Uncaptured rates of postpartum venous thromboembolism: a US national analysis.

OBJECTIVE: To quantify the proportion of postpartum venous thromboembolism (VTE) readmissions, including those that occur at different hospitals from index admission, and describe risk factors for this outcome. DESIGN: Retrospective observational study. SETTING: US hospitals included in the Nationwide Readmissions Database. SAMPLE: A total of 3 719 238 patients >14 years of age with a delivery-associated hospitalisation in 2014. METHODS: Univariate analysis was performed to identify patient and hospital factors associated with readmissions. Significant factors were included in multivariate logistic regression to identify independent risk factors. Results were weighted for national estimates. MAIN OUTCOME MEASURES: Readmission with VTE to both index and different hospitals at 30, 60 and 90 days. RESULTS: The VTE cumulative readmission rate was 0.053% (n = 1477), 0.063% (n = 1765) and 0.069% (n = 1938) at 30, 60 and 90 days, respectively. Patients were readmitted to different hospitals 31% of the time within 90 days. Risk factors for different hospital VTE readmission were unique and included younger age and initial admission to a small/medium-sized hospital. Initial admission to a for-profit hospital increased the likelihood of readmission to a different hospital. CONCLUSIONS: Nearly one in three postpartum VTEs are missed by the current quality metrics, with significant implications for outcomes and quality. For-profit hospitals have a significant portion of their VTE readmissions hidden, falsely lowering their readmission rates relative to public hospitals. TWEETABLE ABSTRACT: US analysis shows 1 in 3 readmissions for postpartum venous thromboembolism currently missed.

Regression of left ventricular hypertrophy in patients with essential hypertension. Results of 6 month treatment with indapamide.

Left ventricular hypertrophy (LVH) is a major risk factor for cardiovascular morbidity in hypertensive patients. The effects of diuretics on LVH have raised controversies, but recent studies suggest that diuretics are able to reduce LVH in hypertensive patients, mainly through a reduction in ventricular diameter. The present multicenter open study was designed to test the effects of indapamide, a widely used nonthiazide diuretic, on LVH in patients with essential hypertension. Patients had to have mild-to-moderate essential hypertension (supine diastolic blood pressure [sDBP] 95 to 115 mm Hg) with echocardiographic evidence of LVH (left ventricular mass index [LVMI] > 130 g/m2 for men and > 110 g/m2 for women). After a 2 week placebo run-in period, eligible patients underwent a 6 month treatment with 2.5 mg indapamide daily. All echograms were performed by the same investigator before and after 6 months of indapamide. Clinical and biological acceptability and quality of life (visual analog scale) were also studied. One hundred and thirty patients were included in the study and 112 completed the trial. Indapamide induced a significant reduction i systolic and diastolic blood pressures. Indapamide induced a marked reduction in posterior wall thickness (from 12.1 +/- 2.0 to 11.2 +/- 1.6 mm) and in interventricular wall thickness (from 12.7 +/- 1.7 to 11.8 +/- 1.9 mm; each P < .001) and a slight decrease in left ventricular diameter (P = .049). This resulted in a 13% reduction in LVMI (from 161.9 +/- 37.9 to 140.7 +/- 33.8 g/m2, P < .001). Left ventricular fractional shortening remained unchanged. There was no significant relation between changes in LVMI and changes in systolic, diastolic, or mean blood pressure. No significant adverse clinical or biological effects were reported during the study. The increased score of the visual analog scale indicated that overall well-being was improved (P < .001). Our study indicates that indapamide, in addition to blood pressure control, is able to reduce LVH. This effect was achieved mainly through a reduction in wall thicknesses rather than in internal cavity diameter.

Efficacy and safety of pravastatin in African Americans with primary hypercholesterolemia.

BACKGROUND: Coronary artery disease strikes early and may prove particularly severe in persons of African-American descent. Therefore, we studied the lipid-lowering efficacy and safety of pravastatin sodium (20 mg/d), a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, in 245 African-American patients with primary hypercholesterolemia. METHODS: After 4 weeks on an American Heart Association phase I low-fat diet, patients were randomized in a double-blind manner to either pravastatin or placebo in a 3:1 ratio. RESULTS: After 12 weeks of pravastatin treatment, low-density lipoprotein cholesterol levels declined 25.8%, total cholesterol levels 20.3%, and triglyceride levels 6.2%, while high-density lipoprotein cholesterol levels remained essentially unchanged. Overall, 72% of pravastatin-treated patients achieved reductions in low-density lipoprotein cholesterol level in excess of 20%, and 44% attained declines in excess of 30% (both P < .01 vs placebo). Pravastatin was generally well tolerated in this population, with one patient (0.5%) exhibiting a reversible myopathy with creatine kinase elevations to 10 times the upper limit of normal. No substantial elevations of aminotransferase levels of two to three times the upper limit of normal occurred in either the pravastatin or the placebo group. Drug compliance was high, exceeding 90%. CONCLUSION: Pravastatin appears to be an effective and safe lipid-lowering agent and is the first 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor to be studied extensively in this underrepresented population.

Distensibility of small pulmonary blood vessels.

Although vasomotor activity in small pulmonary vessels has been studied extensively in the past, using the concept of resistance to flow, information on the distensibility of these vessels is very sparse. In an attempt to reduce this deficit, we adapted a theoretical method developed for small systemic vessels, to estimate distensibility of pulmonary resistance vessels in experimental animals and man. Pressure-flow data from 11 dogs and 10 human subjects (5 control subjects and 5 patients with long-standing left heart failure) were used to calculate distensibility of small pulmonary vessels. The conductance, G, was calculated from these data as the ratio of blood flow to driving pressure. The slope of the relationship between the logarithm of G1/4 and the average distending pressure (ADP) provides a graphic picture of circumferential extensibility, E, defined as percent change in radius for an infinitesimal change in ADP. Results indicate that: (1) the value of E in dogs was 1.85 +/- .40 mmHg-1 for the control state, which decreased to 1.45 +/- .43 mmHg-1 during norepinephrine administration; however, the decrease in the value was not statistically significant (p = 0.53); (2) the value of E in control human subjects was 3.38 +/- .47 mmHg-1 and the value of E in patients with left heart failure was -0.64 +/- 0.39 mmHg-1; the difference was significant (P = .0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Discordance in degree of right and left ventricular dilation in patients with dilated cardiomyopathy: recognition and clinical implications.

OBJECTIVES: The purpose of the present study was to assess the influence of variations in the relative degree of dilation of left and right ventricular chambers on the clinical outcome of patients with dilated cardiomyopathy. BACKGROUND: Dilated cardiomyopathy, a primary myocardial disease characterized by ventricular dilation and systolic dysfunction, is generally associated with a poor prognosis. However, considerable variability has been observed in the clinical course and the morphologic and hemodynamic features in individual patients. METHODS: We evaluated 67 consecutive patients with dilated cardiomyopathy and without evidence of ischemic or primary valvular heart disease. On the basis of diastolic ventricular chamber area measurements obtained by echocardiography, patients were classified into two groups: 38 patients with a relatively equal degree of left and right ventricular dilation (LV congruent to RV) and 29 patients with predominant and disproportionate dilation of the left ventricle (LV > RV). RESULTS: The 67 patients ranged in age from 19 to 81 years (mean 56); 49 (73%) were male. The two subsets of patients with dilated cardiomyopathy did not differ with regard to age, left ventricular diastolic dimension, wall thickness and mass or ejection fraction. However, patients in the LV congruent to RV group showed more severe mitral and tricuspid regurgitation by Doppler echocardiography than did those in the LV > RV group (p = 0.01 for mitral and 0.004 for tricuspid regurgitation). Over the follow-up period of 2 to 60 months (mean 28), there were 19 deaths. Survival in the LV > RV group was significantly better than in the LV congruent to RV group (p = 0.03). CONCLUSIONS: Patients with dilated cardiomyopathy represent a heterogeneous group with regard to both clinical outcome and the relative degree of left and right ventricular chamber dilation. Patients in the LV > RV subset appear to have better overall survival and less severe mitral and tricuspid regurgitation than do patients in the LV congruent to RV subset. Longitudinal studies are needed to determine whether these morphologic subsets in fact represent a continuum within the disease spectrum of dilated cardiomyopathy.

How extracellular potassium affects intracellular sodium pool in human erythrocytes.

In order to evaluate the regulation of intracellular sodium and potassium balance, we investigated the Na+/K(+)-ATPase independent 22Na+ uptake and concentrations of Na+ in erythrocytes from eleven normal subjects. The experiments were performed with the purified erythrocyte suspensions in different assay buffers containing (i) 5 mEq/L KCl and varying amounts of NaCl (5 to 100 mEq/L); and (ii) a range of KCl (5 to 100 mEq/L) and a constant amount of NaCl (5 mEq/L). These erythrocyte suspensions were incubated at 37 degrees C for 30 minutes to assess ouabain insensitive 22Na+ uptake. Erythrocytes (2.0 x 10(9)/mL) showed an uptake of 2.03 to 0.88%, and 2.00 to 1.15% of the total 22Na+ present in the media under these experimental conditions, respectively. The 22Na+ uptake by erythrocytes was decreased by a gradual increase of either NaCl or KCl in the assay buffers. Erythrocytes in the experimental condition (i) showed an increase in intracellular sodium [Na+]i from 8.29 to 10.06 mEq/L. However in the condition (ii), KCl up to 20 mEq/L extracellularly caused a limited inhibition of [Na+]i accumulation (8.29 to 8.23 mEq/L), however, when KCl was raised extracellularly greater than 20 mEq/L it enhanced [Na+]i slowly (8.23 to 9.19 mEq/L). When NaCl 20, 50 and 100 mEq/L were replaced by an equivalent amount of KCl in the assay buffers, this extracellular K+ prevented 7, 6 and 10% [Na+]i accumulation, respectively. We also found that bicarbonate induced ouabain resistance 22Na+ influx was both inhibited and stimulated depending upon the amount of KCl in the assay media.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical relevance of distal arterial compliance.

AIM: To calculate the compliance of resistance vessels. METHODS: Pressure-flow data (plethysmographic and sphygmomanometric) were obtained non-invasively from six normal and six hypertensive subjects, and the results were compared with similar data obtained previously from large blood vessels. The parameter used to represent compliance was extensibility (E), defined as the percentage change in radius for a given change in pressure. RESULTS: The hand vessels of hypertensive subjects (E = 0.126 +/- 0.034/mmHg) were significantly stiffer (P < 0.02) than those of the normotensive subjects (E = 0.272 +/- 0.047/mmHg); and the values of E for the resistance vessels were larger than those for the large arteries.

Antihypertensive and metabolic effects of concomitant administration of terazosin and methyclothiazide for the treatment of essential hypertension.

The efficacy and safety of once-daily 2.5- or 5.0-mg methyclothiazide (MCTZ) added to once-daily 5.0-mg terazosin (TRZ) versus 5.0-mg TRZ alone was evaluated in this double-blind, multicenter study. All patients received TRZ during a 6-week titration period. Hypertensive patients (222) (mean blood pressure of 159/104 mm Hg) were randomized to one of three treatment groups: TRZ alone (N = 76); TRZ+MCTZ-2.5 mg (N = 74); and TRZ+MCTZ-5.0 mg (N = 72) for the 8-week double-blind period. Changes in the supine and standing SBP/DBP from preTRZ period were: TRZ alone (-4.8/-8.1 and -2.6/-6.1 mm Hg); TRZ+MCTZ-2.5 mg (-17.3/-12.4 and -16.0/-11.2 mm Hg); and TRZ+MCTZ-5.0 mg (-20.6/-14.4 and -23.3/-14.6 mm Hg). Blood pressure changes in the combination groups were significantly greater than those in the TRZ alone group. However, there were no statistically significant differences between the TRZ+MCTZ-2.5-mg and TRZ+MCTZ-5.0-mg groups. The combination of TRZ and MCTZ tends to mitigate the adverse effects on serum glucose, uric, potassium and lipids usually associated with thiazide diuretics. Thus, combination treatment that begins with TRZ and adds MCTZ is effective in lowering blood pressure without any significant adverse metabolic effects.

Coronary artery disease in African-Americans.

Contrary to opinions generally accepted in the past, CHD is very common in both African-American men and women, with incidence rates approaching those of US Caucasians. Higher prevalence of hypertension, diabetes, cigarette smoking, and obesity all contribute to the high level of CHD in African-Americans. Additional research is needed about the interrelations and management of various risk factors for CHD in African-Americans outside of the sudden death of African-Americans outside of the hospital is urgent, and special attention should be given to accessibility and use of health services by minority populations.

Coronary artery disease in blacks: past perspectives and current overview.

It is difficult to draw strong conclusions from the available data. One must simply accept the fact that vital statistics show that cardiovascular disease is the most common cause of death among black Americans. Health care providers, policymakers, and funding agencies should use this information to develop preventive and therapeutic strategies to conquer this dreadful disease.

Preparticipation echocardiographic screening for cardiovascular disease in a large, predominantly black population of collegiate athletes.

Sudden death in young competitive athletes is most commonly due to underlying cardiovascular disease. Echocardiography has the potential to identify structural cardiovascular abnormalities, such as hypertrophic cardiomyopathy (HC), that have been incriminated in such events. In this study, echocardiography (2-dimensional and M-mode) was used as a primary screening test to assess 265 Howard University collegiate athletes for cardiovascular disease; 262 (99%) were black. Most athletes (234, 88%) had no definitive echocardiographic evidence of HC or other major cardiovascular diseases, but 30 (11%) had mitral valve prolapse, and 1 other athlete had a small atrial septal defect. In addition, 4 athletes were identified as having mild systemic hypertension. Most athletes (236 of 265) showed normal left ventricular wall thickness of less than or equal to 12 mm, but an important minority (29, 11%) had maximal ventricular septal thicknesses of greater than or equal to 13 mm that could not always be distinguished (by morphology alone) from mild anatomic expressions of nonobstructive HC. Based on this experience, preparticipation athletic screening using echocardiography as the primary test does not appear to be justified on a cost-effective basis. In addition, the substantial minority of subjects with increased wall thickness made clinical interpretation of the echocardiographic findings difficult in individual athletes.

Anomalous coronary artery originating from the left anterior descending artery and ending in a blind aneurysm.

To the authors' knowledge this is the first report of an anomalous coronary artery originating from the left anterior descending artery and ending in a blind aneurysm.

A simpler procedure to study sodium-22 uptake (ouabain insensitive) in human erythrocytes.

We report a modification of the technique of Mahoney et al. (Blood 1982; 59: 439) for the determination of sodium-22 (22Na+) uptake in human erythrocytes. This modification facilitates the separation of 22Na+ taken up by erythrocytes from the free 22Na+ in the buffer by the addition of dibutyl phthalate, which forms an immiscible layer between the two. To further improve the sensitivity of 22Na+ uptake, we incubated a range of known numbers of erythrocytes with 22Na+ as opposed to the single cell suspension of known hematocrit used in Mahoney's et al. procedure (1). Erythrocytes are incubated in KCI buffer containing 2627 Bq (0.071 microCi) 22Na+ in a total volume of 0.5 mL for 0.5 h at 37 degrees C. Incubation is terminated by placing the tubes in ice for 10 min and the amount of 22Na+ taken up by the erythrocytes determined. We observe a linear relationship between erythrocyte concentrations (0.5 to 2.5 X 10(9) cells/mL) and percent uptake of 22Na+ (0.37 +/- 0.06 (1 SD) to 1.85 +/- 0.27 (1 SD) of the total 22Na+, respectively). The procedure is simple and sensitive, and can be used in clinical laboratories for the routine evaluation of 22Na+ uptake in erythrocytes.

Comparison of human erythrocyte insulin binding and adenosinetriphosphatase activity.

Twelve healthy, non-obese male volunteers were selected to measure cellular magnesium (Mg(++)), calcium (Ca(++)), sodium/potassium (Na(+)/K(+)), and adenosinetriphosphatase (ATPase) activities. Measurements were performed using a crude hemolysate as well as a membrane fraction representing cytosolic pump activity. Binding-site data were subjected to Scatchard analysis for determination of receptor number and affinity.There were 432 ± 1.87 insulin-binding sites per cell. ATPase activity was measured in units of moles of inorganic phosphate (Pi) released per gram of hemoglobin (Hgb) every two hours (µmol of Pi/g of Hgb/2 h). Na(+)/K(+)-ATPase activity in the hemolysate and membrane fractions was 18 ± 0.99 µmol of Pi/g of Hgb/2 h and 11.0 ± 0.88 µmol of Pi/g of Hgb/2 h, respectively. Calcium-ATPase activity was 136 ± 1.92 µmol of Pi/g of Hgb/2 h in the hemolysate, and 82 ± 2.07 µmol of Pi/g of Hgb/2 h in the membrane. Magnesium-ATPase activity in these fractions measured 24 ± 1.09 and 16 ± 0.91, respectively.Linear regression analysis of binding capability vs pump activity failed to disclose a significant relationship. Given the narrow range of values in this small study group, a much larger sample size will be required before a relationship can be established.

Coronary artery bypass grafting in a predominately black group of patients.

The preoperative profiles of a predominately non-white group of patients undergoing coronary artery bypass grafting were reviewed. Data were obtained from a retrospective analysis of medical records of 163 patients operated on at Howard University Hospital between July 1983 and July 1986. The analysis was carried out primarily to determine whether patients requiring myocardial revascularization were somehow different from their non-black counterparts. Ninety-one percent of the patients were black, 5 percent white, 0.5 percent Hispanic, and 3.5 percent others (Iranian, Filipino, etc).The study was not designed to review the prevalence of coronary disease in blacks, or to determine the natural history following coronary artery bypass grafting, but to determine whether those with established coronary disease of such a severity as to warrant revascularization had the usual clustering of risk factors. Patient records were reviewed to determine the prevalence of hypertension, diabetes, obesity, cigarette smoking, previous myocardial injury, and total serum cholesterol. Because of the well-recognized increased incidence of hypertension in black patients, and its role as a major risk factor in coronary heart disease, the sequelae of hypertension were considered in relation to results of surgical therapy.The study population included 93 men (57 percent) and 70 women (43 percent); mean age was 59 years (fourth to ninth decade). Seventy-four percent of the patients were hypertensive, 35 percent were diabetic, and 77 percent had a smoking history. Obesity was prevalent among the female patients in general, with 36 percent of the diabetics and 21 percent of the nondiabetics being greater than 50 percent over ideal body weight. Ninety percent of the female patients and 80 percent of the male patients presented with New York Heart Association class III or IV angina. Left ventricular function was, on the average, well preserved. The immediate surgical mortality (following exclusion of patients in extremis) was 4 percent. The surgical mortalities were related to easily identifiable factors. Peri-operative infarctions were profoundly influenced by the presence of diabetes.Although this group was distinguished from most reported groups of patients undergoing aortocoronary bypass grafting by the presence of advanced age, the large percentage of women and diabetics and the marked prevalence of hypertension, and the usual risk factors for coronary artery disease reported in the majority population, the study reconfirms previous epidemiologic findings. It appears that racial "clumping" of a heterogeneous non-white population has minimal usefulness, except as it may be related to socioeconomic status and access to quality health care.

Comparative efficacy and safety of immediate-release and controlled-release hydralazine in black hypertensive patients.

Twenty-nine black hypertensive patients were randomized to treatment with controlled-release hydralazine capsules administered BID or QD, or immediate-release hydralazine tablets administered TID, for at least four weeks in a double-blind, parallel study. Hydralazine was begun after a two-week to four-week period in which blood pressure was not adequately controlled with diuretics alone. Each patient initially received 75 mg/day of the assigned drug. The dosage could be increased to 150 or 300 mg/day at weekly intervals if sitting diastolic blood pressure was not adequately controlled (greater than 90 mmHg). A beta-blocker (80 mg/day of nadolol) was added only for patients who had beta-blocker-responsive adverse effects that could not be controlled otherwise. Nine patients were considered unevaluable because of protocol violations or withdrawal from the study before completion of four weeks of treatment, primarily because of adverse effects. Twenty patients were included in the efficacy evaluation. Controlled-release hydralazine BID produced statistically significant mean falls from baseline in sitting diastolic blood pressure and in standing systolic blood pressure and an almost significant drop in standing diastolic blood pressure. Although the other two treatment groups also had substantial falls in all blood pressure measurements, the changes from baseline were not statistically significant. No significant difference in response was noted between patients who received a beta-blocker and those who did not. There were no statistically significant differences among the three treatment groups in incidence and severity of adverse effects or electrocardiographic abnormalities. A statistically, but not clinically, significant fall in hemoglobin, hematocrit, and red blood cell count was observed in all three treatment groups.