Immersion pulmonary edema: an analysis of 31 cases from Oceania.

AIM: To review incidents of immersion pulmonary edema (IPE) from Oceania, to determine the demographics, diving parameters, and comorbidities that may be related to this disorder. METHOD: Incidents of IPE, most of which were documented by Divers Alert Network Asia-Pacific (DAN AP) or reported in our medical literature, were analyzed. They included interviews with the survivors and a review of available medical records. Only incidents diagnosed as IPE by specialist diving physicians or pathologists with experience in the investigation of diving accidents were included. RESULTS: Thirty-one IPE incidents in divers from Oceania were documented. There were two surface snorkelers, 22 scuba air divers and seven nitrox divers, which included three closed-circuit rebreathers (CCR). The mean (SD) age was 53 (12) years, 58% of victims were females, and the average dive profile was to a maximum depth of 19 msw for 25 minutes. Six victims (19%) had previous episodes of IPE. There were nine recorded fatalities in this cohort. Medical comorbidities were recorded in 68%, with 42% being cardiac. The latter included valvular disease in 29%, transient cardiomyopathies in 26% and dysrhythmias in 16%. CONCLUSION: IPE was more likely in middle-aged females, in experienced divers, and during ascent or after surfacing. Commonly reported associations such as exertion, stress, cold exposure, negative inspiratory pressure, hypertension, overhydration, tight wetsuit, aspiration and certain medications were identified. This series supports the hypothesis that the elderly IPE subjects are likely to have comorbidities and be susceptible to IPE recurrences and fatalities unless the contributing factors can be identified and addressed.

A mixed methods study of symptom perception in patients with chronic heart failure.

BACKGROUND: Early heart failure (HF) symptoms are frequently unrecognized for reasons that are unclear. We explored symptom perception in patients with chronic HF. METHODS: We enrolled 36 HF out-patients into a longitudinal sequential explanatory mixed methods study. We used objectively measured thoracic fluid accumulation and daily reports of signs and symptoms to evaluate accuracy of detected changes in fluid retention. Patterns of symptom interpretation and response were explored in telephone interviews conducted every 2 weeks for 3-months. RESULTS: In this sample, 44% had a mismatch between objective and subjective fluid retention; younger persons were more likely to have mismatch. In interviews, two patterns were identified: those able to interpret and respond appropriately to symptoms were higher in decision-making skill and the quality of social support received. CONCLUSION: Many HF patients were poor at interpreting and managing their symptoms. These results suggest a subgroup of patients to target for intervention.

Sports Cardiology: Core Curriculum for Providing Cardiovascular Care to Competitive Athletes and Highly Active People.

The last few decades have seen substantial growth in the populations of competitive athletes and highly active people (CAHAP). Although vigorous physical exercise is an effective way to reduce the risk of cardiovascular (CV) disease, CAHAP remain susceptible to inherited and acquired CV disease, and may be most at risk for adverse CV outcomes during intense physical activity. Traditionally, multidisciplinary teams comprising athletic trainers, physical therapists, primary care sports medicine physicians, and orthopedic surgeons have provided clinical care for CAHAP. However, there is increasing recognition that a care team including qualified CV specialists optimizes care delivery for CAHAP. In recognition of the increasing demand for CV specialists competent in the care of CAHAP, the American College of Cardiology has recently established a Sports and Exercise Council. An important primary objective of this council is to define the essential skills necessary to practice effective sports cardiology.

Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis.

BACKGROUND: Self-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most. This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension. METHODS AND FINDINGS: Medline, Embase, and the Cochrane Library were searched for randomised trials comparing self-monitoring to no self-monitoring in hypertensive patients (June 2016). Two reviewers independently assessed articles for eligibility and the authors of eligible trials were approached requesting IPD. Of 2,846 articles in the initial search, 36 were eligible. IPD were provided from 25 trials, including 1 unpublished study. Data for the primary outcomes-change in mean clinic or ambulatory BP and proportion controlled below target at 12 months-were available from 15/19 possible studies (7,138/8,292 [86%] of randomised participants). Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (-3.2 mmHg, [95% CI -4.9, -1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (-1.0 mmHg [-3.3, 1.2]), to a 6.1 mmHg (-9.0, -3.2) reduction when monitoring was combined with intensive support. Self-monitoring was most effective in those with fewer antihypertensive medications and higher baseline sBP up to 170 mmHg. No differences in efficacy were seen by sex or by most comorbidities. Ambulatory BP data at 12 months were available from 4 trials (1,478 patients), which assessed self-monitoring with little or no co-intervention. There was no association between self-monitoring and either lower clinic or ambulatory sBP in this group (clinic -0.2 mmHg [-2.2, 1.8]; ambulatory 1.1 mmHg [-0.3, 2.5]). Results for diastolic blood pressure (dBP) were similar. The main limitation of this work was that significant heterogeneity remained. This was at least in part due to different inclusion criteria, self-monitoring regimes, and target BPs in included studies. CONCLUSIONS: Self-monitoring alone is not associated with lower BP or better control, but in conjunction with co-interventions (including systematic medication titration by doctors, pharmacists, or patients; education; or lifestyle counselling) leads to clinically significant BP reduction which persists for at least 12 months. The implementation of self-monitoring in hypertension should be accompanied by such co-interventions.

Sex Differences in Fractional Flow Reserve-Guided Revascularization: A Nationwide Analysis.

BACKGROUND: Women with coronary artery disease are less likely to be revascularized than men based on angiography alone. Recent studies have shown that female patients have higher fractional flow reserve (FFR) values for a given severity of coronary stenosis. However, gender differences in coronary revascularization rates following FFR assessment are unknown. METHODS: The nationwide inpatient sample database was used to identify all patients who underwent FFR in the United States between January 2009 and December 2010. We used propensity score matching to compare revascularization rates and in-hospital outcomes among men and women undergoing FFR measurements. RESULTS: Among 3712 patients who underwent FFR during the study period, 1235 matched pairs of men and women were identified. The overall revascularization rates were lower in women than men (40.1% vs. 52.8%, p < 0.01). Women were less likely to undergo either percutaneous (35.2% vs. 45.6%, p < 0.01) or surgical revascularization following FFR than men (5.2% vs. 7.4%, p = 0.03). Women had a nonsignificant trend toward higher in-hospital mortality (0.8% vs. 0.5%, p = 0.32) and significantly higher rates of access site hematoma formation (2.7% vs. 0.8%, p < 0.01) compared to men. CONCLUSION: In conclusion, this large nationwide study reveals that coronary revascularization rates are significantly lower in women than in men even after functional assessment with FFR.

Pulmonary Aspects of Exercise and Sports.

Although the lungs are a critical component of exercise performance, their response to exercise and other environmental stresses is often overlooked when evaluating pulmonary performance during high workloads. Exercise can produce capillary leakage, particularly when left atrial pressure increases related to left ventricular (LV) systolic or diastolic failure. Diastolic LV dysfunction that results in elevated left atrial pressure during exercise is particularly likely to result in pulmonary edema and capillary hemorrhage. Data from race horses, endurance athletes, and triathletes support the concept that the lungs can react to exercise and immersion stress with pulmonary edema and pulmonary hemorrhage. Immersion in water by swimmers and divers can also increase stress on pulmonary capillaries and result in pulmonary edema. Swimming-induced pulmonary edema and immersion pulmonary edema in scuba divers are well-documented events caused by the fluid shifts that occur with immersion, elevated pulmonary venous pressure during extreme exercise, and negative alveolar pressure due to inhalation resistance. Prevention strategies include avoiding extreme exercise, avoiding over hydration, and assuring that inspiratory resistance is minimized.

Can asthmatic subjects dive?

Recreational diving with self-contained underwater breathing apparatus (scuba) has grown in popularity. Asthma is a common disease with a similar prevalence in divers as in the general population. Due to theoretical concern about an increased risk for pulmonary barotrauma and decompression sickness in asthmatic divers, in the past the approach to asthmatic diver candidates was very conservative, with scuba disallowed. However, experience in the field and data in the current literature do not support this dogmatic approach. In this review the theoretical risk factors of diving with asthma, the epidemiological data and the recommended approach to the asthmatic diver candidate will be described.

Factors Influencing Physician Counseling on Cardiovascular Risk.

BACKGROUND AND IMPORTANCE: A significant reduction in cardiovascular disease (CVD) mortality is related to aggressive management of modifiable CVD risk factors. Therefore, patients at increased risk for CVD should not only benefit from standard pharmacotherapy but also from counseling regarding lifestyle behavioral changes. OBJECTIVE: To determine the patient factors that influence provision of cardiovascular risk reduction counseling from physicians, as well as the frequencies of counseling. DESIGN, SETTING, AND PARTICIPANTS: Secondary analysis of a prospective, randomized trial among an underserved inner-city and rural population (n = 388) with a 10% or greater CVD risk (Framingham 10-year risk score). Subjects were followed for 1 year and were seen for quarterly assessments, which included evaluation of weight, blood pressure, lipid, and glucose status. At each of the 4 quarterly visits, subjects were asked if their physician had discussed or made recommendations regarding lifestyle behaviors, specifically diet, weight loss, and exercise. RESULTS: The average patient age was 61.3 ± 10.1 years, average A1c was 6.7 ± 1.6%, average total cholesterol was 201 ± 44 mg/dL. The average body mass index (BMI) was 31.8 ± 6.4 kg/m2, and the average blood pressure was 146 ± 18/82 ±11 mm Hg. Using binary logistic regression analysis, BMI (P < .025) was the only clinical factor related to physician lifestyle counseling. All other risk factors showed no statistical relationship. CONCLUSION: The data indicate that BMI is the major factor associated with whether or not physicians provide counseling regarding nutrition and weight loss. Physicians may be missing important opportunities to influence behavior in patients at high risk for CVD by limiting their focus to obese patients.

Individual patient data meta-analysis of self-monitoring of blood pressure (BP-SMART): a protocol.

INTRODUCTION: Self-monitoring of blood pressure is effective in reducing blood pressure in hypertension. However previous meta-analyses have shown a considerable amount of heterogeneity between studies, only part of which can be accounted for by meta-regression. This may be due to differences in design, recruited populations, intervention components or results among patient subgroups. To further investigate these differences, an individual patient data (IPD) meta-analysis of self-monitoring of blood pressure will be performed. METHODS AND ANALYSIS: We will identify randomised trials that have compared patients with hypertension who are self-monitoring blood pressure with those who are not and invite trialists to provide IPD including clinic and/or ambulatory systolic and diastolic blood pressure at baseline and all follow-up points where both intervention and control groups were measured. Other data requested will include measurement methodology, length of follow-up, cointerventions, baseline demographic (age, gender) and psychosocial factors (deprivation, quality of life), setting, intensity of self-monitoring, self-monitored blood pressure, comorbidities, lifestyle factors (weight, smoking) and presence or not of antihypertensive treatment. Data on all available patients will be included in order to take an intention-to-treat approach. A two-stage procedure for IPD meta-analysis, stratified by trial and taking into account age, sex, diabetes and baseline systolic BP will be used. Exploratory subgroup analyses will further investigate non-linear relationships between the prespecified variables. Sensitivity analyses will assess the impact of trials which have and have not provided IPD. ETHICS AND DISSEMINATION: This study does not include identifiable data. Results will be disseminated in a peer-reviewed publication and by international conference presentations. CONCLUSIONS: IPD analysis should help the understanding of which self-monitoring interventions for which patient groups are most effective in the control of blood pressure.

Impact of Institutional Volume on Outcomes of Catheter Directed Thrombolysis in the Treatment of Acute Proximal Deep Vein Thrombosis: A 6-Year US Experience (2005-2010).

BACKGROUND: The use of catheter-directed thrombolysis (CDT) in the treatment of acute proximal lower-extremity deep vein thrombosis is increasing in the United States and has been linked to higher bleeding rates. Whether this relationship is interrelated with institution volume of CDT is unknown. METHODS AND RESULTS: The Nationwide Inpatient Sample database was used to identify all patients admitted with a principal diagnosis of proximal or inferior vena caval deep vein thrombosis and treated with CDT from 2005 to 2010. Institutions were divided into high-volume (≥6 procedures a year) and low-volume (<6 procedures a year) centers. Propensity score matching was used to create 2 matched groups for comparative analysis. A total of 90 618 patients were hospitalized for proximal lower-extremity deep vein thrombosis, and 3649 patients (4.1%) underwent CDT. In-hospital mortality was significantly lower at high-volume centers (0.6% versus 1.5%; P=0.04) with a trend toward lower intracranial hemorrhage rates compared with low-volume centers (0.4% versus 1%; P=0.07). No significant difference was seen with blood transfusion (10.4% versus 10.8%; P=0.70), gastrointestinal bleeding (1.4% versus 1.8%; P=0.35), or pulmonary embolism rates (18.4% versus 17.9%; P=0.72). Median length of stay was similar (6 days) and hospital charges were higher ($65 500 versus $75 870) at high-volume centers. CONCLUSIONS: In this observational study, we found that an increase in institutional volume of CDT was associated with lower in-hospital mortality and lower intracranial hemorrhage rates. Further studies are needed to assess whether standardization of CDT protocols across all institutions in the United States improves outcomes.

Cardiovascular Concerns in Water Sports.

The cardiac effects of aquatic sports have increased in interest with the experience of cardiac responses to swimming and diving. The syndrome of swimming-induced pulmonary edema is likely caused by a combination of central blood shifts, sudden onset of high exercise demands, and impaired diastolic relaxation of the left ventricle. Divers also develop venous gas emboli caused by nitrogen supersaturation in blood and tissues during ascent from depth. The physiology and physics of water immersion and diving are unique. Knowledge of pressure effects, gas solubility, and changes in gas volumes with depth is needed to understand the disorders related to these activities.

2015 ACC Health Policy Statement on Cardiovascular Team-Based Care and the Role of Advanced Practice Providers.

The mission of the American College of Cardiology is "to transform cardiovascular care and improve heart health." Cardiovascular team-based care is a paradigm for practice that can transform care, improve heart health, and help meet the demands of the future. One strategic goal of the College is to help members successfully transition their clinical practices to the future, with all its complexity, challenges, and opportunities. The ACC's strategic plan is aligned with the triple aim of improved care, improved population health, and lower costs per capita. The traditional understanding of quality, access, and cost is that you cannot improve one component without diminishing the others. With cardiovascular team-based care, it is possible to achieve the triple aim of improving quality, access, and cost simultaneously to also improve cardiovascular health. Striving to serve the best interests of patients is the true north of our guiding principles. Cardiovascular team-based care is a model that can improve care coordination and communication and allow each team member to focus more on the quality of care. In addition, the cardiovascular team-based care model increases access to cardiovascular care and allows expansion of services to populations and geographic areas that are currently underserved. This document will increase awareness of the important components of cardiovascular team-based care and create an opportunity for more discussion about the most creative and effective means of implementing it. We hope that this document will stimulate further discussions and activities within the ACC and beyond about team-based care. We have identified areas that need improvement, specifically in APP education and state regulation. The document encourages the exploration of collaborative care models that should enable team members to optimize their education, training, experience, and talent. Improved team leadership, coordination, collaboration, engagement, and efficiency will enable the delivery of higher-value care to the betterment of our patients and society.

Elevated Cardiac Troponin in Acute Stroke without Acute Coronary Syndrome Predicts Long-Term Adverse Cardiovascular Outcomes.

Background. Elevated cardiac troponin in acute stroke in absence of acute coronary syndrome (ACS) has unclear long-term outcomes. Methods. Retrospective analysis of 566 patients admitted to Temple University Hospital from 2008 to 2010 for acute stroke was performed. Patients were included if cardiac troponin I was measured and had no evidence of ACS and an echocardiogram was performed. Of 200 patients who met the criteria, baseline characteristics, electrocardiograms, and major adverse cardiovascular events (MACE) were reviewed. Patients were characterized into two groups with normal and elevated troponins. Primary end point was nonfatal myocardial infarction during follow-up period after discharge. The secondary end points were MACE and death from any cause. Results. For 200 patients, 17 patients had positive troponins. Baseline characteristics were as follows: age 63.1 ± 13.8, 64% African Americans, 78% with hypertension, and 22% with previous CVA. During mean follow-up of 20.1 months, 7 patients (41.2%) in elevated troponin and 6 (3.3%) patients in normal troponin group had nonfatal myocardial infarction (P = 0.0001). MACE (41.2% versus 14.2%, P = 0.01) and death from any cause (41.2% versus 14.5%, P = 0.017) were significant in the positive troponin group. Conclusions. Elevated cardiac troponin in patients with acute stroke and no evidence of ACS is strong predictor of long-term cardiac outcomes.

Clinical utility of central venous saturation for the calculation of cardiac index in cardiac patients.

BACKGROUND: Mixed venous saturation (MVS) obtained from the distal pulmonary artery (PA) during Swan-Ganz catheterization is the criterion standard for calculating cardiac output (CO) and cardiac index (CI) with the use of the Fick method. We think that calculating CI with the use of central venous saturation (CVS) instead of PA-MVS is both feasible and accurate. Earlier studies were small, enrolled heterogeneous patient populations, and resulted in inconsistent findings. METHODS: All patients undergoing right heart catheterization from January 2011 to January 2012 in our catheterization lab with simultaneous measurements of MVS obtained from the distal PA and CVS obtained from the superior vena cava (SVC) or right atrium (RA) were included. Out of the 902 patients enrolled, we excluded patients (n = 50) who had known cardiac shunt or dialysis fistula, had duplicate medical records, or were septic. We calculated the CI with the use of the assumed Fick method using both MVS (criterion standard) and CVS (SVC or RA saturations) in the remaining 852 patients. We measured the correlation and the agreement between the 2 methods with the use of the Pearson correlation coefficient and Bland-Altman analysis. RESULTS: Totals of 112 patients with simultaneous PA and RA saturation measurements (group I) and 740 patients with simultaneous PA and SVC saturation measurements (group II) were included. We found an excellent linear correlation between SVC and PA saturation (r = 0.928) and between RA and PA saturation (r = 0.95). There was also an excellent correlation between CI calculated with the use of PA saturation and CI calculated with the use of SVC (r = 0.87) or RA (r = 0.93) saturation. The mean bias of CVS-derived CI compared with MVS-derived CI (criterion standard) was -0.1 (95% limits of agreement [LOA] -1 to +0.77) in the SVC group and -0.006 (LOA -0.68 to +0.69) in the RA group. Patients with low CI had stronger correlation and smaller bias between the 2 methods compared with those with normal or high CI. The presence of baseline hypoxemia, valvular heart disease, or acute coronary syndrome had no significant effect on the correlation or the bias between the 2 methods. CONCLUSIONS: In cardiac patients, CVS can be used as a surrogate to true MVS in the calculation of CI. This method is readily available in patients who have central venous access, and may aid in early goal-directed treatment when cardiogenic shock is suspected.