Coronary vascular dysfunction is associated with increased risk of death in patients with peripheral artery disease.

BACKGROUND: Peripheral artery disease (PAD) and coronary vascular dysfunction are common in patients with cardiometabolic disease. Neither the prevalence of coronary vascular dysfunction among patients with PAD nor the prognostic impact with these two conditions present together has been well studied. METHODS: Consecutive patients who underwent PET MPI were analyzed for presence of coronary vascular dysfunction [myocardial blood flow reserve (MBFR) < 2]. Cox regression was used to examine the association of reduced MBFR with mortality in patients with PAD, as well as the association of comorbid MBFR < 2 and PAD with all-cause death. RESULTS: Among 13,940 patients, 1936 (14%) had PAD, 7782 (56%) had MBFR < 2 and 1346 (10%) had both PAD and MBFR < 2. Reduced MBFR was very common (69.5%) and was associated with increased risk of all-cause death (HR 1.69, 95%CI 1.32, 2.16, p < 0.01) in patients with PAD. Patients with both PAD and MBFR < 2, and those with either PAD or reduced MBFR had increased risk of death compared to those with neither condition: PAD + MBFR < 2 [(HR 95%CI), 2.30; 1.97-2.68], PAD + MBFR ≥ 2 (1.37; (1.08-1.72), PAD - MBFR < 2 (1.98; 1.75-2.25), p < 0.001 for all). CONCLUSION: Coronary vascular dysfunction was common in patients with PAD and was associated with increased risk of death.

Racial and Ethnic Differences in Bystander CPR for Witnessed Cardiac Arrest.

BACKGROUND: Differences in the incidence of cardiopulmonary resuscitation (CPR) provided by bystanders contribute to survival disparities among persons with out-of-hospital cardiac arrest. It is critical to understand whether the incidence of bystander CPR in witnessed out-of-hospital cardiac arrests at home and in public settings differs according to the race or ethnic group of the person with cardiac arrest in order to inform interventions. METHODS: Within a large U.S. registry, we identified 110,054 witnessed out-of-hospital cardiac arrests during the period from 2013 through 2019. We used a hierarchical logistic regression model to analyze the incidence of bystander CPR in Black or Hispanic persons as compared with White persons with witnessed cardiac arrests at home and in public locations. We analyzed the overall incidence as well as the incidence according to neighborhood racial or ethnic makeup and income strata. Neighborhoods were classified as predominantly White (>80% of residents), majority Black or Hispanic (>50% of residents), or integrated, and as high income (an annual median household income of >$80,000), middle income ($40,000-$80,000), or low income (<$40,000). RESULTS: Overall, 35,469 of the witnessed out-of-hospital cardiac arrests (32.2%) occurred in Black or Hispanic persons. Black and Hispanic persons were less likely to receive bystander CPR at home (38.5%) than White persons (47.4%) (adjusted odds ratio, 0.74; 95% confidence interval [CI], 0.72 to 0.76) and less likely to receive bystander CPR in public locations than White persons (45.6% vs. 60.0%) (adjusted odds ratio, 0.63; 95% CI, 0.60 to 0.66). The incidence of bystander CPR among Black and Hispanic persons was less than that among White persons not only in predominantly White neighborhoods at home (adjusted odds ratio, 0.82; 95% CI, 0.74 to 0.90) and in public locations (adjusted odds ratio, 0.68; 95% CI, 0.60 to 0.75) but also in majority Black or Hispanic neighborhoods at home (adjusted odds ratio, 0.79; 95% CI, 0.75 to 0.83) and in public locations (adjusted odds ratio, 0.63; 95% CI, 0.59 to 0.68) and in integrated neighborhoods at home (adjusted odds ratio, 0.78; 95% CI, 0.74 to 0.81) and in public locations (adjusted odds ratio, 0.73; 95% CI, 0.68 to 0.77). Similarly, across all neighborhood income strata, the frequency of bystander CPR at home and in public locations was lower among Black and Hispanic persons with out-of-hospital cardiac arrest than among White persons. CONCLUSIONS: In witnessed out-of-hospital cardiac arrest, Black and Hispanic persons were less likely than White persons to receive potentially lifesaving bystander CPR at home and in public locations, regardless of the racial or ethnic makeup or income level of the neighborhood where the cardiac arrest occurred. (Funded by the National Heart, Lung, and Blood Institute.).

Association of Medication Adherence With Health Outcomes in the ISCHEMIA Trial.

BACKGROUND: The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial randomized participants with chronic coronary disease (CCD) to guideline-directed medical therapy with or without angiography and revascularization. The study examined the association of nonadherence with health status outcomes. OBJECTIVES: The study sought to compare 12-month health status outcomes of adherent and nonadherent participants with CCD with an a priori hypothesis that nonadherent patients would have better health status if randomized to invasive management. METHODS: Self-reported medication-taking behavior was assessed at randomization with a modified 4-item Morisky-Green-Levine Adherence Scale, and participants were classified as adherent or nonadherent. Twelve-month health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ-7) summary score (SS), which ranges from 0 to 100 (higher score = better). The association of adherence with outcomes was evaluated using Bayesian proportional odds models, including an interaction by study arm (conservative vs invasive). RESULTS: Among 4,480 randomized participants, 1,245 (27.8%) were nonadherent at baseline. Nonadherent participants had worse baseline SAQ-7 SS in both conservative (72.9 ± 19.3 vs 75.6 ± 18.4) and invasive (71.0 ± 19.8 vs 74.2 ± 18.7) arms. In adjusted analyses, adherence was associated with higher 12-month SAQ-7 SS in both treatment groups (mean difference in SAQ-7 SS with conservative treatment = 1.6 [95% credible interval: 0.3-2.9] vs with invasive management = 1.9 [95% credible interval: 0.8-3.1]), with no interaction by treatment. CONCLUSIONS: More than 1 in 4 participants reported medication nonadherence, which was associated with worse health status in both conservative and invasive treatment strategies at baseline and 12 months. Strategies to improve medication adherence are needed to improve health status outcomes in CCD, regardless of treatment strategy. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Prognostic implications of a one-item health literacy screen on health status outcomes among heart failure patients with depression.

Background: Health literacy (HL) is the degree to which individuals can obtain, process, and understand basic health information and services. Although low HL portends greater risk for clinical events, its association with heart failure (HF)-specific health status- patients' symptoms, function and quality of life- is poorly understood. We thus explored the association of low HL with health status outcomes in depressed patients with HF, for whom treatment regimens can be complex. Methods: Participants with HF with reduced ejection fraction and depression, from the Hopeful Heart trial, were categorized as having low or adequate HL at baseline using a validated, 1-item HL screen. HF-specific health status was measured at baseline, 3, 6, and 12 months using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Using serial risk-adjusted linear regression models, we assessed the association of HL with baseline, 12-month and 12-month change in the KCCQ Overall Summary (OS) scores (range 0-100; lower scores = worse health status). Results: Among 629 participants, 35 % had low HL. Those with low HL had lower health status at all time points, including at 12 months after discharge (-9.8 points, 95%CI [-14.3, -5.3], p < 0.001), with poorer improvements in KCCQ-OS scores after accounting for baseline health status (-6.4 points, 95%CI [-10.5, -2.3], p = 0.002). Conclusions: In those with HF and depression, low HL was common and associated with worse HF-specific health status and poorer improvement over time. A brief HL screen can identify patients at risk for poorer health status outcomes and for whom additional interventions may be warranted.

THYROTOXICOSIS IN A PEDIATRIC PATIENT WITH SUPRAVENTRICULAR TACHYCARDIA AND BORDERLINE FEATURES OF THYROID STORM.

OBJECTIVE: The objective of this report was to emphasize the early recognition of thyrotoxicosis in the assessment of a pediatric patient with tachycardia. We present here the case of a 17-year-old female who presented with supraventricular tachycardia and was found to be in a state of severe thyrotoxicosis with borderline features of a thyroid storm. METHODS: A 17-year-old African American female presented to the hospital with complaints of nausea, vomiting, and diarrhea associated with palpitations for 1 week. Initial workup included electrocardiogram, total blood count, lipase, basic metabolic panel, and thyroid function tests. RESULTS: Initial vital signs were significant for a temperature of 100.1°F, and tachycardia with a heart rate (HR) of 180 beats per minute (bpm). Initial telemetry was significant for supraventricular tachycardia with a HR of 180 bpm. Vagal maneuvers including carotid sinus massage were attempted first followed by 6 mg intravenous (IV) push and then 12 mg IV push of adenosine. However, the patient remained tachycardic with a HR in the 150s. Laboratory evaluation confirmed the presence of thyrotoxicosis with a thyroid-stimulating hormone of 0.17 µIU/mL (normal, 0.5 to 4.7 µIU/mL) with a free thyroxine of 4.90 ng/dL (normal, 0.8 to 2.0 ng/dL) and free triiodothyronine >20 pg/mL (normal, 1.95 to 5.85 pg/mL). She was subsequently treated with propranolol, methimazole, and hydrocortisone, which resolved her symptoms in a few hours. CONCLUSION: Due to high mortality rates, severe thyrotoxicosis needs to be recognized and treated early. This case report highlights the importance of early recognition of thyrotoxicosis in the initial management of tachycardia in the pediatric population.