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Multiple professional societies recommend the Mediterranean and/or Dietary Approaches to Stop Hypertension dietary patterns in their cardiovascular disease prevention guidelines because these diets can improve cardiometabolic health and reduce the risk of cardiovascular events. Furthermore, low sodium intake can be particularly beneficial for patients with hypertension. Carbohydrate restriction, with an emphasis on including high-quality carbohydrates and limiting refined starches and foods and beverages with added sugars, can promote weight loss and cardiometabolic benefits in the short term, compared with higher carbohydrate intake. Evidence is lacking for sustained, long-term effects of low carbohydrate and very low carbohydrate intake on cardiometabolic risk and cardiovascular outcomes. Time-restricted eating, in the context of an overall healthy dietary pattern, can promote cardiometabolic health by aligning food intake with the circadian rhythm, although its effect on hard clinical outcomes remains to be proven. Although there is no one dietary pattern that is appropriate for all patients, engaging in shared decision-making with patients, utilizing behaviour-change principles and engaging members of the health-care team, such as registered dietitian nutritionists, can lead to substantial improvement in the lifestyle and overall health trajectory of a patient. Emphasizing the similarities, rather than differences, of recommended dietary patterns, which include an emphasis on vegetables, fruits, legumes, nuts, whole grains and minimally processed protein foods, such as fatty fish or plant-based proteins, can simplify the process for both patients and clinicians alike., (© 2024. Springer Nature Limited.)

Although great progress has been made in the diagnostic and treatment options for dyslipidemias, unawareness, underdiagnosis and undertreatment of these disorders remain a significant global health concern. Growth in digital applications and newer models of care provide novel tools to improve the management of chronic conditions such as dyslipidemia. In this review, we discuss the evolving landscape of lipid management in the 21st century, current treatment gaps and possible solutions through digital health and new models of care. Our discussion begins with the history and development of value-based care and the national establishment of quality metrics for various chronic conditions. These concepts on the level of healthcare policy not only inform reimbursements but also define the standard of care. Next, we consider the advances in atherosclerotic cardiovascular disease risk score calculators as well as evolving imaging modalities. The impact and growth of digital health, ranging from telehealth visits to online platforms and mobile applications, will also be explored. We then evaluate the ways in which machine learning and artificial intelligence-driven algorithms are being utilized to address gaps in lipid management. From an organizational perspective, we trace the redesign of medical practices to incorporate a multidisciplinary team model of care, recognizing that atherosclerotic cardiovascular disease risk is multifaceted and requires a comprehensive approach. Finally, we anticipate the future of dyslipidemia management, assessing the many ways in which atherosclerotic cardiovascular disease burden can be reduced on a population-wide scale., Competing Interests: Robert Ostfeld receives research grants from the Purjes and Greenbaum Foundations; and scientific advisory board member, Mesuron Inc., with stock options. Vera Bittner served on the Steering Committee for the Odyssey Outcomes Trial (Sanofi and Regeneron), served as National Coordinator for the CLEAR Outcomes Trial (Esperion), the STRENGTH Trial (Astra Zeneca), and the DalGene Trial (DalCor); she is Site PI for ORION (Novartis) and EVOLVE-MI (Amgen), and is co-investigator on an industry/academic collaboration between Amgen and the UAB School of Public Health (PIs: Muntner and Colantonio). All monies for these activities go to the institution. VB serves on a DSMB for Verve Therapeutics and serves as Senior Guest Editor for Circulation and receives personal honoraria for these activities. Seth Martin reports funding from the American Heart Association (20SFRN35380046, 20SFRN35490003, COVID19-811000, #878924, #882415, and #946222), the Patient-Centered Outcomes Research Institute (ME-2019C1-15 328, IHS-2021C3-24147), the National Institutes of Health (P01 HL108800 and R01AG071032), the David and June Trone Family Foundation, the Pollin Digital Innovation Fund, Sandra and Larry Small, CASCADE FH, Google, Amgen, and Merck. Dr. Martin has received material support from Apple and iHealth. Under a license agreement between Corrie Health and the Johns Hopkins University, the University owns equity in Corrie Health and the University and Dr. Martin are entitled to royalty distributions related to the Corrie technology. Additionally, Dr. Martin is a co-founder of and holds equity in Corrie Health. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. Furthermore, Dr. Martin reports personal consulting fees from Amgen, AstraZeneca, Chroma, Kaneka, NewAmsterdam, Novartis, Novo Nordisk, Sanofi, and 89bio. Michael Shapiro serves on the scientific advisory boards of Amgen, Ionis, Novartis and Precision BioScience and is a consultant for Ionis, Novartis, Regeneron, EmendoBio and Aidoc. Leandro Slipczuk has received institutional grants from Amgen and Philips and consulting honoraria from Amgen, BMS and Philips. Michael D. Shapiro is serving as Guest Editor and one of the Editorial Board members of this journal. We declare that Michael D. Shapiro had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Carmela Rita Balistreri. Others report no conflict., (Copyright: © 2023 The Author(s). Published by IMR Press.)

Background: Associations of weight changes and intentionality of weight loss with longevity are not well described., Methods: Using longitudinal data from the Women's Health Initiative (N = 54 437; 61-81 years), we examined associations of weight changes and intentionality of weight loss with survival to ages 90, 95, and 100. Weight was measured at baseline, year 3, and year 10, and participants were classified as having weight loss (≥5% decrease from baseline), weight gain (≥5% increase from baseline), or stable weight (<5% change from baseline). Participants reported intentionality of weight loss at year 3., Results: A total of 30 647 (56.3%) women survived to ≥90 years. After adjustment for relevant covariates, 3-year weight loss of ≥5% vs stable weight was associated with lower odds of survival to ages 90 (OR, 0.67; 95% CI, 0.64-0.71), 95 (OR, 0.65; 95% CI, 0.60-0.71), and 100 (OR, 0.62; 95% CI, 0.49-0.78). Compared to intentional weight loss, unintentional weight loss was more strongly associated with lower odds of survival to age 90 (OR, 0.83; 95% CI, 0.74-0.94 and OR, 0.49; 95% CI, 0.44-0.55, respectively). Three-year weight gain of ≥5% vs stable weight was not associated with survival to age 90, 95, or 100. The pattern of results was similar among normal weight, overweight, and obese women in body mass index (BMI)-stratified analyses., Conclusions: Weight loss of ≥5% vs stable weight was associated with lower odds of longevity, more strongly for unintentional weight loss than for intentional weight loss. Potential inaccuracy of self-reported intentionality of weight loss and residual confounding were limitations., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In cardiology clinic visits, the discussion of optimal dietary patterns for prevention and management of cardiovascular disease is usually very limited. Herein, we explore the benefits and risks of various dietary patterns, including intermittent fasting, low carbohydrate, Paleolithic, whole food plant-based diet, and Mediterranean dietary patterns within the context of cardiovascular disease to empower clinicians with the evidence and information they need to maximally benefit their patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Despite numerous advances in all areas of cardiovascular care, cardiovascular disease (CVD) is the leading cause of death in the United States (US). There is compelling evidence that interventions to improve diet are effective in cardiovascular disease prevention. This clinical practice statement emphasizes the importance of evidence-based dietary patterns in the prevention of atherosclerotic cardiovascular disease (ASCVD), and ASCVD risk factors, including hyperlipidemia, hypertension, diabetes, and obesity. A diet consisting predominantly of fruits, vegetables, legumes, nuts, seeds, plant protein and fatty fish is optimal for the prevention of ASCVD. Consuming more of these foods, while reducing consumption of foods with saturated fat, dietary cholesterol, salt, refined grain, and ultra-processed food intake are the common components of a healthful dietary pattern. Dietary recommendations for special populations including pediatrics, older persons, and nutrition and social determinants of health for ASCVD prevention are discussed., (© 2022 The Authors. Published by Elsevier B.V.)

Each year, patients are bombarded with diverging and even contradictory reports concerning the impact of certain additives, foods, and nutrients on cardiovascular health and its risk factors. Accordingly, this third review of nutrition controversies examines the impact of artificial sweeteners, cacao, soy, plant-based meats, nitrates, and meats from grass compared to grain-fed animals on cardiovascular and other health outcomes with the goal of optimizing clinician-led diet counseling., (Copyright © 2021 Elsevier Inc. All rights reserved.)

•Cardiovascular and cardiometabolic diseases are largely preventable, and are propagated by a poor diet.•Poor diet may be due to a lack of supply and access to healthy foods, agricultural subsidies, and marketing.•Improving national dietary intake starts with enhancing dietary guidelines, enacting legislative changes to optimize agricultural subsidies and food advertising, and incentivizing a plant-forward diet., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: R.J.O.: Research Grants: Purjes Foundation, Greenbaum Foundation. Consultant: BrightPlate. Non-compensated: Scientific Advisory Board, Physicians Committee for Responsible Medicine. Board Member, Center for Nutrition Studies. E.D.M.: Advisory boards: Esperion, Amarin, Novartis, and Astra Zeneca., (© 2021 The Author(s).)

The secondary prevention (SP) of coronary heart disease (CHD) has become a major public health and economic burden worldwide. In the United States, the prevalence of CHD has risen to 18 million, the incidence of recurrent myocardial infarctions (MI) remains high, and related healthcare costs are projected to double by 2035. In the last decade, practice guidelines and performance measures for the SP of CHD have increasingly emphasized evidence-based lifestyle (LS) interventions, including healthy dietary patterns, regular exercise, smoking cessation, weight management, depression screening, and enrollment in cardiac rehabilitation. However, data show large gaps in adherence to healthy LS behaviors and low rates of enrollment in cardiac rehabilitation in patients with established CHD. These gaps may be related, since behavior change interventions have not been well integrated into traditional ambulatory care models in the United States. The chronic care model, an evidence-based practice framework that incorporates clinical decision support, self-management support, team-care delivery and other strategies for delivering chronic care is well suited for both chronic CHD management and prevention interventions, including those related to behavior change. This article reviews the evidence base for LS interventions for the SP of CHD, discusses current gaps in adherence, and presents strategies for closing these gaps via evidence-based and emerging interventions that are conceptually aligned with the elements of the chronic care model., Competing Interests: Declaration of Competing Interest Todd M.Brown receives research support from Amgen, Inc. and serves as site PI for a clinical trial funded by Omthera Pharmaceuticals/Astra Zeneca. Robert Ostfeld has performed consulting work for Better Therapeutics LLC. Neil Gordon is the managing member of a commercial population health management company, INTERVENT International, LLC. Dean Ornish receives royalties from general-interest books on health; sometimes receives lecture honoraria; consulting and licensing fees from Sharecare; stock for being on the advisory board of Obvious Ventures, Andrew M. Freeman does nonpromotional speaking for Boehringer-Ingleheim, all remaining authors have no relevant disclosures., (Copyright © 2021. Published by Elsevier Inc.)

Periodontal disease (PD) is common in the US and globally. Evidence suggests that poor oral health is associated with atherosclerotic cardiovascular disease (ASCVD); however, this relationship has not been a major focus in clinical cardiology. This manuscript will review the growing evidence linking PD to ASCVD, including pathophysiologic mechanisms and coexistent risk factors. Public health considerations with a focus on disparities, social determinants, preventive strategies, and a call to action to reduce the burden of coincident ASCVD and PD are also reviewed., Competing Interests: EAJ Research funding: (NIH [R01AG045136, UL1TR001417, UOA-212,513, P30CA013148-47S6], Amgen; Consulting: ACC, McKesson; Roylaties: UpToDate; Editorial Board: American Heart Association; JOK major ownership interest: CardioTabs; DI Research Funding Amgen; RO Consulting: Better Therapeutics; AMF: Speaker Board Boehringer-Ingleheim; All other authors have nothing to disclose., (© 2021 The Author(s). Published by Elsevier B.V.)

Aims: Although obesity is associated with increased mortality, epidemiologic studies in heart failure have reported lower mortality in obese patients compared with matched nonobese patients (the 'obesity paradox'). However, the relationship between survival and extreme (morbid) obesity (BMI ≥ 40) is poorly understood. We evaluate survival in low ejection fraction patients across a range of BMI categories, including extreme obesity., Methods: In a retrospective review, 12 181 consecutive patients receiving nuclear stress testing at a tertiary care center were stratified based on BMI and ejection fraction. Eight-year mortality data were collected using the social security death index., Results: Normal ejection fraction patients (internal control, ejection fraction ≥50%) exhibited the J-shaped association between mortality and BMI that is observed in the general population. Among patients with reduced ejection fraction (<50%), survival improved as obesity increased (P < 0.0001). Those with extreme obesity had the lowest mortality (n = 1134, P < 0.05)., Conclusion: In this cohort of reduced Ejection fraction patients, the obesity paradox was observed in all weight categories, with the highest survival of all observed in the extremely obese BMI category. This further supports hypotheses that an obesity-related physiologic phenomenon affects mortality in reduced ejection fraction patients., (Copyright © 2020 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Vasculogenic erectile dysfunction has been aptly called the "canary in the coal mine" for cardiovascular disease because it almost always precedes other manifestations of atherosclerotic cardiovascular disease, including myocardial infarction and stroke. It is common, associated with the presence of modifiable cardiovascular risk factors, and impacted by diet and lifestyle choices. This concise review provides an update on the use of dietary and other lifestyle interventions to improve vasculogenic erectile dysfunction and atherosclerotic cardiovascular disease., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Experimental evidence suggests that sedentary time (ST) may contribute to cardiovascular disease by eliciting detrimental hemodynamic changes in the lower limbs. However, little is known about objectively measured ST and lower extremity peripheral artery disease (PAD)., Methods: We included 7,609 Hispanic/Latinos (ages 45-74) from the Hispanic Community Health Study/Study of Latinos. PAD was measured using the ankle brachial index (≤0.9). ST was measured using accelerometry. We used multivariable logistic regression to assess associations of quartiles of ST and PAD, and then used the same logistic models with restricted cubic splines to investigate continuous nonlinear associations of ST and PAD. Models were sequentially adjusted for traditional PAD risk factors, leg pain, and moderate- to vigorous-intensity physical activity (MVPA)., Results: Median ST was 12.2 h/d, and 5.4% of individuals had PAD. In fully adjusted restricted cubic splines models accounting for traditional PAD risk factors, leg pain, and MVPA, ST had a significant overall (P = .048) and nonlinear (P = .024) association with PAD. A threshold effect was seen such that time spent above median ST was associated with higher odds of PAD. That is, compared to median ST, 1, 2, and 3 hours above median ST were associated with a PAD odds ratio of 1.16 (95% CI = 1.02-1.31), 1.44 (1.06-1.94), and 1.80 (1.11-2.90), respectively., Conclusions: Among Hispanic/Latino adults, ST was associated with higher odds of PAD, independent of leg pain, MVPA, and traditional PAD risk factors. Notably, we observed a threshold effect such that these associations were only observed at the highest levels of ST., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Poor dietary quality is a leading contributor to mortality in the United States, and to most cardiovascular risk factors. By providing education on lifestyle changes and, specifically, dietary changes, hospitals have the opportunity to use the patient experience as a "teachable moment." The food options provided to inpatients and outpatients can be a paradigm for patients to follow upon discharge from the hospital. There are hospitals in the United States that are showcasing novel ways to increase awareness of optimal dietary patterns and can serve as a model for hospitals nationwide., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Hallberg et al. provide a limited literature review on the reversal of type 2 diabetes mellitus (T2DM) [...].

Continued improvement in medical and device therapy for heart failure (HF) has led to better survival with this disease. Longer survival and increasing numbers of unhealthy lifestyle factors and behaviors leading to occurrence of HF at younger ages are both contributors to an increase in the overall prevalence of HF. Clinicians treating this complex disease tend to focus on pharmacological and device therapies, but often fail to capitalize on the significant opportunities to prevent or treat HF through lifestyle modification. Herein, the authors review the evidence behind weight management, exercise, nutrition, dietary composition, supplements, and mindfulness and their potential to influence the epidemiology, pathophysiology, etiology, and management of stage A HF., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The potential cardiovascular (CV) benefits of many trending foods and dietary patterns are still incompletely understood, and scientific inquiry continues to evolve. In the meantime, however, a number of controversial dietary patterns, foods, and nutrients have received significant media attention and are mired by "hype." This second review addresses some of the more recent popular foods and dietary patterns that are recommended for CV health to provide clinicians with current information for patient discussions in the clinical setting. Specifically, this paper delves into dairy products, added sugars, legumes, coffee, tea, alcoholic beverages, energy drinks, mushrooms, fermented foods, seaweed, plant and marine-derived omega-3-fatty acids, and vitamin B12., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Oral retinoids are commonly prescribed for many dermatological conditions and may induce hyperlipidemia. We document the case of a 35-year-old man taking acitretin for congenital lamellar ichthyosis associated with a homozygous deleterious mutation in NIPAL4 who developed retinoid-induced hyperlipidemia that responded dramatically to a whole-food plant-based (WFPB) diet. On presentation, his diet consisted of chicken, fish, low fat meats and dairy, grains, and some fruits and vegetables. He then adopted a WFPB diet without making changes to his medications. His serum lipid levels dropped and his exercise capacity improved. Five months later, after discontinuing the plant-based diet and returning to his baseline diet, his hyperlipidemia returned and persisted despite adjustments to his medications. After a year and a half, the patient again adopted a plant-based diet and his lipid levels fell sharply again. A WFPB diet helped improve and control serum lipid levels in a patient with retinoid-induced hyperlipidemia. Future interventions should focus on ways to help patients successfully adopt and maintain a WFPB diet, as increased adherence to a healthy lifestyle is associated with greater health benefits., (Copyright © 2018 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Background: Despite variations in the prevalence of cardiovascular disease and related risk factors among US Hispanic/Latino adults of diverse backgrounds, there is little information on whether disparities exist in the use of medications for the primary and secondary prevention of cardiovascular disease. We examined the prevalence of statin and aspirin use among diverse US Hispanic/Latino adults at high cardiovascular risk., Methods and Results: A multicenter population-based study, the Hispanic Community Health Study/Study Of Latinos, included a total of 16 415 participants of Mexican, Puerto Rican, Cuban, Dominican, South American, and Central American backgrounds who were aged 18 to 74 years and enrolled between March 2008 and June 2011. Our analyses were limited to 4139 participants considered to be at high cardiovascular risk. Age-adjusted prevalence of statin and aspirin use was 25% and 44%, respectively, overall but varied by Hispanic/Latino background among those at high cardiovascular risk; statin use was significantly higher (P<0.001) among adults of Puerto Rican (33%) and Dominican (28%) backgrounds compared with adults of other backgrounds (Mexican, 24%; Cuban, 22%; Central American, 20%; South American, 22%). There was no difference in aspirin use. After adjusting for health insurance coverage, the difference in prevalence of statin use was substantially reduced among participants with a Puerto Rican background, from an odds ratio of 1.73 (95% CI 1.30-2.31) to 1.30 (95% CI 0.97-1.75), and with a Dominican background, from an odds ratio of 1.45 (95% CI 1.04-2.02) to 1.07 (95% CI 0.75-1.52), in comparison to their counterparts., Conclusions: Among Hispanic/Latino adults of diverse backgrounds, statin use was more prevalent among adults with Puerto Rican and Dominican backgrounds at high cardiovascular risk. These differences in statin use were explained, in part, by differences in insurance coverage. These findings have important implications for the prevention of disparities in cardiovascular outcomes within the growing US Hispanic/Latino population., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Objectives: Meditation is a stress reduction intervention that is of potential benefit to patients with cardiovascular disease, but its interest in inner city cardiology patients is unknown. We surveyed patients at an inner city cardiology clinic about their interest in learning meditation and the impact of stress on their lifestyles., Methods: A survey was distributed to 215 consecutive patients in an inner city cardiology clinic. Chi-square tests were used to compare those interested and not interested in meditation., Results: Of the 215 surveys, 54 were excluded because of 2 or more missing responses, leaving 161 for analysis. The mean age was 61 (+/- 16.5) years; 59% were female, 37% were black non-Hispanic, and 34% were Hispanic, and 18% were white. Overall, 46% expressed interest in learning meditation, and 64% agreed that less stress would facilitate living a healthy lifestyle. In subgroup analysis, the highest levels of interest in meditation classes occurred in patients who were younger than 65 years old (69% interested) and those who agreed that less stress would facilitate living a healthy lifestyle (71% interested)., Conclusion: Many of the patients at an inner city cardiology clinic may have interest in learning meditation. Given the effects of stress in this population, clinical trials involving meditation are warranted.

Objective: Because Hispanic ethnicity in the United States is heterogeneous, the purpose of this study was to determine the epidemiology of peripheral arterial disease (PAD) within U.S. Hispanic/Latino groups defined by national background., Methods: This analysis included 9648 men and women older than 45 years enrolled in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). The ankle-brachial index (ABI) was computed as the higher of the posterior tibial and dorsalis pedis systolic blood pressures for each leg divided by the higher brachial artery systolic blood pressure. The index ABI was the higher of the two. An ABI ≤0.90 was the criterion for the presence of PAD., Results: The mean age was 56 years, and 55% were female. Overall, the prevalence of an ABI ≤0.90 (PAD), 0.90 to 0.99 (borderline), 1.0 to 1.39 (normal), and ≥1.40 (high) was 5.7%, 19.3%, 72.5%, and 2.6%, respectively. After multivariable adjustment for PAD risk factors and compared with Mexicans, Cubans had a nearly threefold higher odds for PAD (odds ratio, 2.9; 95% confidence interval, 1.9-4.4). The odds of PAD for the other Hispanic/Latino groups ranged from 1.2 to 1.8. Although men had a more than threefold higher odds of an ABI ≥1.40 (3.6; 2.0-6.5), the odds did not differ significantly by Hispanic/Latino background., Conclusions: Compared with Mexican Americans, all other Hispanic/Latino background groups have a significantly higher odds of having PAD, with the odds being nearly threefold higher among Cubans., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

A 60-year-old man presented with typical angina and had a positive stress test. He declined both drug therapy and invasive testing. Instead, he chose to adopt a whole-food plant-based diet, which consisted primarily of vegetables, fruits, whole grains, potatoes, beans, legumes, and nuts. His symptoms improved rapidly, as well as his weight, blood pressure, and cholesterol levels. Plant-based diets have been associated with improved plasma lipids, diabetes control, coronary artery disease and with a reduction in mortality. Adoption of this form of lifestyle therapy should be among the first recommendations for patients with atherosclerosis.

Low-flow low-gradient aortic stenosis with normal ejection fraction (LFLGNEF AS) is a newly characterized poorly understood entity within the AS spectrum. Whether LFLGNEF AS has a worse prognosis than typical AS remains controversial. We retrospectively identified 4,546 individual patients with any type of AS on echocardiogram from 2003 through 2013 and categorized them into 5 cohorts: (1) mild AS, (2) moderate AS, (3) severe AS, (4) LFLGNEF AS (ejection fraction≥55%), and (5) low-flow low-gradient low ejection fraction AS (LFLGLEF AS; ejection fraction<55%). Survival analysis was used to compare outcomes of LFLGNEF AS with those of the other cohorts. AS was classified as mild in 591 patients, moderate in 2,358, severe in 500, LFLGNEF in 776, and LFLGLEF in 318. The study group had a mean age of 80.5 years, 61% were women, and the patients were followed for 2.26±1.16 years. Among subjects managed without valve replacement, total mortality for the LFLGNEF AS group was lower compared with that in both the severe AS and the LFLGLEF AS groups (p=0.007 and p<0.001, respectively). The prognosis for LFLGNEF AS was worse, however, compared with those with mild and moderate AS (p<0.001, both). In conclusion, no survival differences were found among AS types among those who received valve replacement. The survival rate in LFLGNEF is better than that in severe AS or LFLGLEF but is worse than that in mild or moderate AS. Valve replacement seems reasonable to pursue in select patients., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Peripheral arterial disease (PAD) is common and carries an increased risk of morbidity and mortality. The level of knowledge among incoming medical trainees about PAD is unknown. During orientation to a single internal medicine residency program, incoming medical interns were given a 19-question multiple-choice questionnaire. The questions fell into 1 of 4 categories about PAD: (1) prevalence, (2) screening, (3) treatment, and (4) outcome. Sixty-two incoming interns were queried. The percentage of questions answered correctly overall was 41.7% (10.5%-73.7%). The percentage of questions answered correctly in the prevalence, screening, treatment, and outcome groups were 48.9% (0 to 100%), 33.8% (0 to 80%), 45.0% (0 to 87.5%), and 42.5% (0 to 100%), respectively. Internal medicine interns have poor knowledge about PAD including its prevalence, screening, treatment, and outcomes. Increased education during medical school is encouraged.

Background: Despite the 2008 revision of a previously issued black box warning of the US Food and Drug Administration against the use of perflutren ultrasound contrast agents, the warning still reports fatalities having occurred following their administration. We sought to assess 1-day mortality associated with contrast use across a wide range of clinical settings and co-morbidities., Methods: We conducted a retrospective study involving 96,705 transthoracic echocardiograms (TTE) in 63,189 adults at our institution between July 2003 and June 2008. A contrast agent was used in 2,518 TTE during this time. The primary outcome was total mortality within 1 day of TTE., Results: Death occurred in 10 patients (0.44%) in the contrast group and in 421 patients (0.69%) in the non-contrast group (p = 0.14). In a multivariate model, use of contrast enhancement was not associated with increased mortality (p = 0.67) after adjustment for age, gender, race, patient location, ejection fraction, and the presence of various co-morbidities. Cause of death analysis did not identify any cases where contrast played a likely role., Conclusion: Definity contrast use during TTE was not associated with increased acute mortality risk. Contrast administration during TTE should not be withheld when the additional information obtained could potentially improve patient management., (Copyright © 2012 S. Karger AG, Basel.)

Background: Transient ischemic dilation (TID) in the setting of an abnormal SPECT radionuclide myocardial perfusion imaging (MPI) study is considered a marker of severe and extensive coronary artery disease (CAD). However, the clinical significance of TID and its association with CAD in patients with an otherwise normal MPI study is unclear., Methods: From a database of patients who underwent MPI over a 9-year period, 96 without known cardiac history who had normal image perfusion patterns, and who underwent coronary angiography within 6 months, were identified. TID quantitative values were derived. To adjust for varying stress and image protocols, a TID index based on published threshold values was derived for each patient, with >1 considered as TID. We examined the relationship of TID to the presence/extent of CAD, and to a CAD prognostic index. TID was also correlated with patient survival. To address referral bias, survival in a separate cohort of 3,691 patients with a normal perfusion MPI who did not undergo angiography in the 6-month interval was correlated with the presence and severity of TID., Results: For 28 (29.2%) patients with normal MPI perfusion patterns but with TID, there was no increased incidence of CAD, multivessel or left main disease, or a higher prognostic index compared with no TID. In addition, there was no increased mortality associated with TID in both the angiography cohort and in the patients who did not undergo immediate angiography., Conclusions: TID in patients with an otherwise normal SPECT MPI study does not increase the likelihood of CAD, its extent or severity, and is not associated with worsened patient survival.

Background: There is growing evidence that periodontal disease may be a source of systemic inflammation that impacts overall health. As such, periodontal disease is associated with an increased risk of systemic illnesses such as cardiovascular disease and adverse outcomes in diabetes mellitus and pregnancy. With the aim of assessing oral health knowledge and orientations of physicians in training, we surveyed incoming internal medicine trainees about their general knowledge, attitudes, and behaviors/practices about periodontal health and disease., Methods: A 16-question survey was distributed during orientation to incoming internal medicine trainees at a single urban teaching hospital in New York City in 2007 and 2008. Questions aimed to assess the knowledge levels of the subjects about periodontal disease and their attitudes toward discussing/evaluating the periodontal status of their patients. The study was approved by the Montefiore Institutional Review Board., Results: Of 125 incoming medical trainees queried, 115 responded (92% response rate). Of the 115 responders, 96% were medical interns. The median age of the trainees was 27 years (interquartile range: 26 to 29 years), and 61% were female. Overall, 34% of the trainees answered all five true/false general knowledge questions correctly, 82% reported that they never asked patients if they were diagnosed with periodontal disease, 90% reported not receiving any training about periodontal disease during medical school, 69% reported that they were not comfortable at all performing a simple periodontal examination, 17% agreed that patients expect physicians to discuss/screen for periodontal disease, 46% felt that discussing/evaluating the periodontal status of their patients was peripheral to their role as physicians, 76% reported never screening patients for periodontal disease, and 23% stated that they never referred patients to dentists., Conclusions: In this study, incoming internal medicine trainees had inadequate knowledge regarding periodontal disease. They were also generally uncomfortable with performing a simple periodontal examination. Oral health training in medical school and the medical postgraduate setting is recommended.

Background: The effect of beta (beta) blockers on the accuracy, particularly the sensitivity, of vasodilator radionuclide myocardial perfusion imaging (MPI) is not entirely clear. This study aimed to further assess the effect of beta-blockers on the ability of MPI to identify significant and high-risk coronary artery disease (CAD)., Methods and Results: For 555 patients who underwent vasodilator MPI and had coronary angiography within 90 days, global and per-vessel sensitivities and specificities were calculated, and were found to be similar between patients taking beta-blockers and those who were not. beta-blockers did not decrease the ability to detect patients with multivessel disease. Summed stress scores and summed rest scores were likewise similar in both groups. To account in part for catheterization referral bias and the potential of false-negative MPI studies in patients receiving beta-blockers, survival analysis was performed on 2646 patients with normal MPI studies who did not undergo cardiac catheterization and failed to demonstrate significant mortality difference related to the taking of beta-blockers., Conclusions: beta-blocker therapy does not diminish the ability of vasodilator stress MPI to detect clinically significant CAD, nor hide the mortality risk of patients with normal studies not referred for catheterization.

Background: Newer three-dimensional imaging technologies provide insight into cardiac shape and geometry from views previously unobtainable. Standard formulae like the continuity equation (CE) that rely on inherent assumptions about left ventricular outflow tract (LVOT) shape may need to be revisited. In the CE, small changes in LVOT diameter may significantly change calculated aortic valve area (AVA). Using 64-slice Multi-detector CT (MDCT), we performed LVOT planimetry to obviate the need for any geometric assumptions., Methods: 64-slice MDCT was performed in 30 consecutive patients. The diameter-derived LVOT area (ALVOTdiam) was calculated from a view analogous to the 2D echo parasternal long axis. Direct planimetry of the LVOT (ALVOTplan) was performed just beneath the aortic valve in a plane perpendicular to the LVOT long axis. Further, assuming an ellipsoid outflow tract shape, LVOT area (ALVOTellip) was calculated using piab from the long and short diameters of the planimetered LVOT view. Eccentricity index (EI) was estimated by subtracting the ratio of shortest and longest LVOT diameters from one., Results: ALVOTdiam always measured smaller than ALVOTplan (mean 3.7 +/- 1.2 cm2 vs. 4.1 +/- 1.3 cm2, respectively). The median EI was 0.18 (95% CI = 0.16-0.2; P = 0.0001). ALVOTellip more closely agreed with ALVOTplan (correlation = 0.96; P < 0.0001) than did ALVOTdiam (correlation = 0.87; P < 0.0001)., Conclusion: Using MDCT, the LVOT was shown to be elliptical in most patients. Applying the CE which assumes roundness of the LVOT consistently underestimated the LVOT area which may affect estimated AVA. Planimetry of the LVOT utilizing three-dimensional imaging modalities such as 3-D echocardiography, MRI, or MDCT may render a more precise AVA.

Background: Classification of diastolic heart function is best defined by the degree of leftward and upward shift of the diastolic pressure-volume relationship (DPVR). Direct measurement of DPVR, however, requires invasive techniques. Increased left atrial (LA) size is a marker of left ventricular (LV) diastolic hypertension, and so, the LA/LV diameter ratio has the potential to mark the degree of upward and leftward shift in the LV-DPVR. We thus investigated the association of this novel marker with exposures known to induce diastolic dysfunction and with clinical evidence of diastolic dysfunction., Methods and Results: Reports from 7,803 patients undergoing maximal exercise stress echocardiography were reviewed. Increased LA/LV diameter ratio predicted diminished exercise capacity (P < 0.001) in a multivariate regression analysis. Increased LA and decreased LV diameters were each independently associated with exercise capacity (P < 0.001, both). Increased LA/LV diameter ratio was associated with hypertension (P = 0.001), diabetes (P = 0.03) and with increased severity of LV hypertrophy (P< 0.001). Those with LA/LV diameter ratio > or = 1.0 were more likely to use loop diuretics, odds ratio = 2.5 [95% CI, 1.4, 4.5], compared to those with lower ratio values., Conclusions: Increased LA/LV diameter ratio was observed in subjects with hypertension, diabetes and LV hypertrophy. Increased ratio predicted worse exercise capacity and was associated with more frequent loop diuretic use. These data are consistent with the hypothesis that this ratio is a noninvasive marker of the LV-DPVR.

Background: Determination of the left ventricular outflow tract cross-sectional area (ALVOT) is necessary for calculating aortic valve area (AVA) by echocardiography using the continuity equation (CE). In the commonly applied form of CE, pir(2) is used to estimate ALVOT utilizing the assumptions that LVOT is round and the parasternal long axis (PLAX) plane bisects LVOT. Imaging LVOT using real time 3D echocardiography (RT3DE) eliminates the need for these assumptions. We tested the hypothesis that LVOT is round based on a formula for eccentricity., Methods and Results: In 53 patients, 2D echocardiography (2DE) and RT3DE were acquired. ALVOT was calculated by 2DE using pir(2) (ALVOT-2D). Using RT3DE, ALVOT planimetry was performed immediately beneath the aortic valve (ALVOT-3Dplan). Eccentricity Index (EI) was calculated using the shortest and longest LVOT diameters. The long axis was measured to be larger by 0.53 cm +/- 0.36 (P < 0.005). The median EI was 0.20 (0.00-0.54), indicating that half the subjects had at least a 20% difference between the major and minor diameters. ALVOT-3Dplan was larger than ALVOT-2D (3.73 +/- 0.95 cm(2) vs. 3.18 +/- 0.73 cm(2); P < 0.001) by paired analysis. Using the equation of an ellipse (piab), ALVOT-3Dellip was 3.57 +/- 0.95 resulting in improved agreement with ALVOT-3Dplan., Conclusions: In our small patient sample with normal aortic valves, we showed the LVOT shape is usually not round and frequently, elliptical. Incorrectly assuming a round LVOT underestimated the ALVOT-3Dplan and consequently the AVA by 15%. Investigating the LVOT in aortic stenosis is warranted to evaluate whether RT3DE may improve measurement of AVA.

We report a case of pseudodyskinesis, where there is dyssynchronous contraction of the heart's diaphragmatic wall despite normal wall thickening. This finding has previously been reported in a small group of patients with liver disease, and has been attributed to elevation of the diaphragm as a result of hepatomegaly and ascites. Our case demonstrates similar findings in a patient without liver disease, in whom the diaphragm was elevated secondary to volume loss in the chest. Our case supports the assertion that diaphragmatic elevation, regardless of cause, is indeed responsible for this probably common echocardiographic finding.

We present the case of a 40 year-old man with biventricular nonvalvular vegetations presenting with acute onset of unilateral hearing loss and headache as a result of septic emboli. The medical literature involving the rare diagnosis of mural vegetation is reviewed and unusual features of this case are discussed.

Background: The role of statin drugs in the reduction of serum lipids has been well documented. More recently, evidence suggesting that statins may positively impact many organ systems and disease states independent of lipid reduction has emerged. The term "pleiotropic effects" has been used to refer to these properties. We reviewed the evidence exploring such potential effects., Methods: A search of the MEDLINE database was conducted for articles published between 1985 to 2005 on the pleiotropic and the lipid-lowering independent effects of statin drugs. The search terms "statin", "HMG-CoA reductase inhibitor", "pleiotropic effects", and "inflammation" were used. English language articles were selected for inclusion along with selected cross-references., Results: Numerous animal and clinical studies support the presence of a spectrum of beneficial effects for statins that are independent of their lipid-lowering properties. These effects are mediated by a variety of mechanisms and they suggest that the therapeutic role of statins may expand., Conclusion: Statins have shown great promise beyond their lipid-lowering effects. Ongoing and future studies will help to further clarify the potential clinical impact of these "pleiotropic effects".

Background: A 71-year-old woman presented with severe chest pain after an episode of acute emotional distress. Her serum levels of cardiac enzymes were slightly elevated and electrocardiography revealed anterior ST-segment elevations. Significant coronary stenoses were excluded. A left ventriculogram revealed apical ballooning and a hypercontractile basal segment., Investigations: Serum cardiac enzyme measurements, echocardiography, coronary angiography and left ventriculography., Diagnosis: Takotsubo cardiomyopathy., Management: Treatment with beta-blockers, aspirin, angiotensin-converting-enzyme inhibitors, and intravenous diuretics.

Objective: The CD40/CD40 ligand pathway mediates inflammatory processes important in atherogenesis and the formation of the intraplaque lipid pool. We tested the hypothesis that plasma levels of soluble CD40 ligand are elevated in patients with evidence of a lipid pool on high-resolution magnetic resonance imaging (MRI) of carotid stenoses., Methods and Results: We recruited 49 patients with evidence of carotid atherosclerosis on ultrasonography; 3 patients could not undergo carotid MRI because of claustrophobia. The remaining 46 patients underwent high-resolution MRI of the carotid arteries. Two radiologists blinded to all other data determined the presence or absence of an intraplaque lipid pool based on the loss of signal between the 20-ms echo time (TE20) and the fat-suppressed TE55 fast spin-echo images. Plasma levels of soluble CD40 ligand were determined by ELISA. Baseline levels of soluble CD40 ligand were higher among patients with evidence of intraplaque lipid (n=14) than among those without it (n=32; median, 2.54 ng/mL; interquartile range [IQR], 1.85 to 3.52 vs median, 1.58 ng/mL; IQR, 1.21 to 2.39; P=0.02). In contrast, soluble CD40 ligand levels were not correlated with percent diameter stenosis (r=-0.19; P=0.21). The relative risk for intraplaque lipid associated with soluble CD40 ligand levels above the median was 6.0 (95% confidence interval, 1.15 to 31.23; P=0.03). The magnitude of this predictive effect did not substantially change after adjustment for traditional cardiovascular risk factors (relative risk, 5.12; 95% confidence interval, 0.78 to 33.73; P=0.09)., Conclusions: Plasma levels of soluble CD40 ligand may predict patients with features of high-risk atherosclerotic lesions. These data provide novel insight into the mechanism through which elevated levels of soluble CD40 ligand may reflect cardiovascular risk in humans and illustrate the potential value of interfacing high-resolution MRI with studies of vascular inflammation.

We have developed methods for the measurement of the medium-chain fatty acids octanoate, decanoate and cis-4-decenoate and the acylglycines n-hexanoylglycine (HG) and 3-phenylpropionylglycine (PPG) in blood spots using gas chromatography and mass spectrometry. Normal ranges were obtained for octanoate and decanoate. HG, PPG and cis-4-decenoic acid were not detected in control blood spots. In blood spots from nine patients (including two newborn) with medium-chain acyl-CoA dehydrogenase (MCAD) deficiency, all metabolites were present in elevated concentrations although PPG was close to the detection limits and there was overlap for octanoate and decanoate. The lack of detection of cis-4-decenoic acid and HG in controls suggests that these are the metabolites of choice for blood spot identification of infants with MCAD deficiency.