were tested by ICG while sitting upright and supine. All patients had no symptoms or history of a structural or functional heart disorder. Echocardiographic testing showed 17 patients with abnormalities and 17 as normal. ICG testing yielded 16 true positives for heart dysfunction with 1 false negative (sensitivity = 94%) and 17 true negatives with no false positives (specificity = 100%). Considering that the cost, technical skill, and time required for this ICG test are comparable to those of an electrocardiograph, this new approach has potential as a point-of-care screening test for asymptomatic heart disease.

Heart failure (HF) is a disabling chronic illness that is increasing in prevalence. Despite advances in its medical treatment, little is known about its psychosocial correlates. This investigation compared the prevalence of depression in patients with and without HF who were hospitalized with myocardial infarction (MI) and also at high psychosocial risk.Baseline data from the 2444 participants in the ENRICHD clinical trial were used. Within 28 days of the MI, all patients were assessed for depression using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, for HF based upon left ventricular dysfunction or history of HF and for demographic and medical confounders.Eight hundred forty-seven patients (34.7%) met the criteria for HF. Major depression was observed in 43% in the HF group compared with 36% in the non-HF group (P.001). Multivariate modeling showed a 38% increase in odds of HF for patients with major depression, after adjustment for sociodemographic factors and medical comorbidities (adjusted OR 1.38, 95% CI 1.09-1.76).These findings suggest that in patients with new MI who are at psychosocial risk, major depression is more prevalent in those who also have HF. Because major depression undermines adherence and lowers quality of life, special efforts to diagnose and treat it in post-MI patients with HF appear warranted.

We compared the predictive value of the Rush score with the Thrombolysis In Myocardial Infarction (TIMI) risk score in unselected patients with an acute coronary syndrome and evaluated the effect of compliance with established guidelines on the accuracy of these models. The Registry of Acute Coronary Syndromes is a retrospective registry of 3,754 consecutive patients (38% women; mean age 67 years) who presented with acute coronary syndrome to the emergency department between April 1, 1999, and December 31, 2000, at 9 hospitals. The primary end point was death, myocardial infarction, or urgent revascularization during hospitalization. Rush classification was based on quartiles of predicted risk of cardiac complication (2% for class I vs15% for class IV). The TIMI score was implemented as published. Compliance with guidelines for acute coronary syndrome was assessed with a 4-point scale based on the aggregate use of aspirin, beta blockers, heparin, and glycoprotein IIb/IIIa inhibitors. Fifteen percent of patients met the primary end point. The primary end point rates for TIMI scores 0/1, 2, 3, 4, 5, and 6/7 were 11%, 14%, 13%, 11%, 14%, and 12%, respectively (p = NS). The primary end point rates for Rush classes I, II, III, and IV were 6%, 8%, 9%, and 17%, respectively (p0.001). After controlling for compliance with established guidelines, the odds ratio of an event increased by 46% for each unit increase in Rush score (p0.001). After adjusting for the Rush score, the odds ratio decreased by 54% for each unit increase in compliance (p0.001). Thus, compliance with current American College of Cardiology/American Heart Association guidelines significantly improves prognosis, regardless of the risk score. The use of established risk scores may overestimate event rates in unselected populations.

A lthough the undertreatment of hypercholesterolemia in patients with coronary heart disease (CHD) has been well documented, few studies have demonstrated effective interventions to overcome this problem. We hypothesized that undertreatment did not result from physician’s lack of agreement with the use of such therapy based on clinical or scientific data, but rather physicians are not in the practice of routinely considering and implementing preventive strategies. We postulated a simple intervention that would identify patients who require preventive treatment and remind physicians to consider such therapy, which could effectively increase the number of patients with CHD who receive appropriate treatment for hypercholesterolemia. The objective of the present study was to examine the ability of chart reminders to improve physician compliance with the National Cholesterol Education Program (NCEP) treatment guidelines. • • • This was a randomized, controlled study, which took place in the Cardiology Clinic at Cook County Hospital, Chicago, Illinois. Cook County Hospital is a large, inner-city teaching hospital that serves as a primary care facility to a mostly African-American patient population. Enrollment took place between July 1999 and November 1999. Consecutive patients were entered into the study if coronary artery disease could be documented by any 1 of the following criteria: (1) cardiac catheterization showing a 70% occlusion of 1 of the major epicardial vessels or a 50% occlusion of the left main coronary artery; (2) hospital admission for myocardial infarction, which included chest pain of 30 minutes in duration along with an increase in cardiac enzymes, or (3) a chest pain syndrome compatible with angina along with a noninvasive test that was positive for ischemia or infarction. The intervention group included a consecutive sample of 145 patients with CHD, who were examined by 8 physicians (4 cardiology fellows, 4 attending cardiologists) randomly chosen to receive the intervention. Participating physicians were not notified about the study. The control group included a consecutive sample of 145 patients with CHD, who were examined by 8 physicians (4 cardiology fellows, 4 attending cardiologists) randomly chosen to not receive the intervention. Patients charts were reviewed by a research assistant before their arrival in the clinic and data were collected regarding patient demographics, medical history, and current medications. A research assistant briefly interviewed patients before their visit with the physician, to confirm and update information gathered from the chart. Laboratory data were collected using the hospital laboratory information system. Intervention consisted of attaching a reminder to the front of the chart when patients were not being managed in accordance with NCEP guidelines, either by virtue of inappropriate medical therapy or the lack of appropriate cholesterol screening. Reminders were individualized to the given patient, citing the NCEP guidelines and suggesting the specific change in management required to restore compliance with the guidelines. Control group patients received no such reminder. Suggested changes in management included: (1) in patients with a low-density lipoprotein (LDL) cholesterol of 130 mg/dl who were not on therapy, a recommendation was made to begin lipid-lowering therapy; (2) in patients with an LDL cholesterol of 100 mg/dl who were on lipid-lowering therapy, a recommendation was made to increase the dosage of the current agent or to add an additional agent; and (3) in patients without a documented fasting lipid panel or in those whose most recent lipid panel was obtained 1 year before their visit, a recommendation was made to obtain a fasting lipid panel. Carbon copies of the laboratory order forms and prescriptions were routinely left in patients’ charts after their clinic visit. Change in management for all intervention and control group patients was assessed by inspecting the charts following their clinic visit for carbon copies of the laboratory order forms and prescriptions, as well as through review of physicians’ progress notes. After completion of the study, all 16 physicians received a questionnaire containing 6 open-ended questions intended to assess their knowledge of the NCEP guidelines and their personal approach to the management of hypercholesterolemia in patients with CHD. Statistical analysis was performed using computer software (SPSS Inc., Chicago, Illinois). General descriptive statistics and analysis of univariate association between baseline variables and compliance with NCEP guidelines were performed using Student’s t test for continuous variables and chi-square or FishFrom the Division of Cardiology, Cook County Hospital, Chicago, Illinois; and Section of Cardiology, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois. This study was supported in part by an unrestricted educational grant from the Bristol-Myers Squibb Corporation, New York, New York. Dr. Stamos’ address is: Evanston Northwestern Healthcare, 2560 Ridge Avenue, Evanston, Illinois 60201. E-mail: tstamos@ enh.org. Manuscript received April 27, 2001; revised manuscript received and accepted August 23, 2001.

OBJECTIVES We sought to determine whether men and women are equally likely to receive coronary angiography and revascularization after acute myocardial infarction (AMI) when they are risk stratified according to American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines for post-MI care. BACKGROUND Several previous studies have suggested that women may undergo angiography and revascularization procedures less frequently than men. METHODS In 439 consecutive patients admitted to a public hospital with AMI, rates of coronary angiography and revascularization were compared in men and women categorized, according to ACC/AHA practice guidelines, as having strong (class I or IIa) or weaker (class IIb) indications for angiography. RESULTS Women were older and more likely to be diabetic or hypertensive, but men and women were equally likely to meet class I/IIa criteria for post-MI angiography (both 51%). Angiography rates were nearly identical in men and women overall (63% vs. 64%), as well as in patients in class I/IIa (80% vs. 82%) and class IIb (46% vs. 46%) (all p > 0.80, with >80% power to detect important differences); the only multivariate predictors of post-MI angiography were age and ACC/AHA class. Significant coronary artery disease was equally prevalent in men and women undergoing angiography, and men and women were equally likely to undergo revascularization, whether they were in class I/IIa (both 55%, p = 0.90) or class IIb (59% vs. 58%, p = 0.88). No significant differences in mortality were noted between men and women. CONCLUSIONS Despite being older and having more risk factors than men, women were equally likely to undergo coronary angiography and revascularization procedures after AMI, and they had in-hospital clinical outcomes that were at least as favorable.

As coronary interventional technology improves, the influence of lesion length (LL) on procedural success and device selection may vary. Thus, the authors prospectively analyzed 957 consecutive coronary interventions (CI) in 1,404 stenoses to ascertain the influence of lesion length on CI outcome. Stenosis morphology was prospectively classi fied by the AHA/ACC criteria. LL was analyzed both as dichotomous (S: < 10 mm, L: > 10 mm) variables and by the three-tiered AHA/ACC criteria (I: < 10 mm, II: 10-20 mm, III: > 20 mm). There was a significant univariate relationship between CI success and S stenosis (S: 95.8% vs L: 91.8%, p = 0.002 and I: 96.0%, II: 91.7%, III: 89.3%). Numerous interrelationships involving the morphologic characteristics were noted: lesion morphologies associated with S lesions were concentric (p = 0.0001) and had smooth contour (p = 0.0001), ostial location (p = 0.05) and little calcification (p = 0.0007), while irregular contour (p = 0.0001), calcification (p = 0.0076), eccentric (p = 0.0001), thrombus (p = 0.0001), recent (p = 0.0001) or chronic (p = 0.001) total occlusion were associated with L lesions. When these relationships were taken into account by multiple logistic regression analysis, lesion length was not predictive of procedural outcome (p = 0.099). One morphologic type was associated with increased CI success: irregular contour (p = 0.022); recent (p < 0.0001) or chronic (< 0.0001) occlusions were associ- ated with decreased CI success. Another factor considered was device selection: S lesions were associated with greater balloon angioplasty usage (p = 0.002), whereas more coronary stents (p = 0.024) and rotoblator (p = 0.018) devices were used in L lesions. More balloon angioplasty was performed in concentric (p < 0.0001) lesions; interven tional devices were employed more often in eccentric (p < 0.0001) and irregular lesions (p < 0.0001). More complications were noted in lesions with thrombus (p = 0.0002), but lesion length was not predictive (p = NS). Lesion length is not a significant predictor of procedural success when adjusted for other lesion morphologies in the modern inter ventional era. The availability of new devices has improved the results in longer lesions since the AHA/ACC criteria were originally proposed.

The oral antiplatelet agent clopidrogel has been widely used by interventional cardiologists for the past two years as an adjunct therapy to prevent subacute thrombosis after coronary stenting. Interestingly, the substitution of clopidrogel for ticlopidine occurred even though no conclusive data

Objectives. The goal of this review is to reevaluate the unstable coronary syndromes in the setting of new therapies and biochemical markers. Background. Patients with acute coronary syndromes comprise a large subset of many cardiology practices. Patients with unstable angina (UA) and non-Q wave myocardial infarction (NQMI) may sustain a small amount of myocardial loss but have significant amounts of viable, yet ischemic, myocardium, placing them at high risk for future cardiac events. In the past, enzyme differentiation of NQMI from UA was considered important to assess prognosis and direct therapy. Methods. Manuscripts published in peer-reviewed journals over the past three decades were reviewed and selected for this review. Recent abstracts were also considered and cited where appropriate. Results. In the late 1990’s, although UA and NQMI remain parts of a spectrum, it is apparent that the distinction between these two entities is no longer sufficient to identify high risk patients; rather, specific electrocardiographic changes, aspects of the clinical history, newer biochemical markers, and angiographic findings help to better distinguish higher risk individuals from a large patient population with unstable coronary syndromes and these factors usually determine therapy. Conclusions. Based on these results, it is likely that newer therapies such as glycoprotein IIb/IIIa receptor antagonists, low molecular weight heparins, and coronary stents will be directed toward these high risk patients.

Quality improvement efforts in cardiology over the past decade have focused largely on the inpatient care of myocardial infarction and congestive heart failure. Collaborative efforts such as the CRUSADE and the National Registry of Acute Myocardial Infarction have taught us a great deal about the state of the quality of medical care and sources of variation in care. They have also advocated use of standing order sets and reminder systems as a means to improve the quality of care. Both registries have demonstrated the impact of adherence to evidence-based medicine and clinical outcomes. Efforts to improve outpatient adherence to evidencebased medicine in cardiology have focused more on improving delivery systems in heart failure and preventing coronary artery disease, emphasizing with varying success the important roles of multidisciplinary care through the use of nurse practitioners and specialized clinics in heart failure especially. The needs of patients and their families are more complex in chronic disease and require planning, proactive interventions by caregivers, and patient self-management. The Institute of Medicine declared 6 aims for health care systems in the United States. Health care should be safe, effective, patient centered, timely, efficient, and equitable. To fulfill these aims, the institute also declared 10 rules that need to be followed (Table I). Following these rules will drive significant reengineering of care delivery, especially in chronic disease, with important implications for patients, providers, and systems. Patients must be the source of control for decision making with regard to their care, and this requires provision of necessary information in an understandable manner by providers. Patients must also have freedom of choice for their health care. For providers, evidencebased care must be provided, which increasingly places a burden on clinical decision support. Communication and collaboration among care providers will also be necessary for effective care provision. The system of

ObjectivesClinical prediction rules and models are developed by applying statistical techniques to find combinations of predictors that categorize a heterogeneous group of patients into subgroups of risk. Our goal is to teach clinicians how to evaluate the validity, results, and applicability of art

Critical care medicine has progressed significantly over the past two to three decades. We will review the history and evolution of critical care medicine and ICUs in the United States. The evolving health care delivery system and the changing and important role of the intensivist will be addressed. Finally, a discussion about what critical care physicians must do to prepare for the future is presented.

Heart failure with preserved ejection fraction (HFpEF) is recognized as a major cause of cardiovascular morbidity and mortality. An ability to identify patients with HFpEF who are at increased risk for adverse outcomes can facilitate their more careful management. We studied the patients having heart failure (HF) using data from the Heart Failure Adherence and Retention Trial (HART). HART enrolled 902 patients in the New York Heart Association (NYHA) class II or III who had been recently hospitalized for HF to study the impact of self-management counseling on the primary outcome of death or HF hospitalization. In HART, 208 patients had HFpEF and 692 had HF with reduced ejection fraction (HFrEF) and were followed for a median of 1,080 days. Two final multivariate models were developed. In patients having HFpEF, predictors of primary outcome were male gender (odds ratio [OR] 3.45, p = 0.004), NYHA class III (OR 3.05, p = 0.008), distance covered on a 6-minute walk test (6-MWT) of620 feet (OR 2.81, p = 0.013), and80% adherence to prescribed medications (OR 2.61, p = 0.018). In patients having HFrEF, the predictors were being on diuretics (OR 3.06, p = 0.001), having ≥3 co-morbidities (OR 2.11, p = 0.0001), distance covered on a 6-MWT of620 feet (OR 1.94, p = 0.001), NYHA class III (OR 1.90, p = 0.001), and age65 years (OR 1.63, p = 0.01). In conclusion, indicators of functional status (6-MWT and NYHA class) were common to both patients with HFpEF and those with HFrEF, whereas gender and adherence to prescribed therapy were unique to patients having HFpEF in predicting death or HF hospitalization.

In patients with recurrent symptoms ≥1 year after successful percutaneous transluminal coronary angioplasty (PTCA), the decision of whether to proceed directly with coronary angiography or to evaluate the patient noninvasively can be difficult. To determine which demographic, historical, clinical, and laboratory factors are useful in helping to make this decision, 76 consecutive patients who presented >1 year (768 ± 309 days) after successful PTCA with resolution of symptoms were studied. The initial PTCA successfully treated all stenoses (except chronically occluded vessels) in all major vessels and segments. The patient group was predominantly men (68%), with a mean age of 64 ± 10 years. A prior myocardial infarction was present in 39 patients (51%), and there was a mean or 2.8 risk factors per patient. In patients who presented with recurrent symptoms, the Canadian Cardiovascular Society functional class was 2.0 ± 0.9; 2 patients presented with acute infarctions, 57 were admitted to the hospital with unstable angina, and 17 had stable angina. New electrocardiographic changes at rest were found in 19 of 74 patients (26%) with recurrent angina. A thallium stress test was performed in 40 patients (53%), with a sensitivity of 77% and a specificity of 36% for the presence of a significant stenosis. No nonangiographic variable was predictive of angiographic findings. At angiography, the number of coronary arteries with ≥50% diameter narrowing was 1.4 ± 1.0. Forty-two patients had stenosis at a new site, 7 had restenosis, and 27 had no new stenoses. Thus, differentiation between restenosis, disease progression, and quiescence is only accomplished by coronary angiography, since neither clinical nor noninvasive parameters are predictive of changes in coronary anatomy.

The Heart Failure Adherence and Retention Trial (HART) provided an opportunity to determine adherence to evidence-based guidelines (EBG) in patients with heart failure (HF). Ten hospitals were the source of 692 patients with HF (EF40%). Physicians of patients with HF were classified as adherent to EBG if the patient chart audit showed they were on a beta-blocker, ACE-inhibitor (ACE-I), or angiotensin receptor blocker (ARB). Patients were classified as adherent to EBG if MEMS pill caps were used appropriately more than 80% of the time. Sixty-three percent of physicians prescribed evidence-based medications that were adherent to clinical practice guidelines. New York Heart Association (NYHA) III patients were less likely to be adherent (P0.001), as were those with renal disease (P0.001) and asthmatics (P0.001). Nonadherent physicians were less likely to treat patients with beta-blockers (39% vs 98%, P0.001) and ACE-I or ARBs (71% vs 98% P0.001). Thirty-seven percent of patients prescribed evidence-based therapy failed to use the MEMS pill cap bottles appropriately and were more likely a minority or higher NYHA class. Adherence to evidence-based therapy is less than optimal in HF patients based on a combination of both physician and patient nonadherence.

Context Motivating patients with heart failure to adhere to medical advice has not translated into clinical benefit, but past trials have had methodological limitations. Objective To determine the value of self-management counseling plus heart failure education, compared with heart failure education alone, for the primary end point of death or heart failure hospitalization. Design, Setting, and Patients The Heart Failure Adherence and Retention Trial (HART), a single-center, multiple-hospital, partially blinded behavioral efficacy randomized controlled trial involving 902 patients with mild to moderate heart failure and reduced or preserved systolic function, randomized from the Chicago metropolitan area between October 2001 and October 2004 and undergoing follow-up for 2 to 3 subsequent years. Interventions All patients were offered 18 contacts and 18 heart failure educational tip sheets during the course of 1 year. Patients randomized to the education group received tip sheets in the mail and telephone calls to check comprehension. Patients randomized to the self-management group received tip sheets in groups and were taught self-management skills to implement the advice. Main Outcome Measure Death or heart failure hospitalization during a median of 2.56 years of follow-up. Results Patients were representative of typical clinical populations (mean age, 63.6 years; 47% women, 40% racial/ethnic minority, 52% with annual family income less than $30 000, and 23% with preserved systolic function). The rate of the primary end point in the self-management group was no different from that in the education group (163 [40.1%)] vs 171 [41.2%], respectively; odds ratio, 0.95 [95% confidence interval, 0.72-1.26]). There were no significant differences on any secondary end points, including death, heart failure hospitalization, all-cause hospitalization, or quality of life. Conclusions Compared with an enhanced educational intervention alone, the addition of self-management counseling did not reduce death or heart failure hospitalization in patients with mild to moderate heart failure. Trial Registration clinicaltrials.gov Identifier: NCT00018005

Background Low vitamin D has been associated with low levels of high-density lipoprotein (HDL) cholesterol, a marker of coronary risk. Whether atheroprotective HDL particle composition accounts for this association and whether fat affects this association is not known. Objective To explore the association between HDL particle composition and 25-hydroxy vitamin D (25[OH]D) in post-menopausal women. Methods Vitamin D levels and lipoprotein composition were assessed in fasting blood samples of apparently healthy women from a diverse Chicago community. Visceral (VAT) and subcutaneous (SAT) abdominal fat area were assessed using computed tomography. Total body fat mass was measured by dual-energy X-ray absorptiometry. Results We enrolled 78 women (50% black; 50% white), age 48 to 64 years, all of whom were participants in a longitudinal study of fat patterning. They had a mean 25[OH]D of 31 ± 15 μg/L, HDL cholesterol 57±11 mg/dL, and large HDL particle subclass 8.6±3.4 μmol/L. In a multivariable-adjusted regression model, each 5 μg/L higher 25[OH]D predicted 0.57 μmol/L (95%CI 0.20–0.95) higher large HDL particles, independent of race, season, and total HDL particle concentration. This association was only partially confounded by total body fat mass (0.49, 95%CI 0.10–0.89), SAT (0.50, 95%CI 0.11–0.90), or VAT (0.37, 95%CI 0.01–0.74). Age did not significantly influence the strength of associations. Conclusions Higher 25[OH]D levels are associated with large HDL particles. This association is stronger than that of HDL cholesterol and only partially confounded by body fat. Theoretically, vitamin D may protect against cardiovascular risk by promoting formation of large HDL particles, affecting reverse cholesterol transport.

To determine whether leftward septal shifting mediates primary changes in left ventricular (LV) preload and diastolic function, seven animals were studied after instrumentation with right ventricular (RV) and LV Millar microtip pressure transducers and RV and LV segment length crystals. This allowed assessment of LV preload and LV diastolic pressure segment length relationships before and after the pulmonary artery pressure was first doubled, then tripled by embolizing the pulmonary circulation with glass beads, and then after an additional injection of glass beads reduced the cardiac output by 30%. Echocardiographic images were also acquired to assess LV size and septal configuration. To determine whether reversal of the transseptal pressure gradient and leftward septal shifting during acute pulmonary hypertension is associated with RV ischemia, transmural biopsies of the right ventricle for adenosine triphosphate and creatine phosphate analysis were performed at each stage. We determined that doubling and tripling of the pulmonary artery pressure was not associated with RV ischemia or alteration in septal configuration or diastolic function of the left ventricle. However, LV preload, measured by both segment length crystals and echo-derived areas and circumferences, was decreased when the pulmonary artery was tripled. When cardiac output was decreased 30% there was depletion of adenosine triphosphate and creatine phosphate, a reversal of the transseptal pressure gradient, and reduction of the LV shape and eccentricity indices consistent with leftward septal shift. The LV diastolic pressure/ segment length relationships were not consistently altered. We conclude that (1) LV preload decreases before the transseptal pressure gradient decreases and the septum shifts leftward, (2) LV distensibility does not appear to be altered by leftward septal shift when it occurs provided the pericardium is opened, and (3) RV ischemia likely contributes to the reversal of the transseptal pressure gradient and shifting of the septum leftward.

Management of depression, if it is independently associated with repeated hospitalizations for heart failure (HF), offers promise as a viable and cost-effective strategy to improve health outcomes and reduce health care costs for HF. The objective of this study was to assess the association between depression and the number of HF-related hospitalizations in patients with low-to-moderate systolic or diastolic dysfunction, after controlling for illness severity, socioeconomic factors, physician adherence to evidence-based medications, patient adherence to HF drug therapy, and patient adherence to salt restrictions.The Heart Failure Adherence and Retention Trial (HART) was a randomized behavioral trial to evaluate whether patient self-management skills coupled with HF education improved patient outcomes. Depression was measured at baseline with the Geriatric Depression Scale (GDS). The number of hospitalizations was analyzed with a negative binomial regression model that included an offset term to account for the differential duration of follow-up for individual subjects. The average unadjusted number of hospitalizations per year was 0.40 in the depressed group (GDS ≥10) and 0.33 in the nondepressed group (GDS10). Depression was a strong predictor (incident rate ratio 1.45; P = .006) after adjusting for physician adherence to evidence-based medication use, patient adherence to HF drug therapy, patient adherence to salt restriction, illness severity, HF severity (6-minute walk620 feet), and socioeconomic factors.Depression is a strong psychosocial predictor of repeated hospitalizations for HF. Compared with nondepressed individuals, those with depression were hospitalized for HF 1.45 times more often, even after controlling for physician adherence to evidence-based medications and patient adherence to HF drug therapy and salt restrictions. This finding suggests that clinicians should screen for depression early in the course of HF management.

Heart failure (HF) is a common, debilitating, and costly syndrome. Approximately 5 million patients in the U.S. have HF and more than 550,000 new cases are identified each year.1 HF has a substantial adverse impact on quality of life (QOL). HF patients generally report significantly poorer QOL than patients with other common cardiac conditions or other chronic medical conditions.2-4 The impact of HF on QOL is related to stage of disease, although disease symptoms and functional capacity tend to have a greater adverse effect on QOL than clinical indicators of disease severity, such as ejection fraction or abnormal wall motion.5-9 QOL in HF may also be affected by the psychosocial status of the patient. Psychosocial characteristics of particular interest include depression and social support, as these characteristics have been found to predict long-term prognosis in HF.10-14 Although several studies have focused on these characteristics in relation to QOL in HF patients,5,6,9,15-17 their exact role in HF-related QOL remains poorly specified. With few exceptions,9 most studies have been conducted in small samples with limited data on disease aspects that may affect QOL, in particular well-validated measures of disease symptoms or functional capacity. In addition, previous studies generally have been limited to patients with systolic dysfunction, rather than the full spectrum of HF, and have lacked sufficient representation of minority patients. Patients with diastolic dysfunction and from minority backgrounds tend to account for substantial portions of the total HF patient population.18-20 Thus, our understanding of how depression and social support affect various aspects of QOL across a sociodemographically and clinically broad range of HF patients remains limited. This study was aimed at investigating the cross-sectional association of depression and social support with QOL in HF patients, using baseline data from a large behavioral clinical trial. Two QOL domains are the focus of analysis. The first domain emphasizes satisfaction with health, daily functioning, and psychological and spiritual aspects of life, or satisfaction with QOL (S-QOL). The second domain emphasizes limitations in the ability to perform basic activities due to poor health, or physical functioning QOL (PF-QOL). Both domains fall under the general definition of QOL as “the functional effect of an illness and its consequent therapy upon a patient as perceived by the patient”.21 Based on Wilson and Cleary’s conceptual framework of QOL in chronic disease populations,22 we hypothesize that depression and social support account for a greater portion of the impact of HF on satisfaction with QOL (S-QOL) than on perceived limitations in basic activities (PF-QOL).

Structured Abstract Objective: To emphasize the importance of troponin in the context of a new score for risk stratifying acute coronary syndromes (ACS) patients. Although troponins have powerful prognostic value, current ACS scores do not fully capitalize this prognostic ability. Here, we weigh troponin status in a multiplicative manner to develop the TRACS score from previously published Rush score risk factors (RRF). Methods: 2,866 ACS patients (46.7% troponin positive) from 9 centers comprising the TRACS registry, were randomly split into derivation (n=1,422) and validation (n=1,444) cohorts. In the derivation sample, RRF sum was multiplied by 3 if troponins were positive to yield the TRACS score, which was grouped into five categories of 0-2, 3-5, 6-8, 9-11, 12-15 (multiples of 3). Predictive performance of this score to predict hospital death was ascertained in the validation sample. Results: The TRACS score had ROC AUC of 0.71 in the validation cohort. Logistic regression, Kaplan-Meier analysis, likelihood-ratio and Bayesian Information Criterion (BIC) test indicated that weighing troponin status with 3 in the TRACS score improved the prediction of mortality. Hosmer-Lemeshow test indicated sound model fit. Conclusions: We demonstrate that weighing troponin as a multiple of 3 yields robust prognostication of hospital mortality in ACS patients, when used in the context of the TRACS score.

The impact of analysis of the severity of illness on the in-hospital mortality was reviewed retrospectively on a cohort of patients admitted to a coronary care unit. Three hundred and eighty-six patients were admitted during the study period, with diagnoses including myocardial infarction (49 percent), unstable angina (23 percent), arrhythmias (11 percent), congestive heart failure (5 percent), and nondiagnostic chest pain (5 percent). Total in-hospital mortality was 13 percent. Severity of illness was measured using the acute physiology and chronic health evaluation (APACHE 2) score. Mortality was found to be influenced by admitting diagnosis (p = 0.01), source of referral (p = 0.03), and APACHE 2 score (nonsurvivors, 16.5 +/- 10.1; survivors, 8.5 +/- 4.8; p less than 0.001). The receiver operating characteristic (ROC) curve for the APACHE 2 confirmed it as a predictor of mortality, with an area under the curve (+/- SE) of 0.75 +/- 0.04 (95 percent confidence limits, 0.67 to 0.83). Logistic regression analysis showed the APACHE 2 score and the diagnosis on admission to be significant multivariate predictors of mortality, and a series of diagnosis-specific coefficients are presented. We conclude that the APACHE 2 score is a useful tool for the overall assessment and management of the CCU, as it is in the multidisciplinary medical-surgical intensive care unit.

This study was designed to investigate whether intracoronary diltiazem given before reperfusion could enhance myocardial salvage in the canine heart. Twenty-five dogs were subjected to 90 min of coronary occlusion followed by 4 h of reperfusion. The dogs were assigned to one of three experimental groups. The early diltiazem group received intracoronary diltiazem into the distal coronary bed at the onset of coronary occlusion and for 60 min after reperfusion. The late diltiazem group received the same amount of drug beginning 15 min before reperfusion and the control group received saline solution for 90 min of occlusion and 60 min of reperfusion.Infarct size expressed as a percent of the area at risk was significantly smaller in the early and late diltiazem groups (15.6 ± 3.6% and 21.2 ± 5.1%, respectively) than in the control group (49 ± 4.6%) (p < 0.05).Intracoronary diltiazem restored systolic function of the stunned, previously ischemic tissue to essentially normal preocclusion values. Segmental shortening after reperfusion averaged 21.6% in the early diltiazem group versus 0 ± 1.7% and 7.3 ± 4% for the control and late diltiazem groups, respectively (p < 0.05). Low dose intracoronary diltiazem did not alter hemodynamic variables or myocardial blood flow but did improve segmental shortening 2 and 6 h after reperfusion.These data indicate that intracoronary diltiazem given during occlusion or just before reperfusion increases the salvage of myocardium compared with the salvage achieved by reperfusion alone. These results also suggest that intracoronary diltiazem given during the ischemic period enhances systolic contractile function of postischemic stunned myocardium. Improvement in function and salvage of myocardium was obtained in the absence of coronary flow effects, suggesting that diltiazem acts by favorably altering the calcium balance within ischemic myocytes.

Background Heart failure (HF) is increasing in prevalence and is associated with prolonged morbidity, repeat hospitalizations, and high costs. Drug therapies and lifestyle changes can reduce hospitalizations, but nonadherence is high, ranging from 30% to 80%. There is an urgent need to identify cost-effective ways to improve adherence and reduce hospitalizations. Trial Design The Heart Failure Adherence and Retention Trial (HART) evaluated the benefit of patient self-management (SM) skills training in combination with HF education, over HF education alone, on the composite end points of death/HF hospitalizations and death/all-cause hospitalizations in patients with mild to moderate systolic or diastolic dysfunction. Secondary end points included progression of HF, quality of life, adherence to drug and lifestyle regimens, and psychosocial function. The HART cohort was composed of 902 patients including 47% women, 40% minorities, and 23% with diastolic dysfunction. After a baseline examination, patients were randomized to SM or education control, received 18 treatment contacts over 1 year, annual follow-ups, and 3-month phone calls to assess primary end points. Self-management treatment was conducted in small groups and aimed to activate the patient to implement HF education through training in problem-solving and 5 SM skills. The education control received HF education in the mail followed by a phone call to check comprehension. Conclusions The significance of HART lies in its ability to determine the clinical value of activating the patient to collaborate in his or her care. Support for the trial hypotheses would encourage interdisciplinary HF treatment, drawing on an evidence base not only from medicine but also from behavioral medicine.

This review examined whether nonpharmacologic treatment was associated with reductions in all-cause mortality and heart failure (HF) hospitalizations and investigated the effects of face-to-face contact and longer treatment duration on these outcomes. MEDLINE and PsycINFO databases were searched through June 2006 and bibliographies of potential articles were hand-searched. Nonpharmacologic treatment was associated with significantly lower odds of HF hospitalizations (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.30-0.56) and death (OR, 0.69; 95% CI, 0.56-0.85) compared with control treatment. Face-to-face contact was associated with significantly lower odds of HF hospitalization (OR, 0.42; 95% CI, 0.22-0.81; P.05) and death (OR, 0.63; 95% CI, 0.44-0.91; P.05) as compared with control treatment. Longer treatment duration (or=12 months) was associated with a 65% reduction in the rate of HF hospitalizations and a 36% reduction in death rate. Nonpharmacologic treatment featuring face-to-face contact is particularly effective in reducing HF hospitalization and all-cause mortality rates.

Early detection of asymptomatic left ventricular systolic dysfunction (LVSD) is beneficial in managing heart failure. Recent studies have cast doubt on the usefulness of cardiac output as an indicator of LVSD. In impedance cardiography (ICG), the dZ/dt waveform has a systolic wave called the E wave. This study looked at measurements of the amplitude and area of the E wave compared with ICG-derived cardiac output, stroke volume, cardiac index, and stroke index as methods of assessing LVSD. ICG data were obtained from patients (n=26) admitted to a coronary care unit. Clinical LVSD severity was stratified into 4 groups (none, mild, moderate, and severe) based on echocardiography data and standard clinical assessment by a cardiologist blinded to ICG data. Statistical analysis showed that the E wave amplitude and area were better indicators of the level of LVSD than cardiac output, stroke volume, cardiac index, or stroke index. ICG waveform analysis has potential as a simple point-of-care test for detecting LVSD in asymptomatic patients at high risk for developing heart failure and for monitoring LVSD in patients being treated for heart failure.

Increasingly, academic institutions are grappling with financial pressures that threaten the academic mission. The author presents an actual case history in which a section of cardiology in an academic health center was confronted with huge projected deficits that had to be eliminated within the fiscal year. The section used eight principles to shift from deficit to profitability (i.e., having revenue exceed costs). These principles included confronting the brutal facts, managing costs and revenue cycles, setting expectations for faculty, and quality improvement. The section accomplished deficit reduction through reducing faculty salaries (nearly $2 million) and nonfaculty salaries ($1.3 million) and reducing operational costs while maintaining revenues by increasing individual faculty productivity and reducing accounts receivable. In the face of these reductions, clinical revenues were maintained, but research revenue and productivity fell (but research is being fostered now that clinical services are profitable again). These principles can be used to stabilize the financial position of clinical practices in academic settings that are facing financial challenges.

Although adherence to guidelines recommendations is assumed to be more difficult for nonacademic community hospitals, patterns of adherence have not been evaluated by hospital type. We sought to identify hospital characteristics associated with high levels of adherence in order to gain insight into successful processes of care.From January 2001 through March 2004, we analyzed data from 86,042 patients in the CRUSADE Initiative with high-risk non-ST-segment elevation acute coronary syndromes (NSTE ACS) defined by positive cardiac markers or ischemic ST-segment changes. Academic sites were defined by Council of Teaching Hospital affiliation in the American Hospital Association database. Adherence was determined for each hospital based on guidelines recommendations for the use of 4 acute (24 hrs) and 5 discharge therapies in patients without contraindications. Multivariable modeling was used to standardize hospital estimates for patient characteristics and control for clustering within centers.A total of 60,285 patients were admitted to nonacademic hospitals (n=355), and 25,757 were admitted to academic hospitals (n=125). Academic hospitals were larger (median 500 vs 268 beds, P.001) and more often had bypass services (88% vs 60%, P.001). Composite adherence to recommended therapies was slightly higher at academic vs. nonacademic hospitals (median 77.8% vs 73.7%, P0.01), and variance in individual hospital performance was greater among nonacademic sites. Nonacademic hospitals accounted for 15 of the 20 highest performing sites and 19 of the 20 lowest performing sites. In-hospital clinical outcomes, including cardiogenic shock, stroke, and death were similar for patients admitted to both types of hospital.Adherence to American College of Cardiology and American Heart Association (ACC/AHA) guidelines for NSTE ACS care at academic hospitals is slightly higher than at nonacademic hospitals; however there is significant room for improvement within both systems. The larger performance variation in care among nonacademic hospitals highlights the need for continued emphasis on consistent care processes.

Nonadherence to medical treatment among heart failure patients is high and results in frequent exacerbations and premature death. This treatment-only pilot study examined whether a year-long group-based self-management intervention is feasible and improves self-management skills in patients with mild-to-moderate heart failure (ejection fraction < or =40% and New York Heart Association functional class I, II, or III). A total of 31 of 100 recruited patients (31%) agreed to participate. Twenty-six (84%) completed the year-long self-management program. Compared with baseline, the intervention was associated with an increase in overall self-efficacy in practicing self-management skills (p

For the diagnosis and management of heart failure, it would be useful to have a simple point-of-care test for assessing ventricular function that could be performed by a nurse. An impedance cardiography (ICG) parameter called systolic amplitude (SA) can serve as an indicator of left ventricular systolic function (LVSF). This study tested the hypothesis that patients with normal LVSF should have a significant increase in SA in response to an increase in end-diastolic volume caused by postural change from sitting upright to supine, while patients with depressed LVSF associated with heart failure should have a minimal increase or a decrease in SA from upright to supine. ICG data were obtained in 12 patients without heart disease and with normal LVSF and 18 patients with clinically diagnosed heart failure. Consistent with the hypothesis, patients with normal LVSF had a significant increase in SA from upright to supine, whereas heart failure patients had a minimal increase or a decrease in SA from upright to supine. This ICG procedure may be useful for monitoring the trend of patient response to titration of beta blockers and other medications. ICG potentially could be used to detect worsening LVSF and provide a means of measurement for adjusting treatment.

Background Patients with myocardial infarction (MI) are at further increased risk for untoward events when patients also exhibit low social support and/or depression. The ENRICHD study was the largest controlled trial in post-MI patients attempting to treat these psychological comorbidities and provides an opportunity to examine the medical and psychological characteristics that may affect risk in this population. Methods We analyzed the baseline characteristics and their relationship to the primary end point of long-term mortality and recurrent infarction and to the secondary end points of overall mortality and cardiovascular mortality in 2481 post-MI patients. Cox proportional hazards models were used to predict the risk of these outcomes over a mean of 2.5 years of follow-up. Results Death or nonfatal MI occurred in 24.1%, all-cause mortality in 13.7%, and cardiovascular mortality in 8.4% of the sample (62% of the total). Age, heart failure, pulmonary disease, Killip class, ejection fraction, an elevated creatinine, the use of non–angiotensin-coverting enzyme asodilators, prior MI, diabetes, depression, and bypass surgery after acute MI were all significant multivariable predictors. Conclusions The medical predictors of adverse events in post-MI patients with low social support and/or depression were similar to those of patients with MI in other clinical trials.

Heart failure (HF) is an increasingly prevalent condition contributing to significant morbidity and mortality among African-Americans. The Heart Failure Adherence and Retention Trial (HART) is the largest NHLBI funded behavioral clinical trial of patients with HF (R01 HL65547). The HART trial has recruited approximately 40% minority participants, with 33% being African-American. The purpose of this qualitative study is to conduct an in-depth examination of the subjective experience of African-American participants in the intervention arm of the HART. Five focus groups were conducted with a total of 25 participants. The mean age of those attending was 55 years, with a range between 39 and 82 years, 52% of the participants were female, and 92% were African-American. Participants gained overall general medical knowledge about HF and how HF influenced their own lives. Participants appeared not only to understand the self-management skills that were taught; but also how to apply them. They also demonstrated understanding of the connection between lifestyle and HF. Factors that may promote retention include mutual support, the opportunity to engage in meaningful social activity, and feeling cared for. Factors that may limit retention include anxiety and denial about HF and logistical and emotional barriers to attending groups. Factors with unclear effects on retention include remuneration, ethnicity of the group leader, and the role of religious or spiritual content in meetings. While a number of perceived benefits exist to group participation, there are significant and logistical barriers to retention. Ongoing attention to cultural sensitivity is a likely factor in successful retention of study participants.

The objective of this study was to determine the clinical and angiographic profile of patients with extremely high coronary artery calcium scores (CACS;or=1000) by electron beam computed tomography (EBCT).All patients at Rush University Medical Center who had a calcium scoreor=1000 and a coronary angiogram performed from 1997 to 2002 were identified using a prospectively collected database. The baseline demographics, symptom status, and degree of coronary stenosis by angiography and subsequent rate of coronary intervention were compared with that of patients with calcium scores1000.The clinical and angiographic profile of patients with severe coronary calcification, detected by EBCT, revealed that patients with scoresor=1000 had a significantly higher prevalence of coronary stenosisor=50% compared with patients with scores1000 (97% vs. 57%, P.001). The group with CACSor=1000 was more likely to be male (90% vs. 75%, P=.027) and was older (64+/-8 vs. 59+/-10, P=.001) compared with the group with less severe calcification. Although there was a significantly higher rate of luminal stenosis detected by coronary angiography in the cohort with CACSor=1000, there was no difference in subsequent percutaneous coronary intervention (PCI) and utilization of intracoronary stents between the two groups.A markedly elevated coronary calcium score (or=1000) is correlated with increasing age and is associated with an increased likelihood of coronary stenosisor=50%. However, the decision to perform coronary angiography in patients with severe coronary calcification should not be based solely on these findings, but should remain primarily dependent on the degree of ischemia detected by clinical and functional assessment.