Obesity and cardiovascular health.

Obesity has risen to epidemic levels worldwide over the past few decades and has become a huge global health burden owing to its direct contribution to the development of some of the most prevalent chronic diseases including diabetes, hypertension, hyperlipidaemia, and other cardiovascular diseases. Obesity is a disease of positive energy balance resulting from complex interactions between abnormal neurohumoral responses and an individual's socioeconomic, environmental, behavioural, and genetic factors leading to a state of chronic inflammation. Understanding the complex nature of the disease is crucial in determining the best approach to combat its rising numbers. Despite recent advancements in pharmacological therapy for the treatment of obesity, reversing weight gain and maintaining weight loss is challenging due to the relapsing nature of the disease. Prevention, therefore, remains the key which needs to start in utero and continued throughout life. This review summarizes the role obesity plays in the pathophysiology of various cardiovascular diseases both by directly affecting endothelial and myocyte function and indirectly by enhancing major cardiovascular risk factors like diabetes, hypertension, and hyperlipidaemia. We highlight the importance of a holistic approach needed to prevent and treat this debilitating disease. Particularly, we analyse the effects of plant-based diet, regular exercise, and non-exercise activity thermogenesis on obesity and overall cardiorespiratory fitness. Moreover, we discuss the significance of individualizing obesity management with a multimodal approach including lifestyle modifications, pharmacotherapy, and bariatric surgery to tackle this chronic disease.

Patiromer for the management of hyperkalemia in heart failure with reduced ejection fraction: the DIAMOND trial.

AIMS: To investigate the impact of patiromer on the serum potassium level and its ability to enable specified target doses of renin-angiotensin-aldosterone system inhibitor (RAASi) use in patients with heart failure and reduced ejection fraction (HFrEF). METHODS AND RESULTS: A total of 1642 patients with HFrEF and current or a history of RAASi-related hyperkalemia were screened and 1195 were enrolled in the run-in phase with patiromer and optimization of the RAASi therapy [≥50% recommended dose of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, and 50 mg of mineralocorticoid receptor antagonist (MRA) spironolactone or eplerenone]. Specified target doses of the RAASi therapy were achieved in 878 (84.6%) patients; 439 were randomized to patiromer and 439 to placebo. All patients, physicians, and outcome assessors were blinded to treatment assignment. The primary endpoint was between-group difference in the adjusted mean change in serum potassium. Five hierarchical secondary endpoints were assessed. At the end of treatment, the median (interquartile range) duration of follow-up was 27 (13-43) weeks, the adjusted mean change in potassium was +0.03 mmol/l in the patiromer group and +0.13 mmol/l in the placebo group [difference in the adjusted mean change between patiromer and placebo: -0.10 mmol/l (95% confidence interval, CI -0.13, 0.07); P < 0.001]. Risk of hyperkalemia >5.5 mmol/l [hazard ratio (HR) 0.63; 95% CI 0.45, 0.87; P = 0.006), reduction of MRA dose (HR 0.62; 95% CI 0.45, 0.87; P = 0.006), and total adjusted hyperkalemia events/100 person-years (77.7 vs. 118.2; HR 0.66; 95% CI 0.53, 0.81; P < 0.001) were lower with patiromer. Hyperkalemia-related morbidity-adjusted events (win ratio 1.53, P < 0.001) and total RAASi use score (win ratio 1.25, P = 0.048) favored the patiromer arm. Adverse events were similar between groups. CONCLUSION: Concurrent use of patiromer and high-dose MRAs reduces the risk of recurrent hyperkalemia (ClinicalTrials.gov: NCT03888066).

Implementation of a Patient Navigator Program to Reduce 30-day Heart Failure Readmission Rate.

With increasing awareness to provide personalized care our institution applied the American College of Cardiology (ACC) Patient Navigator Program to identify hospitalized heart failure (HF) patients and improve transitions and outcomes. Utilizing a Navigator Team (NT) composed of a nurse and clinical pharmacist, we delivered evidenced-based interventions and hypothesized this approach would improve identification of HF inpatients and reduce the 30-day all-cause readmission rate. Patients were followed from admission to discharge and received at least one intervention, tailored to the patient's health literacy and social needs. The 30-day all-cause readmission rate was 17.6% for the Patient Navigator Program and 25.6% for the medical center. Compared to the medical center there was a statistically significant increase in education and follow-up. For patients who received specific NT interventions of education and follow-up the readmission rate was 10.3% and 6.1% respectively. Hospital programs can easily embed a NT into existing initiatives to further reduce the readmission rate.

A framework for describing health care delivery organizations and systems.

Describing, evaluating, and conducting research on the questions raised by comparative effectiveness research and characterizing care delivery organizations of all kinds, from independent individual provider units to large integrated health systems, has become imperative. Recognizing this challenge, the Delivery Systems Committee, a subgroup of the Agency for Healthcare Research and Quality's Effective Health Care Stakeholders Group, which represents a wide diversity of perspectives on health care, created a draft framework with domains and elements that may be useful in characterizing various sizes and types of care delivery organizations and may contribute to key outcomes of interest. The framework may serve as the door to further studies in areas in which clear definitions and descriptions are lacking.

A randomized controlled trial of high dose vitamin D3 in patients with heart failure.

OBJECTIVE: To investigate the effect of Vitamin D3 on physical performance in patients with HF. BACKGROUND: HF is associated with functional decline and frailty. Vitamin D deficiency is associated with loss of muscle strength and poor outcomes in patients with HF. METHODS: Sixty-four patients participated in a 6-month parallel design double blind RCT to test the hypothesis that oral vitamin D3 would improve physical performance. Vitamin D3 50,000 IU or placebo was given weekly; all received daily calcium. Patients were included regardless of EF and 25OHD ≤ 37.5 ng/ml. The primary outcome was peak VO2, and secondary outcomes were the 6MW, TGUG and knee isokinetic muscle strength. Between group comparisons were made using ANCOVA models that adjust for baseline measures. RESULTS: Patients were age 65.9 ± 10.4 years old, 48% women, 64% African American, EF 37.6±13.9, 36% NYHA III, the remainder NYHA II. At baseline the vitamin D group 25OHD was 19.1 ± 9.3 ng/ml and increased to 61.7 ± 20.3 ng/ml; in the placebo group baseline 25OHD was 17.8 ± 9.0 ng/ml and decreased to 17.4 ± 9.8 ng/ml at 6 months (between groups p<0.001). There was no significant change from baseline to 6 months in peak VO2, 6MW, TGUG or isokinetic muscle strength. CONCLUSIONS: Vitamin D3 did not improve physical performance for patients with HF despite a robust increase in serum 25OHD. Vitamin D repletion in patients with HF should conform to standard adult guidelines for vitamin D supplementation.

Disseminating QI interventions.

BACKGROUND: Partnerships contributed to the success of three diverse health care quality improvement (QI) projects. The Partnerships for Quality (PFQ) Dissemination Planning Tool was used to identify the most appropriate partners to disseminate the QI interventions for three projects, that is, partners most likely to reach and influence the target user(s)-(1) the Catholic Healthcare Partners Heart Failure Partnership, a multisite demonstration of the efficacy of a collaborative approach in the management of heart failure, (2) the Center for Value Purchasing, a collaborative study of the effects of quality incentives on the delivery of chronic disease care, and (3) the New York State Information Dissemination project, a collaborative partnership that targeted dissemination of evidence-based practices in the long term care setting. RESULTS: The RE-AIM model, a construct to aid planning, implementation, and evaluation of health behavior interventions, was used as a framework to examine the impact of partnerships on the three collaborative projects. DISCUSSION: When carefully selected and nurtured, partnerships can substantially facilitate the dissemination and impact of quality improvement projects. The PFQ Dissemination Planning Tool was helpful in identifying and developing strategies for working with partners who could facilitate dissemination of promising practices. The RE-AIM model was a useful framework for examining the impact of the partnerships on the QI projects.

Practical recommendations for the use of ACE inhibitors, beta-blockers, aldosterone antagonists and angiotensin receptor blockers in heart failure: putting guidelines into practice.

Surveys of prescribing patterns in both hospitals and primary care have usually shown delays in translating the evidence from clinical trials of pharmacological agents into clinical practice, thereby denying patients with heart failure (HF) the benefits of drug treatments proven to improve well-being and prolong life. This may be due to unfamiliarity with the evidence-base for these therapies, the clinical guidelines recommending the use of these treatments or both, as well as concerns regarding adverse events. ACE inhibitors have long been the cornerstone of therapy for systolic HF irrespective of aetiology. Recent trials have now shown that treatment with beta-blockers, aldosterone antagonists and angiotensin receptor blockers also leads to substantial improvements in outcome. In order to accelerate the safe uptake of these treatments and to ensure that all eligible patients receive the most appropriate medications, a clear and concise set of clinical recommendations has been prepared by a group of clinicians with practical expertise in the management of HF. The objective of these recommendations is to provide practical guidance for non-specialists, in order to increase the use of evidenced based therapy for HF. These practical recommendations are meant to serve as a supplement to, rather than replacement of, existing HF guidelines.