Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System?

BACKGROUND: Hospital-related factors associated with mortality and morbidity after hip fracture surgery are not completely understood. The Veterans Health Administration (VHA) is the largest single-payer, networked healthcare system in the country serving a relatively homogenous patient population with facilities that vary in size and resource availability. These characteristics provide some degree of financial and patient-level controls to explore the association, if any, between surgical volume and facility resource availability and hospital performance regarding postoperative complications after hip fracture surgery. QUESTIONS/PURPOSES: (1) Do VHA facilities with the highest complexity level designation (Level 1a) have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-complexity level facilities? (2) Do VHA facilities with higher hip fracture surgical volume have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-volume facilities? METHODS: We explored the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database from October 2001 to September 2012 for records of hip fracture surgery performed. Data reliability of the VASQIP database has been previously validated. We excluded nine of the 98 VHA facilities for contributing fewer than 30 records. The remaining 89 VHA facilities provided 23,029 records. The VHA designates a complexity level to each facility based on multiple criteria. We labeled facilities with a complexity Level 1a (38 facilities)-the highest achievable VHA designated complexity level-as high complexity; we labeled all other complexity level designations as low complexity (51 facilities). Facility volume was divided into tertiles: high (> 277 hip fracture procedures during the sampling frame), medium (204 to 277 procedures), and low (< 204 procedures). The patient population treated by low-complexity facilities was older, had a higher prevalence of severe chronic obstructive pulmonary disease (26% versus 22%, p < 0.001), and had a higher percentage of patients having surgery within 2 days of hospital admission (83% versus 76%, p < 0.001). High-complexity facilities treated more patients with recent congestive heart failure exacerbation (4% versus 3%, p < 0.001). We defined major postoperative complications as having at least one of the following: death within 30 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, new q-wave myocardial infarction, deep vein thrombosis and/or pulmonary embolism, ventilator dependence for at least 48 hours after surgery, reintubation for respiratory or cardiac failure, acute renal failure requiring renal replacement therapy, progressive renal insufficiency with a rise in serum creatinine of at least 2 mg/dL from preoperative value, pneumonia, or surgical site infection. We used the observed-to-expected ratio (O/E ratio)-a risk-adjusted metric to classify facility performance-for major postoperative complications to assess the performance of VHA facilities. Outlier facilities with 95% confidence intervals (95% CI) for O/E ratio completely less than 1.0 were labeled "exceed expectation;" those that were completely greater than 1.0 were labeled "below expectation." We compared differences in the distribution of outlier facilities between high and low-complexity facilities, and between high-, medium-, and low-volume facilities using Fisher's exact test. RESULTS: We observed no association between facility complexity level and the distribution of outlier facilities (high-complexity: 5% exceeded expectation, 5% below expectation; low-complexity: 8% exceeded expectation, 2% below expectation; p = 0.742). Compared with high-complexity facilities, the adjusted odds ratio for major postoperative complications for low-complexity facilities was 0.85 (95% CI, 0.67-1.09; p = 0.108).We observed no association between facility volume and the distribution of outlier facilities: 3% exceeded expectation and 3% below expectation for high-volume; 10% exceeded expectation and 3% below expectation for medium-volume; and 7% exceeded expectation and 3% below expectation for low-volume; p = 0.890). The adjusted odds ratios for major postoperative complications were 0.87 (95% CI, 0.73-1.05) for low- versus high-volume facilities and 0.89 (95% CI, 0.79-1.02] for medium- versus high-volume facilities (p = 0.155). CONCLUSIONS: These results do not support restricting facilities from treating hip fracture patients based on historical surgical volume or facility resource availability. Identification of consistent performance outliers may help health care organizations with multiple facilities determine allocation of services and identify characteristics and processes that determine outlier status in the interest of continued quality improvement. LEVEL OF EVIDENCE: Level III, therapeutic study.

Sleep hygiene program implementation in patients with traumatic brain injury.

PURPOSE: Traumatic brain injury (TBI) is a serious public health problem. The impact of TBI on the individual is multifaceted and includes neurocognitive, behavioral, and psychiatric disturbances as well as greater predisposition for dementia. A common but significant problem reported by patients after TBI is sleep disturbance. The purpose of this manuscript is twofold: (1) to describe our experience with implementation of the newly developed sleep hygiene guidelines; and (2) to report our preliminary results of implementation of the sleep hygiene guidelines on TBI patient outcomes. METHODS: A mixed methods approach was used to assess implementation of sleep hygiene guidelines and to gather preliminary data on outcomes. RESULTS: Although not statistically significant, the average self-reported sleep duration of these TBI patients was slightly higher in 2010 than 2009, with a FIM score that was similar for both time points. In 2009, the mean change in functional independence measure (FIM) score (n = 34) was 1.44. In 2010, the mean change in FIM score (n = 33) was 1.42. In 2009, most patients (n = 13) admitted to the hospital continued to take medications and were discharged with a sleep aid. In 2010, most patients reported a change in their sleep medication prescriptions (on medications at admission and none at discharge) or had continued to take their prescribed sleep medications from admission to discharge (n = 12). CONCLUSION: Sleep disorders have a major impact on health outcomes in patients with TBI. To optimize rehabilitation and ultimately improve functional outcomes of patients with TBI, implementation of evidence-based clinical guidelines for sleep is imperative. We report our initial experience with implementation of sleep guidelines.

Efficacy of optimal long-term management of multiple cardiovascular risk factors (CVD) on walking and quality of life in patients with peripheral artery disease (PAD): protocol for randomized controlled trial.

Peripheral artery disease (PAD) is an understudied chronic illness most prevalent in elderly individuals. PAD patients experience substantial walking impairment due to symptoms of limb ischemia that significantly diminishes quality of life (QOL). Cardiovascular disease (CVD) morbidity and mortality is increased in this population because of aggressive atherosclerosis resulting from untreated CVD risk factors. Despite current national guidelines recommending intensive CVD risk factor management for PAD patients, untreated CVD risk factors are common. Interventions that bridge this gap are imperative. The Vascular Insufficiency - Goals for Optimal Risk Reduction (VIGOR(2)) study is a randomized controlled trial (RCT) that examines the effectiveness of a long-term multifactor CVD risk reduction program on walking and quality of life in patients with PAD. The purpose of this article is to provide a detailed description of the design and methods of VIGOR(2). Clinical Trial Registration - URL: http://clinicaltrials.gov/ct2/show/NCT00537225.

Increasing community capacity to reduce tobacco-related health disparities in African American communities.

OBJECTIVE: The purpose of this study was to understand the processes and interactions that African American tobacco control organizations use to engage African American communities in tobacco control efforts. DESIGN AND SAMPLE: The study used grounded theory methods to interpret participant's perspectives on tobacco control. The study sample consisted of African American tobacco control program directors from African American tobacco control organizations throughout the United States. MEASURES: Data collection involved 1 interview per participant using a semistructured interview at a location selected by the participant. Each interview lasted approximately 30-90 min. RESULTS: The results showed that organizations used specific strategies to involve African Americans in tobacco control. The tobacco control organizations built community capacity using 3 processes: developing relationships and partnerships, raising awareness, and creating collective power. CONCLUSION: Contextual, cultural processes, and historical references used by African American tobacco control organizations provide insight into how to engage African American communities in tobacco control efforts and achieve tobacco-related health parity. Public health professionals and nurses should be aware of these and other strategies that may increase the involvement of African American communities in tobacco control.

Peripheral arterial disease in older adults: management of cardiovascular disease risk factors.

Patients with peripheral arterial disease experience significant functional limitations due to ischemic symptoms (claudication) and are at high risk for cardiovascular disease morbidity and mortality resulting from untreated cardiovascular disease risk factors and aggressive atherosclerosis. Peripheral arterial disease is commonly undiagnosed and cardiovascular disease risk factors are frequently untreated in this population. The increased risk associated with peripheral arterial disease necessitates greater emphasis on detection and management, not only to improve survival but to improve functional capacity and quality of life. This article briefly describes the detection and medical management with emphasis on lifestyle modification for elders with peripheral arterial disease.

Endothelial dysfunction induced by hyperhomocyst(e)inemia: role of asymmetric dimethylarginine.

BACKGROUND: Endothelial function is impaired by hyperhomocyst(e)inemia. We have previously shown that homocyst(e)ine (Hcy) inhibits NO production by cultured endothelial cells by causing the accumulation of asymmetric dimethylarginine (ADMA). The present study was designed to determine if the same mechanism is operative in humans. METHODS AND RESULTS: We studied 9 patients with documented peripheral arterial disease (6 men; 3 women; age, 64+/-3 years), 9 age-matched individuals at risk for atherosclerosis (older adults; 9 men; age, 65+/-1 years), and 5 young control subjects (younger adults; 5 men; age, 31+/-1 years) without evidence of or risk factors for atherosclerosis. Endothelial function was measured by flow-mediated vasodilatation of the brachial artery before and 4 hours after a methionine-loading test (100 mg/kg body weight, administered orally). In addition, blood was drawn at both time points for measurements of Hcy and ADMA concentrations. Plasma Hcy increased after the methionine-loading test in each group (all, P<0.001). Plasma ADMA levels rose in all subjects, from 0.9+/-0.2 to 1.6+/-0.2 micromol/L in younger adults, from 1.5+/-0.2 to 3.0+/-0.4 micromol/L in older adults, and from 1.8+/-0.1 to 3.9+/-0.3 micromol/L in peripheral arterial disease patients (all, P<0.001). Flow-mediated vasodilatation was reduced from 13+/-2% to 10+/-1% in younger adults, from 6+/-1% to 5+/-1% in older adults, and from 7+/-1% to 3+/-1% in peripheral arterial disease patients (all, P<0.001). Furthermore, we found positive correlations between plasma Hcy and ADMA concentrations (P=0.03, r=0.450), as well as ADMA and flow-mediated vasodilatation (P=0.002, r=0.623). CONCLUSIONS: Our results suggest that experimental hyperhomocyst(e)inemia leads to accumulation of the endogenous NO synthase inhibitor ADMA, accompanied by varying degrees of endothelial dysfunction according to the preexisting state of cardiovascular health.

The impact of exercise on body composition and nutritional intake in patients with heart failure.

Little is known about the nutritional status of heart failure patients and the potential synergistic effects between nutritional intake and exercise. This small, randomized trial examined the effects of a 3-month exercise program on body composition and nutritional intake in 31 men (17 exercisers; 14 controls), aged 30-76 years (mean, 56 years) with stable class II-III heart failure. Baseline and 3-month evaluations included body mass index, body fat mass by triceps skinfold thickness, dietary intake by food frequency questionnaire, and the 6-minute walk test. Exercise consisted of walking 3 d/wk and resistance exercises 2 d/wk for 40-60 minutes. Dietary recommendations were consistent with the American Heart Association/American College of Cardiology heart failure guidelines. Exercisers decreased body weight (p=0.001), body mass index (p=0.0001), and triceps skinfold thickness (p=0.03) and improved 6-minute walk test (p=0.01) compared with controls. Exercisers also demonstrated trends toward decreased total caloric and cholesterol intake and a three-fold higher carbohydrate, fiber, and beta carotene intake vs. controls. In this study population, protein, fiber, and magnesium intake were below recommended daily allowance. After exercise, body mass index was reduced, accompanied by dietary modifications including greater intake of foods with higher moisture content. Further study is needed to investigate the interaction among diet, exercise, and weight.

The impact of type 2 diabetes and peripheral arterial disease on quality of life.

Peripheral arterial disease (PAD) is associated with impaired walking distance as the result of claudication and reduced quality of life (QOL). Diabetes mellitus (DM) is commonly associated with PAD. The combined effect of DM and PAD versus PAD alone on walking distance and QOL is not well understood. This prospective, descriptive study examined walking distance and QOL associated with DM and PAD compared with PAD alone. Walking distance was assessed by an exercise treadmill test to determine initial claudication distance and absolute claudication distance and by self-report using the Walking Impairment Questionnaire. QOL was measured using the Short Form-36. The overall sample consisted of 92 men and women with PAD and DM or PAD alone. Of the total sample, 74 participants had PAD with ABI less than 0.9 mm Hg and 18 subjects had PAD and uncontrolled DM with hemoglobin A1c 7.0 mg/dL or greater. The mean age was 72 years (standard deviation [SD] = 7) for the PAD only group and 75 years (SD = 8) (not significant) for the PAD and DM groups. Initial claudication distance was greater in subjects with PAD only (186.9 m, SD = 136.4) than in diabetic subjects with PAD (127.3 m, SD = 70.0, P = .01). Absolute claudication distance was higher in patients with PAD only (461.3 m, SD 308) than in diabetic subjects with PAD (279.1 m, SD = 100, P = .01). Self-reported walking speed was reduced in patients with DM and PAD compared with patients with PAD only (P = .05). Diabetic patients with PAD reported impaired role function (P = .007), general health (P = .03), and social function (P = .04) compared with patients with PAD only. We conclude that DM has a significant detrimental impact on walking distance and QOL in patients with PAD. These findings suggest that diabetic patients with PAD are at greater risk for experiencing social isolation, impaired role function, reduced overall perceptions of general health, and impaired functional capacity. Future studies with larger sample sizes are needed to identify factors that contribute to these perceptions in diabetic patients with PAD.

Abnormal cardiovascular response to exercise in patients with peripheral arterial disease: Implications for management.

Exercise is beneficial in improving claudication and functional capacity in patients with peripheral arterial disease (PAD). However, the physiologic response during and after exercise testing in this patient population has not been fully described. This study examined the cardiovascular response to exercise and explored the potential contribution of vascular noncompliance to exercise-induced hypertension in 124 patients with PAD and claudication and 31 comparison (C) patients with PAD with no walking limitations. Maximal walking distance was determined by an exercise treadmill test. Heart rate and blood pressure were monitored before, during, and immediately after an exercise test. Vascular compliance of the small and large vessels was measured using pulse waveform analysis. Individuals with low supine resting heart rate had longer pain-free walking distance (r = -0.195, P = .019) and maximal walking versus the C group (62 beats/min, standard deviation [SD] = 10, P = .02). Systolic blood pressure during supine rest was significantly lower for the PAD group (mean = 141 mm Hg, +/- SD = 22) versus the C group (mean = 153 mm Hg, +/- SD = 20, P = .003). Vascular compliance of large vessels was higher in the C group (mean = 4.13 +/- 4.13 mL/mm Hg x 100) compared with the PAD group (mean = 2.95 +/- 1.6 mL/mm Hg x 100). This study describes the exaggerated exercise cardiovascular response and impaired vascular compliance in patients with PAD. These results provide further evidence supporting the importance of a monitored treadmill exercise test before initiation of an exercise program to ensure safe and accurate exercise recommendations, and to identify individuals that require more intensive pharmacotherapy to prevent exercise-induced hypertension and tachycardia.

Predictors of physical function in patients with peripherial arterial disease and claudication.

Limitation of walking due to claudication is the hallmark of peripheral arterial disease. The purpose of this secondary analysis was to identify biobehavioral predictors of physical function in peripheral arterial disease patients that included walking ability, gender, age, disease severity, environmental factors (social support), and medical comorbidity (arthritis). All subjects performed an exercise treadmill test to determine initial and absolute claudication distance. The sample consisted of 97 peripheral arterial disease patients, 71 (73%) men and 26 (27%) women, with a mean age of 73+/-8 years (range 52-90 years). Initial claudication distance occurred at 171.88+/-136.35 m. Absolute claudication distance was 421.03+/-286.37 m. A simultaneous multiple regression analysis was performed to determine predictors of physical function. The model accounted for 35% of the variance (p<0.001) and included personal characteristics (age, gender, years of education), severity of disease by ankle-brachial index, environmental factors of social support (marital status), absolute claudication distance, and arthritis. Education (p=0.011), absolute claudication distance (p=0.014), social support (p=0.026), arthritis (p=0.028), and age (p=0.033) were the strongest predictors of physical function. This study identifies biobehavioral factors that place peripheral arterial disease patients at greater risk for reduced physical function and provides a rationale for interventions that improve walking ability.

Exercise patterns and cardiovascular fitness of patients with peripheral arterial disease.

Peripheral arterial disease (PAD) is characterized by walking impairment as the result of claudication, which is improved by exercise. Few studies have examined the impact of existing exercise patterns in community-dwelling patients with PAD on cardiovascular fitness and absolute claudication distance (ACD). This descriptive study examines exercise patterns, walking distance, and cardiovascular fitness in a sample of community-dwelling older adults with PAD. Approximately 50% of subjects reported walking 4 (+/-2) days per week for 38 +/- 24 minutes. ACD (exercisers = 459.9 +/- 272; non-exercisers = 351.2 +/- 266.3, P = .06) and initial claudication distance (exercisers = 198.5 +/- 139.7; non-exercisers = 138.7 +/- 95.8 P = .02) were similar between groups. The workload accomplished was approximately 4.1-4.7 metabolic equivalents. Resting heart rate (HR) was associated with initial claudication distance ( r = -.37, P = .001) and ACD ( r = -.46, P < .01) and was lower in the group of exercisers versus the non-exercisers ( P = .05). Mean resting SBP was elevated and continued to increase at peak exercise with no difference between groups ( P = .75). Quality of life was poor for both groups. Simultaneous multiple regression analysis was performed to determine predictors of peak exercise HR. The model included gender, age, current exercise, ankle-brachial index, coronary artery disease, beta blockers, ACD, and atrial fibrillation (R = 44%, P = .01). Higher peak exercise HR was associated with older age, female gender, no beta blockers, and greater ACD ( P < .01). The findings from this descriptive study demonstrate the need for larger long-term studies to address issues of exercise adherence and the psychologic and functional benefits of exercise.

Differences in nutrition status by body mass index in patients with peripheral artery disease.

Peripheral Arterial Disease (PAD) is most prevalent in the elderly and associated with increased cardio vascular disease (CVD) morbidity and mortality. Treatment focuses on improving functional capacity and reducing CVD risk factors. To date, little is understood about dietary habits and weight in this patient population. Nutritional and weight recommendations are based on heart health, and little is known about the unique needs of elderly PAD patients with multiple comorbidities. This prospective study compared 1) the dietary intake of nonobese PAD patients in comparison with those who were obese and; 2) dietary intake of those patients with the Estimated Average Requirement (EAR) based on age, gender and BMI. Nutritional intake was assessed with the Block 98 Food Frequency Questionnaire. Body mass index (BMI) was calculated in accordance with the National Heart, Lung, and Blood Institute (NHLBI) guidelines.The study population was divided into obese (BMI ≥ 30) and nonobese (NO) groups. Comparisons between groups were performed using the Mann-Whitney U test for continuous variables and the Chi-square test for ordinal variables. All tests were two-tailed and P < 0.05 was considered significant. The Estimated Average Requirement (EAR) cut-point method was used to compare nutritional variables with Dietary Reference Intakes (DRI). The study population included 189 NO (BMI < 30) and 111 obese (BMI > 30) individuals. Obese participants reported greater intake of foods containing cholesterol and trans-fatty acids and more frequent intake of B vitamins in comparison with the NO BMI group. Additionally, the nutrient intake of all participants by age, gender and BMI was lower than the EAR for magnesium, folate, and Vitamin E. These results suggest that the nutritional intake of PAD patients differs based on gender and BMI. Additionally, EAR was lower for specific nutrients than recommended. Further investigation is needed to examine the association between nutritional intake and nutrition-related deficits.

Accuracy of peak VO2 assessments in career firefighters.

BACKGROUND: Sudden cardiac death is the leading cause of on-duty death in United States firefighters. Accurately assessing cardiopulmonary capacity is critical to preventing, or reducing, cardiovascular events in this population. METHODS: A total of 83 male firefighters performed Wellness-Fitness Initiative (WFI) maximal exercise treadmill tests and direct peak VO2 assessments to volitional fatigue. Of the 83, 63 completed WFI sub-maximal exercise treadmill tests for comparison to directly measured peak VO2 and historical estimations. RESULTS: Maximal heart rates were overestimated by the traditional 220-age equation by about 5 beats per minute (p < .001). Peak VO2 was overestimated by the WFI maximal exercise treadmill and the historical WFI sub-maximal estimation by ~ 1MET and ~ 2 METs, respectively (p < 0.001). The revised 2008 WFI sub-maximal treadmill estimation was found to accurately estimate peak VO2 when compared to directly measured peak VO2. CONCLUSION: Accurate assessment of cardiopulmonary capacity is critical in determining appropriate duty assignments, and identification of potential cardiovascular problems, for firefighters. Estimation of cardiopulmonary fitness improves using the revised 2008 WFI sub-maximal equation.

Limb hemodynamics are not predictive of functional capacity in patients with PAD.

To the practicing clinician, it seems obvious that limb hemodynamics would be the primary determinant of walking distance. However, other determinants, such as skeletal muscle metabolism, may play a role. Accordingly, in the current study, we examined the relationship between measures of limb hemodynamics and walking capacity in patients with peripheral arterial disease (PAD). We measured toe and ankle pressures for calculation of toe- (TBI) and ankle (ABI)-brachial indices; basal and hyperemic calf blood flow (CBF; by plethysmography); and initial (ICT) and absolute (ACT) claudication time using the Skinner-Gardner protocol. As expected, PAD patients had impaired limb hemodynamics with reduced TBI, ABI and a reduction in ABI post-exercise. However, there was no relationship between any of the hemodynamic variables (including ABI, ABI reduction post-exercise, TBI, baseline or maximal CBF) and walking distance as assessed by ICT or ACT. A subset of PAD patients with an ACT >750s (n = 16; 'long claudicators') were compared with a subset of PAD patients with an ACT <260s (n = 16; 'short claudicators'). The average ACT in the long claudicants was over fivefold greater than the short claudicators. Surprisingly, there were no differences between the two groups in any of the hemodynamic variables. There was also no relationship between the initial ABI, TBI, toe pressure, baseline or hyperemic CBF, and the improvement in ACT over the 3-month course of the study. This study found little relationship between hemodynamic variables and functional capacity in PAD. Accordingly, to assess the response to therapeutic interventions, exercise performance and functional status need to be directly measured, and cannot be predicted from hemodynamic measurements.

Quantifying smoking cessation outcomes: from The Women's Initiative for Nonsmoking Study (X): methodological implications.

BACKGROUND: Classification of smoking status has a major impact on the conclusions drawn from smoking cessation intervention research, yet few studies have addressed this critical issue. OBJECTIVES: The aim of this study was to compare three classifications (naïve, optimistic, and pessimistic) of smoking cessation outcomes or smoking status from the Women's Initiative for Nonsmoking Study (WINS). METHODS: This is a longitudinal prospective study nested within a randomized clinical trial (RCT) design of WINS, an RCT of 277 women over the age of 18 years who reported smoking cigarettes continuously for 1 month prior to a cardiovascular event requiring hospital admission. Women were randomized to either the usual care group (UC) or the intervention group (IG). Recruitment for WINS occurred between October 1996 and December 1998 in 10 hospitals in the San Francisco Bay area. Follow-up data on smoking status was obtained from the UC and the IG using a structured telephone interview at 6 and 12 months from baseline and was confirmed by family members and salivary cotinine levels. RESULTS: Seven-day point prevalence(self-report of not smoking in the past 7 days; "not even a puff") using the naïve (the most liberal) classification yields a greater number of nonsmokers than the pessimistic or most conservative classification (cotinine level verification of smoking status). The classification of smoking status also affects time to continuous smoking. The pessimistic classification results in the shortest time to continuous smoking, whereas the opposite is observed with the naïve classification. DISCUSSION: It is important to critically evaluate the underlying assumptions made by study investigators when measuring and reporting smoking status. The classification of smoking status and the selection of analysis, meaning point prevalence versus survival analysis, affect study results and contribute to the variability observed in the research findings of smoking cessation intervention trials and the challenges faced in making appropriate comparisons across studies.

Statin therapy in heart failure.

PURPOSE OF REVIEW: The 3-hydroxy-3-methylglutaryl-coenzyme-A reductase inhibitors, or statins, have been shown to reduce cardiovascular morbidity and mortality among a wide spectrum of patients with established atherosclerotic vascular disease. Mounting experimental and clinical evidence also suggest a potential benefit as well as theoretical harm of statin therapy in patients with heart failure. RECENT FINDINGS: This article briefly summarizes the therapeutic properties of statins that may be of benefit to patients with heart failure and the theoretical adverse effects of cholesterol reduction in this group of patients. A number of nonrandomized clinical studies over the past several years have shown an association between statin use and reduced overall mortality. Several large-scale randomized studies designed to confirm these findings are currently under way. SUMMARY: Statin therapy appears to improve clinical outcomes in patients with both ischemic and nonischemic cardiomyopathy independently of their cholesterol-lowering properties. The theoretical adverse properties of statins in heart failure patients have not been substantiated in small to medium-sized clinical trials. Although the encouraging results of these preliminary studies suggest a role for statin therapy in heart failure, larger studies are needed to validate these findings. Several ongoing randomized trials are currently under way to evaluate the effect of statin therapy on cardiovascular outcomes in heart failure patients. The results of these studies, expected in the next several years, should provide scientific evidence for the role of statins in the treatment of failure.

Effect of treadmill testing and exercise training on self-efficacy in patients with heart failure.

BACKGROUND: Self-efficacy is a person's confidence in being able to successfully perform a specific activity or behavior. Self-efficacy has been shown to influence exercise capacity in patients post myocardial infarction, but has not been fully explored in patients with heart failure (HF). This study examined the impact of performance of a single treadmill exercise test and participation in a 3-month program of walking and resistance exercise on self-efficacy in HF patients. METHODS: 24 patients were randomized to either a home-based walking and resistance exercise program or usual care for 3 months. Prior to enrollment into the exercise program all participants performed a single treadmill exercise test with respiratory gas analysis. Self-efficacy questionnaires were completed at 3 time points, 1) prior to performance of an exercise treadmill test; 2) immediately after completing an exercise test; and 3) at the end of a 3-month exercise program. RESULTS: Self-efficacy for walking (p=0.07), climbing (p=0.17), lifting (p=0.73) and general activity (p=0.15) did not improve after performance of a single treadmill exercise test and usual care. However, self-efficacy for walking increased after 3 months of a walking and resistance exercise program. (p=0.04). CONCLUSIONS: The findings from this study suggest that in patients with stable mild to moderate heart failure, self-efficacy is improved with participation in a home-based walking and endurance exercise program. Self-efficacy is not enhanced by performance of a single treadmill exercise test and usual care.

A pilot study of L-arginine supplementation on functional capacity in peripheral arterial disease.

Peripheral arterial disease (PAD) impairs walking capacity and is often associated with a profound endothelial vasodilator dysfunction, characterized by reduced bioactivity and/or synthesis of endothelium-derived nitric oxide (NO). Previous studies have suggested that dietary supplementation of L-arginine, the precursor of NO, improves endothelium-dependent vasodilation, limb blood flow and walking distance. However, these studies have been small, and have used large intravenous doses of L-arginine. The optimal dose of L-arginine has not been determined. Accordingly, this pilot study was conducted to establish the lowest effective oral dose of L-arginine to improve walking distance in preparation for the definitive study. Patients with PAD and intermittent claudication (n = 80) participated in this study. Eligibility criteria included: (1) ankle-brachial index (ABI) at rest < or = 0.90; (2) post-exercise reduction in ABI > or = 25%; and (3) difference in absolute claudication distance of < or = 25% between two consecutive treadmill tests. Treadmill testing was performed using the Skinner-Gardner protocol and community-based walking was assessed using the walking impairment questionnaire. Patients were randomly assigned to oral doses of 0, 3, 6 or 9 g of L-arginine daily in three divided doses for 12 weeks. Treadmill testing was performed prior to administration of the study drug and again after 12 weeks of treatment. The study drug was well tolerated, with no significant adverse effects of L-arginine therapy. The safety laboratory studies were unremarkable, except for a statistically significant reduction in hematocrit in the L-arginine-treated groups. There was no significant difference observed in absolute claudication distance between the groups. However, a trend was observed for a greater increase in walking distance in the group treated with 3 g L-arginine daily, and there was a trend for an improvement in walking speed in patients treated with L-arginine. This pilot study provided data for safety, for power calculation and for dosing for the larger definitive trial that is now underway.