Prevalence of cardiovascular disease risk factors among National Football League players.

CONTEXT: Concern exists about the cardiovascular health implications of large size among professional football players and those players who aspire to professional status. OBJECTIVES: To assess cardiovascular disease (CVD) risk factors in active National Football League (NFL) players and to compare these findings with data from the Coronary Artery Risk Development in Young Adults (CARDIA) study. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study of 504 active, veteran football players from a convenience sample of 12 NFL teams at professional athletic training facilities between April and July 2007. Data were compared with men of the same age in the general US population (CARDIA study, a population-based observational study of 1959 participants aged 23 to 35 years recruited in 1985-1986). MAIN OUTCOME MEASURES: Prevalence of CVD risk factors (hypertension, dyslipidemia, glucose intolerance, and smoking). RESULTS: The NFL players were less likely to smoke when compared with the CARDIA group (0.1% [n = 1]; 95% confidence interval [CI], 0%-1.4%; vs 30.5% [n = 597]; 95% CI, 28.5%-32.5%; P < .001). Despite being taller and heavier, NFL players had significantly lower prevalence of impaired fasting glucose (6.7% [n = 24]; 95% CI, 4.6%-8.7%; vs 15.5% [n = 267]; 95% CI, 13.8%-17.3%; P < .001). The groups did not differ in prevalence of high total cholesterol and low-density lipoprotein cholesterol (LDL-C), low high-density lipoprotein cholesterol (HDL-C), or high triglycerides. Hypertension (13.8% [n = 67]; 95% CI, 11.0%-16.7%; vs 5.5% [n = 108]; 95% CI, 4.6%-6.6%) and prehypertension (64.5% [n = 310]; 95% CI, 58.3%-70.7%; vs 24.2% [n = 473]; 95% CI, 22.3%-26.1%) were significantly more common in NFL players than in the CARDIA group (both P < .001). Large size measured by body mass index (BMI) was associated with increased blood pressure, LDL-C, triglycerides, and fasting glucose, and decreased HDL-C. CONCLUSIONS: Compared with a sample of healthy young-adult men, a sample of substantially larger NFL players had a lower prevalence of impaired fasting glucose, less reported smoking, a similar prevalence of dyslipidemia, and a higher prevalence of hypertension. Increased size measured by BMI was associated with increased CVD risk factors in this combined population.

Appropriateness of Prescription and Safety of Wearable Cardioverter Defibrillators: A Single-center Experience.

Introduction Wearable cardioverter defibrillators (WCD) are recommended for patients with a high risk of sudden cardiac death (SCD) secondary to arrhythmia that have not qualified for placement of an implantable cardiac defibrillator (ICD). This study provides insights into a single-center experience with WCD in terms of its usage and safety. Materials and methods We studied all patients that were prescribed a WCD in the Fairview Hospital in Cleveland Clinic Health System, from January 2014 to June 2016. Institutional Review Board of the Cleveland Clinic approved the study. A retrospective chart review was performed to collect data regarding demographics and baseline comorbidities including age, gender, history of hypertension, diabetes, coronary artery disease, and chronic kidney disease. The patients that were lost to follow up in our electronic medical record (EMR) were excluded. Ejection fraction (EF) at the time of diagnosis and follow-up was recorded. The primary outcome was ICD placement at follow up focusing on appropriate use while the secondary outcome was delivery of shock (appropriate or inappropriate) focusing on efficacy and safety of the device. Patients were stratified based on ICD placement. Statistical Package for the Social Sciences (SPSS), version 23 (IBM Corp., NY, USA) was used for the statistical analysis. Results We identified 73 patients with WCD placement. After the exclusion of 23/73 (31.5%) patients due to loss of follow-up, 50 patients were included in the study (n=50). Clinical characteristics showed 66% patients were males, 76% had hypertension, 40% had diabetes, 34% had chronic kidney disease, 56% patient had a New York Heart Association functional status of >II and 34% were on anti-arrhythmic medication. Indication for WCD use was ischemic cardiomyopathy in 23/50 (46%) patients and non-ischemic cardiomyopathy in 27/50 (54%) patients. No ICD was placed in 39/50 (78%) patients and ICD was placed in 11/50 (22%) patients at end time of follow up. Mean age was 59.9 years (95% confidence interval (CI), 55.9 - 63.9 years) in the group with no ICD placement and 63.5 years (95% CI, 56.5 - 70.6 years) in the group with ICD placement. Mean EF in the group with no ICD placement at the time of diagnosis was 25.8% (95% CI, 23.8% - 27.9%) which improved by 18.8% to a mean EF of 44.6% (41.1% - 48.1%) at the follow-up. Mean EF in the group with ICD placement was 32.7% (95% CI, 27.6% - 37.9%) which reduced by 4.1% to mean EF of 28.6% (95% CI, 12.2% - 44.9%) which was statistically significant (p<0.0001). Patients who had no ICD placement were followed for an average of 162 days and with ICD placement for 78 days. There was no difference between ischemic or nonischemic groups in getting the ICD. There were no shocks delivered whether appropriate or inappropriate in our population. Conclusion Almost a quarter of the patients that were prescribed WCD in our center ended up with an implanted device which demonstrates appropriate use. Equally important was the observed safety of WCDs as a treatment modality with no inappropriate shocks recorded in the followed cohort.

Arrhythmias and Adaptations of the Cardiac Conduction System in Former National Football League Players.

Background Habitual high-intensity endurance exercise is associated with increased atrial fibrillation (AF) risk and impaired cardiac conduction. It is unknown whether these observations extend to prior strength-type sports exposure. The primary aim of this study was to compare AF prevalence in former National Football League (NFL) athletes to population-based controls. The secondary aim was to characterize other conduction system parameters. Methods and Results This cross-sectional study compared former NFL athletes (n=460, age 56±12 years, black 47%) with population-based controls of similar age and racial composition from the cardiovascular cohort Dallas Heart Study-2 (n=925, age 54±9 years, black 53%). AF was present in 28 individuals (n=23 [5%] in the NFL group; n=5 [0.5%] in the control group). After controlling for other cardiovascular risk factors in multivariable regression analysis, former NFL participation remained associated with a 5.7 (95% CI: 2.1-15.9, P<0.001) higher odds ratio of AF. Older age, higher body mass index, and nonblack race were also independently associated with higher odds ratio of AF, while hypertension and diabetes mellitus were not. AF was previously undiagnosed in 15/23 of the former NFL players. Previously undiagnosed NFL players were rate controlled and asymptomatic, but 80% had a CHA2DS2-VASc score ≥1. Former NFL players also had an 8-fold higher prevalence of paced cardiac rhythms (2.0% versus 0.25%, P<0.01), compared with controls. Furthermore, former athletes had lower resting heart rates (62±11 versus 66±11 beats per minute, P<0.001), and a higher prevalence of first-degree atrioventricular block (18% versus 9%, P<0.001). Conclusions Former NFL participation was associated with an increased AF prevalence and slowed cardiac conduction when compared with a population-based control group. Former NFL athletes who screened positive for AF were generally rate controlled and asymptomatic, but 80% should have been considered for anticoagulation based on their stroke risk.

Trends in medication treatment for ADHD.

OBJECTIVE: This study examines demographic trends in the use of medications to treat ADHD in adult and pediatric populations. METHOD: Using pharmacy claims data for a large population of commercially insured Americans, the study measures ADHD treatment prevalence and drug use from 2000 to 2005. RESULTS: In 2005, 4.4% of children (ages 0 to 19) and 0.8% of adults (ages 20 and older) used ADHD medications. Treatment rates were higher in boys (6.1%) than in girls (2.6%), but the rates for men and women were approximately equal (0.8%). During the period of the study, treatment prevalence increased rapidly (11.8% per year) for the population as a whole. Treatment rates grew more rapidly for adults than for children, more rapidly for women than for men, and more rapidly for girls than for boys. CONCLUSION: Improved identification of ADHD in adult and female patients has contributed to rapid growth in ADHD medication use.

Clinical Characteristics and Outcomes of Patients with Ischemic and Non-Ischemic Complete Heart Block.

INTRODUCTION: Third degree or complete heart block (CHB) is a medical emergency and usually requires permanent pacemaker placement. CHB can be caused by cardiac ischemia or non-ischemic conditions such as infiltrative diseases or fibrosis. The purpose of this study is to identify the baseline clinical characteristics associated with ischemic versus non-ischemic causes of complete heart block and compare their outcomes. MATERIALS AND METHODS: An institutional review broad approval was granted by the Cleveland Clinic Health System. In our study, 216 patients with CHB presenting to Fairview Hospital between January 2014 and June 2016 were initially identified using the International Classification of Disease (ICD) codes at discharge. Only the patients with a new diagnosis of complete heart block (CHB) were included in the study (total N=62), which led to the exclusion of 154 patients. The patients were characterized into non-ischemic and ischemic groups based on cardiac marker elevation, electrocardiogram changes and/or cardiac catheterization findings. In all the patients, data including the following was collected: demographics such as age, gender, ethnicity and body mass index; pre-existing comorbidities such as hypertension, chronic kidney disease, diabetes mellitus, thyroid disease, previous coronary artery disease, history of cancer; use of nodal blocking agents, electrolyte abnormalities on admission, echocardiographic parameters such as ejection fraction (EF), right ventricular systolic pressure (RVSP), left ventricular end diastolic and systolic volumes (LVEDV and LVESV, respectively). The primary outcome was all-cause mortality and the secondary outcome was pacemaker placement. Categorical variables were analyzed using chi-square and continuous variables using ANOVA. RESULTS: Out of 62 patients (N=62), 48 had non-ischemic and 14 had ischemic CHB. The mean age was 67 years (95% CI, 60.55-74.73) in the ischemic group and 75 years (95% CI, 71.52-78.80) in the non-ischemic group, p=0.04. Patients with ischemic CHB had a lower mean EF of 49.6% (95% CI, 42.04%-57.23%) compared to 57.42% in non-ischemic CHB patients (95% CI, 53.97%-60.87%), p=0.05. History of coronary artery disease was present in 71.4% (10/14) patients with ischemic CHB compared to 37.5% (18/48) patients with non-ischemic CHB, p=0.02. There was no statistically significant difference between the two groups in terms of gender, diabetes, hypertension, thyroid dysfunction, chronic kidney disease, nodal blocking agents, electrolyte abnormalities or smoking status. For outcomes, 6/48 (12.5%) of patients with non-ischemic CHB had died compared to 3/14 (21.4%) ischemic CHB (p=0.327). Permanent pacemaker was implanted in 45/48 patients (93.75%) of the non-ischemic CHB compared to 6/14 (42.83%) in the ischemic group (p<0.001). CONCLUSIONS: Patients with ischemic CHB are younger, and they have a lower ejection fraction but they are less likely to get a pacemaker compared to non-ischemic CHB. Further studies with a bigger sample size are required to understand the long term mortality outcomes of patients with CHB.

Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.

BACKGROUND: Medco Health Solutions, Inc. conducted a project to reduce medication errors in its home-delivery service, which is composed of eight prescription-processing pharmacies, three dispensing pharmacies, and six call-center pharmacies. IMPLEMENTING THE PROJECT: Medco uses the Six Sigma methodology to reduce process variation, establish procedures to monitor the effectiveness of medication safety programs, and determine when these efforts do not achieve performance goals. A team reviewed the processes in home-delivery pharmacy and suggested strategies to improve the data-collection and medication-dispensing practices. A variety of improvement activities were implemented, including a procedure for developing, reviewing, and enhancing sound-alike/look-alike (SALA) alerts and system enhancements to improve processing consistency across the pharmacies. RESULTS: "External nonconformances" were reduced for several categories of medication errors, including wrong-drug selection (33%), wrong directions (49%), and SALA errors (69%). Control charts demonstrated evidence of sustained process improvement and actual reduction in specific medication error elements. DISCUSSION: Establishing a continuous quality improvement process to ensure that medication errors are minimized is critical to any health care organization providing medication services.

Use of a blood test incorporating age, sex, and gene expression influences medical decision-making in the evaluation of women presenting with symptoms suggestive of obstructive coronary artery disease: summary results from two ambulatory care studies in primary care.

OBJECTIVE: Clinicians need better approaches to evaluating women at midlife and beyond who present to primary care with chest pain and related symptoms. A previously validated blood-based test, which includes age, sex, and gene expression levels, showed a 96% negative predictive value for determining an individual's current likelihood of having obstructive coronary artery disease (CAD) in a combined population of men and women. We hypothesized that age/sex/gene expression score (ASGES) would be incorporated into medical decision-making and would influence the rate of further cardiac evaluation. METHODS: An aggregate analysis of female cohorts from the Investigation of a Molecular Personalized Coronary Gene Expression Test on Primary Care Practice Pattern (IMPACT-PCP; NCT01594411) and REGISTRY I (NCT01557855) studies was conducted. Data on 320 women presenting with stable symptoms suggestive of obstructive CAD and undergoing ASGES testing (from 16 primary care providers in geographically diverse sites) were pooled. The primary outcome of this analysis was the association between ASGES and referrals for further cardiac evaluation. RESULTS: The mean participant age was 57.8 years, and the mean ASGES (predefined as low [ASGES ≤15] or elevated [ASGES >15]) was 10.3. The referral rate for further cardiac evaluation was 4.0% (10 of 248) for women with low ASGES versus 83.3% (60 of 72) for women with elevated ASGES, with an overall follow-up major adverse cardiac event/revascularization rate of 1.2%. After adjustment for clinical covariates, women with low ASGES were significantly less likely to be referred for further cardiac evaluation (odds ratio, 0.013; P < 0.0001). CONCLUSIONS: ASGES can be incorporated into medical decision-making to help primary care providers rule out obstructive CAD among symptomatic women who are unlikely to benefit from further cardiac testing.

Molecular monitoring of chronic myeloid leukemia: a personalized approach to optimizing treatment response.

Personalized medicine is rapidly developing a purposeful niche in the field of oncology. Monitoring the activity of the oncogenic fusion gene BCR-ABL1 in chronic myeloid leukemia (CML) is a good example of individualizing CML treatment for patients using patient-specific genetic information. However, the frequency at which molecular monitoring for BCR-ABL1 transcripts occurs during treatment with tyrosine kinase inhibitors (TKIs) for CML in clinical practice is much lower than that recommended by either the National Cancer Center Network or the European LeukemiaNet guidelines. Adherence, one of the most critical factors affecting response to TKIs, is often less than desirable and rarely communicated to physicians by patients or managed by care providers. Less than optimal molecular monitoring and low adherence to TKI treatment can lead to rising transcripts levels, that when not detected, have been shown to contribute to poor outcomes. This review reports the basis for and describes the design of a state-of-the-art program intended to improve communication with physicians through real-time messaging about sequential test results for BCR-ABL1 and patients' adherence to TKI therapy.

Three-dimensional reconstruction of pulmonary veins in patients with atrial fibrillation and controls: morphological characteristics of different veins.

Multidetector computed tomography can be used to evaluate the anatomy of pulmonary veins (PVs) in patients with AF. The study evaluated two groups. Group 1 included 61 patients assessed following PV ablation with ultrasound of RF energy. Group 2 included 15 patients undergoing ablation for AF and 14 control subjects without a history of AF matched for age and sex. The anatomy of the PVs was analyzed in this group prior to the ablation and compared to controls. Computed tomography was used to measure the ostium of the left superior, left inferior, right superior, right inferior PVs, and the left atrial appendage size. In group 1, PV stenosis was seen in 14 (30%) of 46 patients undergoing ablation with RF energy and in none of the 15 patients receiving ablation with ultrasound energy. In group 2, the ostium size was not different between patients with AF and controls. Similarly, the ostium of the PV that appeared to trigger AF was not larger than the ostium of the remaining veins. A "clustering pattern" of PV branches near the right inferior PV ostium was seen in almost every patient, independent of the presence of the arrhythmia. Computed tomography frequently detects PV stenosis following RF ablation. Ultrasound ablation does not appear to result in PV narrowing. Overall, patients with AF do not have larger sizes of PV ostia. Multiple ramifications from the right inferior PV ostium is a common pattern and may represent a protective anatomic variant.