Exercise Training in "At-Risk" Black and White Women: A Comparative Cohort Analyses.

PURPOSE: Few data on the effect of exercise interventions in black women at risk for cardiovascular disease are available. METHODS: Women ≥18 yr of age without known cardiovascular disease with ≥1 coronary risk factor were enrolled in a community-based exercise program ≥3 d·wk for ≥30 min per session for 6 months. Exercise training intensity ~50% to 80% of functional capacity, using heart rate (HR) and/or rating of perceived exertion (RPE) as the primary intensity modulators. Preconditioning versus postconditioning quality of life assessments (depression and level of daytime sleepiness), dietary fat intake, Duke Activity Status Index score, changes in cardiovascular efficiency (systolic/diastolic blood pressure (SBP/DBP), HR, RPE during a standardized submaximal workload), and anthropometric measures, including body weight, body mass index, and waist circumference, were evaluated. RESULTS: Of 556 volunteers, 143 were excluded, leaving 413 women (222 white, 191 black; mean ± SD age, 61 ± 9 yr) who met compliance criteria. Both groups demonstrated significant (P < 0.05) postconditioning decreases in body mass index, waist circumference, resting SBP/DBP, and total and LDL cholesterol, and reductions in HR, SBP/DBP, and RPE at a fixed submaximal workload, and in fat screener, depression, and sleep scores. Duke Activity Status Index scores increased significantly (P < 0.0001) for both groups, signifying increases in self-reported functional capacity. Although 87 women (21%) experienced a musculoskeletal injury/discomfort during the program, there were no exercise-related cardiovascular events. CONCLUSIONS: A progressive moderate-to-vigorous exercise intervention without preliminary exercise testing elicited comparable improvements in coronary risk factors, anthropometric and quality of life measures, and cardiovascular efficiency in "at-risk" black and white women. These adaptations were achieved at exercise levels below those recommended in contemporary physical activity guidelines.

Comparison of the usefulness of enoxaparin versus warfarin for prevention of left ventricular mural thrombus after anterior wall acute myocardial infarction.

Left ventricular (LV) thrombus is one of the most common complications in patients with anterior acute myocardial infarction (AMI) and LV dysfunction. Although anticoagulation is frequently prescribed, data regarding the appropriate drug, duration, risks, and effect on echocardiographic indices of thrombus are lacking. Moreover, given the difficulty in obtaining adequate anticoagulation with warfarin, it is possible that short-term treatment with a more predictable agent would be effective. We randomized 60 patients at high risk of developing LV mural thrombus (anterior acute myocardial infarction with Q waves and ejection fraction≤40%) to receive either enoxaparin 1 mg/kg (maximum 100 mg) subcutaneously every 12 hours for 30 days or traditional anticoagulation (intravenous heparin followed by oral warfarin for 3 months). Clinical evaluations and transthoracic echocardiograms were obtained at baseline, in-hospital, and at 3.5 months. There were no differences between the groups regarding baseline demographics, acute echocardiographic findings, and in-hospital outcomes. The length of hospital stay tended to be shorter for the enoxaparin group (4.6 vs 5.6; p=0.066) and the corresponding hospital costs ($25,837 vs $34,666; p=0.18). At 3 months, bleeding and thromboembolic events were rare and similar between enoxaparin and warfarin groups. Although more patients had probable mural thrombus in the enoxaparin group compared with warfarin at 3.5 months (15% vs 4%; p=0.35), this was not significantly different. In conclusion, the use of enoxaparin tends to shorten hospitalization and lower cost of care. However, at 3.5 months, there appears to be numerically higher (but statistically insignificant) rates of LV thrombus in the enoxaparin group.

Injury or activity-related pain sustained by a population of at-risk women during a 6-month exercise program.

BACKGROUND: Exercise provides numerous cardiovascular (CV) benefits to women; however, identifying women who are likely to sustain musculoskeletal injury or discomfort is important when tailoring exercise activities. PURPOSE: To evaluate factors associated with the incidence of injury in women at risk for CV disease (CVD) during their participation in a structured exercise intervention for primary CVD prevention. STUDY DESIGN: Retrospective comparative study. METHODS: Baseline anthropometric measures, CV efficiency (via standardized submaximal treadmill testing), and questionnaire-based assessments of functional capacity (Duke Activity Status Index [DASI]), daytime sleepiness (Epworth Sleepiness Scale), and depression (9-item Patient Health Questionnaire) were compared between participants sustaining an injury or experiencing persistent pain, regardless of cause, with those reporting no such events. RESULTS: Of 117 women enrolled in the study, 27 (23%) experienced an injury or activity-related musculoskeletal pain during the program (injured group). Baseline characteristics for the entire group were: age, 57.3 years; weight, 203 lb; body mass index, 34.8 kg/m 2 ; and waist circumference, 39.9 in. Characteristics did not differ significantly between the injured and non-injured groups for baseline demographics (P > 0.05), but obesity incidence (body mass index ≥ 30 kg/m 2 ) was more prevalent in the injured group (P = 0.02). On univariate analysis, 9-item Patient Health Questionnaire depression scores were higher for injured participants (5.6 vs 4.1, P = 0.16) and DASI activity scores were significantly lower for injured participants (31.3 vs 41.0, P = 0.004) despite there being no significant difference in baseline exercise capacity, expressed as metabolic equivalents (8.1 vs 7.5, P = 0.20) between groups. The DASI score was an independent predictor of injury by multivariate analysis (P = 0.0092). CONCLUSION: Women study participants who were injured or experienced activity-related pain during a 6-month structured exercise intervention (injured group) had similar waist measurements, lipid/lipoprotein level profiles, and hemodynamic responses compared with women study participants who were event free (non-injured group); however, injured-group participants were more obese, more depressed, and reported lower functional capacity. Women who have the characteristics of the injured-group participants may be at greater risk for activity-induced injury when participating in exercise-based prevention programs for CV health.

Long-term safety and efficacy of telmisartan/amlodipine single pill combination in the treatment of hypertension.

The use of multiple drug regimens is increasingly recognized as a tacit requirement for the management of hypertension, a necessity fueled in part by rising rates of metabolic syndrome and diabetes. By targeting complementary pathways, combinations of antihypertensive drugs can be applied to provide effective blood pressure control while minimizing side effects and reducing exposure to high doses of individual medications. In addition, combination therapies, including angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers (CCBs), have the added benefit of reducing cardiovascular mortality and morbidity over other dual therapies while providing equivalent blood pressure control. It is possible that angiotensin receptor blockers (ARBs), which unlike ACE inhibitors are minimally affected by upregulation of alternative pathways for angiotensin II accumulation following long-term treatment, would also provide such outcome benefits. At issue, however, is maintaining patient compliance, as adding medications is known to reduce adherence to treatment regimens. The purpose of this review is to summarize existing trial data for the long-term safety and efficacy of a recent addition to the armamentarium of dual-antihypertensive therapeutic options, the telmisartan/amlodipine single pill combination. The areas where long-term data are lacking, notably clinical information regarding minorities and women, will also be discussed.

Pheochromocytoma presenting with Takotsubo syndrome.

The clinical presentation of Takotsubo syndrome, or apical ballooning syndrome, resembles an extensive anterolateral myocardial infarction with chest pain symptoms and electrocardiographic ST-elevation or T-wave inversion noted in most patients. However, coronary arteries are invariably found to be normal or to display minimal atherosclerotic disease despite modest elevation of cardiac enzymes. Since most cases of Takotsubo syndrome occur after intense physical and/or emotional stress, catecholamine surge appears to be a common underlying mechanism. We present a case of Takotsubo syndrome, which presented with unusual symptoms and was found to be caused by pheochromocytoma. A sudden rise in blood pressure moments after completion of echocardiographic stress testing aided in uncovering the diagnosis.

Usefulness of breast arterial calcium detected on mammography for predicting coronary artery disease or cardiovascular events in women with angina pectoris and/or positive stress tests.

Breast arterial calcium (BAC) has been suggested as a marker and predictor of cardiovascular risk and coronary artery disease (CAD). However, an association between BAC and these cardiovascular end points has not been fully elucidated in patients undergoing cardiac catheterization. Consecutive patients undergoing mammography and cardiac catheterization within a 36-month period were retrospectively evaluated through chart review. Cardiac catheterization films and mammograms from 94 patients were independently reviewed for the presence of CAD and BAC, respectively. Cardiovascular risk factors, history of revascularization, and history of myocardial infarction were compared between women with and without BAC. BAC was more prevalent in older women (mean age 69 + or - 10 vs 63 + or - 11 years, p = 0.02). Aside from an inverse correlation with smoking, there was no difference in the presence of CAD or cardiovascular risk factors between patients with and without BAC. Patients with BAC had a lesser history of acute myocardial infarction (21% vs 41%, p <0.05) and were less likely to undergo revascularization (23% vs 43%, p <0.05). In conclusion, BAC was not positively associated with cardiovascular risk factors, documented CAD, or acute cardiovascular events, suggesting that the presence of BAC as determined by mammography is not a useful predictor of CAD in intermediate- to high-risk patients.

Usefulness of bone mineral density to predict significant coronary artery disease.

Low bone mineral density (BMD) and coronary artery disease (CAD) share common risk factors. To investigate whether low BMD (osteoporosis and/or osteopenia) independently predicts CAD compared with traditional cardiovascular risk factors, a retrospective analysis was performed in consecutive ambulatory patients (n = 209, 89% women) who underwent dual-energy x-ray absorptiometry and coronary angiography within the same 12-month period. Angiograms were classified as showing significant CAD if > or =50% luminal narrowing in a major coronary artery was noted. Clinical variables associated with CAD (age, hypertension, diabetes, high fasting glucose level, smoking, family history of CAD, and dyslipidemia) were examined. Dual-energy x-ray absorptiometric scans were classified based on World Health Organization criteria: normal (T score >-1.0 SD), osteopenia (T score -1.0 to -2.5 SD), and osteoporosis (T score <-2.5 SD). Univariate and multivariate analyses were employed to determine whether low BMD independently predicts CAD. Univariate predictors of CAD were hypertension, smoking, diabetes, high fasting glucose level, dyslipidemia, family history of CAD, and low BMD. Multivariate predictors were hypertension, family history of CAD, fasting glucose level, and osteoporosis. Odds ratio for the prediction of angiographically documented CAD was highest for osteoporosis (odds ratio 5.6, 95% confidence interval 2.6 to 12.0, p <0.0001). In conclusion, low BMD appears to independently predict significant CAD in women, with a higher odds ratio than traditional risk factors. Our study is the first to report osteoporosis as a predictor of angiographically proved CAD in a population predominantly of women.

Adverse outcome in aortic sclerosis is associated with coronary artery disease and inflammation.

OBJECTIVES: The present study was designed to evaluate the relationship between the presence of aortic sclerosis, serologic markers of inflammation, and adverse cardiovascular outcomes. BACKGROUND: Aortic sclerosis is associated with adverse cardiovascular outcomes. However, the mechanism by which such nonobstructive valve lesions impart excess cardiovascular risk has not been delineated. METHOD: In 425 patients (mean age 68 +/- 15 years, 54% men) presenting to the emergency room with chest pain, we studied the relationship among aortic sclerosis, the presence and acuity of coronary artery disease, serologic markers of inflammation, and cardiovascular outcomes. Patients underwent echocardiography and serologic testing including C-reactive protein (CRP). Aortic valves were graded for the degree of sclerosis, and cardiovascular outcomes including cardiac death and nonfatal myocardial infarction (MI) were analyzed over one year. RESULTS: Aortic sclerosis was identified in 203 patients (49%), whereas 212 (51%) had normal aortic valves. On univariate analysis at one year, patients with aortic sclerosis had a higher incidence of cardiovascular events (16.8% vs. 7.1%, p = 0.002) and worse event-free survival (normal valves = 93%, mild aortic sclerosis = 85%, and moderate to severe aortic sclerosis = 77%, p = 0.002). However, by multivariable analysis aortic sclerosis was not independently associated with adverse cardiovascular outcomes; the only independent predictors of cardiac death or MI at one year were coronary artery disease (hazard ratio [HR] 3.23, p = 0.003), MI at index admission (HR 2.77, p = 0.008), ascending tertiles of CRP (HR 2.2, p = 0.001), congestive heart failure (HR 2.15, p = 0.02) and age (HR 1.03, p = 0.04). CONCLUSIONS: The increased incidence of adverse cardiovascular events in patients with aortic sclerosis is associated with coronary artery disease and inflammation, not a result of the effects of valvular heart disease per se.

Right ventricular performance at rest and during stress with chronic proximal occlusion of the right coronary artery.

Acute proximal right coronary artery (RCA) occlusion results in profound right ventricular (RV) ischemic dysfunction; however, chronic RV dysfunction at rest from persistent RCA occlusion is rare. We studied the responses of the right ventricle to exercise in patients with chronic proximal RCA occlusion, demonstrating preserved RV free wall motion and appropriate augmentation of ejection fraction in nearly all cases.

Diagnosis, management, and clinical outcome of cardiac tamponade complicating percutaneous coronary intervention.

Cardiac tamponade is an uncommon but life-threatening complication of percutaneous coronary intervention (PCI). The purpose of the present study was to characterize the incidence, management, and clinical outcome associated with this complication. We analyzed a prospective database of 25,697 PCIs performed at William Beaumont Hospital (Royal Oak, Michigan) between October 1993 and December 2000. Cardiac tamponade was observed in 31 of 25,697 PCI procedures (0.12%). Cardiac tamponade was diagnosed in the catheterization laboratory in 17 of 31 patients (55%), and 14 patients (45%) had a delayed presentation (mean time from PCI 4.4 hours). Cardiac tamponade was twice as frequent after use of atheroablative devices compared with percutaneous transluminal coronary angioplasty and stenting (0.26% vs 0.11%, p <0.05). All patients with immediate cardiac tamponade had coronary artery perforation. In 11 of 14 patients with delayed tamponade (79%), no actual site of perforation could be identified. A moderate or large pericardial effusion was observed in 20 patients, and 9 had small effusions without typical echocardiographic features of tamponade. Pericardiocentesis was performed in 30 patients; 19 patients (61%) were treated successfully with aspiration alone, but 12 patients (39%) required further emergency surgical intervention. In-hospital complications included death (42%), emergency surgery (39%), myocardial infarction (29%), and transfusion (65%). Cardiac tamponade is an uncommon but important complication of PCI and is associated with high mortality and morbidity. Most cases are recognized in the catheterization laboratory, but delayed cardiac tamponade may occur and must be considered as a cause of late hypotension after PCI.

Range and prevalence of cardiac abnormalities in patients hospitalized in a medical ICU.

BACKGROUND: Patients hospitalized in medical ICUs (MICUs) with acute noncardiac illnesses have an undefined prevalence of underlying cardiovascular abnormalities. Because of the acuteness of illness, the need for frequent concurrent mechanical ventilation, and the nature of the underlying diseases, routine cardiac examination may be suboptimal for identifying concurrent cardiac abnormalities. PURPOSE: The purpose of this study was to utilize transthoracic echocardiography and Doppler echocardiography interrogation to identify the range and prevalence of occult cardiac abnormalities that may be present in patients admitted to an MICU. METHODS: Over a 12-month period, 500 consecutive patients who had been admitted to the MICU of a large university tertiary care center underwent complete two-dimensional echocardiography and Doppler scanning within 18 h of admission. The final study population comprised 467 patients. No study subject had been admitted to the MICU for a primary cardiac diagnosis. Cardiovascular abnormalities were prospectively defined, and all echocardiograms were interpreted independently by blinded observers. Both MICU and overall mortality rates as well as length of stay were compared to the presence or absence of cardiac abnormalities. RESULTS: One or more cardiac abnormalities was noted in 169 patients (36%). The average (+/-SD) age of patients in the study was 52 +/- 17 years (age range, 17 to 100 years), and the average age was 57 +/- 18 years (age range, 18 to 93 years) in patients with underlying cardiac abnormalities. A single cardiac abnormality was noted in 103 patients (22%), two cardiac abnormalities were noted in 34 patients (7.2%), and three or more cardiac abnormalities were noted in 32 patients (6.8%). Based on subsequent requests for cardiac diagnostic studies, 67 patients (14.3%) were clinically suspected of having significant cardiovascular abnormalities, 39 of whom (58%) had one or more cardiac abnormalities on seen on echocardiography. Cardiac abnormalities were unsuspected in 130 of 169 patients (77%) and were only noted at the time they underwent surveillance echocardiography. Although there was no correlation between the presence of cardiac abnormalities and mortality, both MICU and hospital length of stay were increased in patients with cardiac abnormalities. CONCLUSION: A significant proportion of patients admitted to an MICU with noncardiac illness have underlying cardiac abnormalities, which can be detected with surveillance echocardiography at the time of admission. Cardiac abnormalities were associated with an increased length of stay but not with increased mortality.

Initial experience with hyperoxemic reperfusion after primary angioplasty for acute myocardial infarction: results of a pilot study utilizing intracoronary aqueous oxygen therapy.

OBJECTIVES: The purpose of this study was to evaluate the feasibility and safety of intracoronary hyperoxemic reperfusion after primary angioplasty for acute myocardial infarction (MI). BACKGROUND: Hyperoxemic therapy with aqueous oxygen (AO) attenuates reperfusion injury and preserves left ventricular (LV) function in experimental models of MI. METHODS: In a multi-center study of patients with acute MI undergoing primary angioplasty (PTCA), hyperoxemic blood (pO(2): 600 to 800 mm Hg) was infused into the infarct-related artery for 60 to 90 min after intervention. The primary end points were clinical, electrical and hemodynamic stability during hyperoxemic reperfusion and in-hospital major adverse cardiac events. Global and regional LV function was evaluated by serial echocardiography after PTCA, after AO infusion, at 24 h and at one and three months. RESULTS: Twenty-nine patients were enrolled (mean age: 58.9+/-12.6 years). Hyperoxemic reperfusion was performed successfully in all cases (mean infusion time: 80.8+/-18.2 min; mean coronary perfusate pO(2): 631+/-235 mm Hg). There were no adverse events during hyperoxemic reperfusion or the in-hospital period. Compared with baseline, a significant improvement in global wall motion score index was observed at 24 h (1.68+/-0.24 vs. 1.48+/-0.24, p < 0.001) with a trend toward an increase in ejection fraction (48.6+/-7.3% vs. 51.8+/-6.8%, p = 0.08). Progressive improvement in LV function was observed at one and three months, primarily due to recovery of infarct zone function. CONCLUSIONS: Intracoronary hyperoxemic reperfusion is safe and well tolerated after primary PTCA. These preliminary data support the need for a randomized controlled trial to determine if hyperoxemic reperfusion enhances myocardial salvage or improves long-term outcome.