Home Based Cardiac Rehabilitation Participation Among Patients With Heart Failure.

INTRODUCTION: Patients with Heart Failure (HF) have significant morbidity and mortality. Home Based Cardiac Rehabilitation (HBCR) is a form of Cardiac Rehabilitation (CR) which has been proven beneficial for the patients with cardiovascular disease; However, cardiovascular outcomes in patients with HF who was referred to HBCR is not known. METHODS: A retrospective study of 188 patients with HF (HFrEF or heart failure with reduced ejection fraction and HFpEF or heart failure with preserved ejection fraction) referred to HBCR at Veterans Affairs Medical Center (VAMC) from November 2017 to March 2020. We used the outcomes of patients with HF who attended HBCR and compared with the outcomes of patients who did not attend HBCR (Non-HBCR) from 3 months after starting HBCR till 12 months. Primary outcome was composite of all-cause mortality and cardiovascular hospitalizations. Secondary outcomes were all-cause mortality, cardiovascular hospitalizations and all-cause hospitalization, separately. We used cox proportional methods to calculate hazard ratios (HR) and 95% CI. We adjusted for imbalanced characteristics at baseline: age, smoking, PCI and CABG status. In subgroup analysis, we compared HFrEF and HFpEF patients who have completed HBCR and compared differences of their outcomes (weight, blood pressure, cholesterol, LDL, HDL, triglycerides, HbA1C, 6 Minutes walking test, duke score and PHQ-9) pre- and post-HBCR. RESULTS: Mean age of the patients was 72 year and 98% were male. Out of 188 patients total, 11 patients were excluded for the main analysis as their outcomes occurred within first 90 days of HBCR enrollment, 105/177 (59%) patients attended HBCR while 72/177 (41%) patients did not attend HBCR and 93/105 (89%) patients have completed HBCR. The primary outcome occurred in 14 patients (13.3%) in the HBCR group and 19 patients (26.4%) in the Non-HBCR group (adjusted HR=0.32, CI 0.15-0.68). There was no difference in cardiovascular hospitalization among two groups, however patients in HBCR group have lower all-cause hospitalizations and all-cause death, separately. After HBCR completion, all outcomes (weight, blood pressure, cholesterol, LDL, HDL, triglycerides, HbA1C, 6 Minutes walking test, duke score and PHQ-9) have improved in both HFrEF and HFpEF group. CONCLUSION: Patients with HF who have completed HBCR have a lower risk of all-cause mortality, all cause hospitalization separately and lower risk of combined all-cause mortality and cardiovascular hospitalization. Patients with HFrEF and HFpEF have equal degree of improvement after completing HBCR when compared with each other. HBCR is an ideal opportunity for patients with HF who cannot attend center-based CR and also for patients with HFpEF since CR is not approved for those patients.

Long-term statin therapy is associated with severe coronary artery calcification.

BACKGROUND: Atherosclerosis and consequent risk of cardiovascular events or mortality can be accurately assessed by quantifying coronary artery calcium score (CACS) derived from computed tomography. HMG-CoA-reductase inhibitors (statins) are the primary pharmacotherapy used to reduce cardiovascular events, yet there is growing data that support statin use may increase coronary calcification. We set out to determine the likelihood of severe CACS in the context of chronic statin therapy. METHODS: We established a retrospective, case-control study of 1,181 U.S. veterans without coronary artery disease (CAD) from a single site, the Providence VA Medical Center. Duration of statin therapy for primary prevention was divided into 5-year categorical increments. The primary outcome was CACS derived from low-dose lung cancer screening computed tomography (LCSCT), stratified by CACs severity (none = 0; mild = 1-99; moderate = 100-399; and severe ≥400 AU). Statin duration of zero served as the referent control. Ordinal logistic regression analysis determined the association between duration of statin use and CACS categories. Proportional odds assumption was tested using likelihood ratio test. Atherosclerotic cardiovascular disease (ASCVD) risk score, body mass index, and CKD (glomerular filtration rate of <60 ml/min/1.73 m2) were included in the adjustment models. RESULTS: The mean age of the study population was 64.7±7.2 years, and 706 (60%) patients were prescribed a statin at baseline. Duration of statin therapy was associated with greater odds of having increased CACS (>0-5 years, OR: 1.71 [CI: 1.34-2.18], p<0.001; >5-10 years, OR: 2.80 [CI: 2.01-3.90], p<0.001; >10 years, OR: 5.30 [CI: 3.23-8.70], p<0.001), and the relationship between statin duration and CACS remained significant after multivariate adjustment (>0-5 years, OR: 1.49 [CI: 1.16-1.92], p = 0.002; >5-10 years, OR: 2.38 [CI: 1.7-3.35], p<0.001; >10 years, OR: 4.48 [CI: 2.7-7.43], p<0.001). CONCLUSIONS: Long-term use of statins is associated with increased likelihood of severe CACS in patients with significant smoking history. The use of CACS to interpret cardiovascular event risk may require adjustment in the context of chronic statin therapy.

Intensive Cardiac Rehabilitation Attenuates the Gender Gap in Cardiac Rehabilitation Participation.

Traditional cardiac rehabilitation (CR) programs historically have had considerable gender gaps in CR outcomes. Intensive-Cardiac-Rehabilitation (ICR) has nonexercise components such as stress management, peer support and diet modification, in addition to exercise, which may reduce barriers to CR completion. However, there is a paucity of data in ICR outcomes based on gender. We conducted a nationwide retrospective cohort study of 15,613 patients enrolled in 46 Ornish-ICR programs across the United States from January 2016 to December 2020 and compared ICR physical and psychological outcomes in women vs men. Primary endpoints were depression scores (CESD), health status (SF-36 physical and mental composite-scores) and exercise minutes per week. Of 15,613 ICR participants who participated in the program, 6788 (44%) were women. ICR completion rates were 64.7% overall and nearly equal between men and women (63.3% women vs 65.9% men). There were a few small differences in outcomes after ICR completion: women had slightly more improvement in depression scores (women: -6.10 ± 8.79, 49.6% reduction vs men: -4.92 ± 7.80, 46.4% reduction; P < 0.01) and SF-36 physical (women: 5.95 ± 6.86 vs men: 5.28 ± 6.71, P < 0.01) and SF-36 mental (women: 5.76 ± 8.11 vs men: 4.60 ± 7.33, P < 0.01) composite scores than men. There was no significant difference in exercise-minutes per week between the 2 groups. ICR attenuates the gender gap in CR completion. Further, of the completers, women achieved slightly higher depression and quality-of-life improvements compared to men. As such, ICR can be a good option to reduce gender-based differences in CR participation.

Brentuximab vedotin demonstrates an objective response in a patient with refractory CD30+ primary mediastinal B-cell lymphoma.

Diffuse large B-cell lymphomas (DLBCL) with MYC translocations combined with translocations involving BCL-2 or BCL-6 are referred to as double-hit lymphomas. These lymphomas are generally refractory to currently available therapies and have a poor prognosis. Primary mediastinal B-cell lymphoma (PMBL) is a rare subtype of DLBCL, which shares clinical, pathologic, and genetic similarities with classical Hodgkin's lymphoma. Unlike DLBCL, rearrangements involving MYC, BCL-2, and BCL-6 are typically absent in PMBL. We present a patient with PMBL who had increased gene copy numbers of MYC and BCL-2 along with increased protein expression of BCL-2 (c-Myc expression was about 15%-20% by immunostain). The disease was refractory to standard and salvage chemotherapies. The lymphoma, however, responded to brentuximab vedotin, a CD30-directed chemoimmunoconjugate.

Spectrum of Gastrointestinal Manifestations in Joint Hypermobility Syndromes.

Joint hypermobility is a common, primarily benign finding in the general population. However, in a subset of individuals joint hypermobility causes a range of clinical problems mainly affecting the musculoskeletal system and, to a lesser extent, extra-articular disorders. Joint hypermobility often appears as a familial trait and is shared by several inherited connective tissue disorders, including the hypermobility subtype of Ehlers-Danlos syndrome (hEDS) and benign joint hypermobility syndrome (BJHS/JHS). Although joint hypermobility has primarily been thought of as a rheumatological disorder, increasing evidence shows significant associations between both hEDS and BJHS with specific extra-articular disorders. To date, the strongest associations of these 2 conditions are with anxiety disorders, orthostatic tachycardia, various functional gastrointestinal (GI) disorders and pelvic and bladder dysfunction. This review article focuses on GI disorders associated with both hEDS and BJHS. The aim of this review is to evaluate existing research and literature regarding associations between JHS (hEDS/BJHS) and GI disorders. Our goal is to raise awareness of BJHS/JHS and hEDS as an explanation for chronic unexplained symptoms and functional GI disorders as well as to review the current standard tests available for proper evaluation of GI symptoms in these patients.

Usefulness of left ventricular mass change to predict progression of renal dysfunction in Hispanics.

There is a strong relation between metabolic syndrome (MetS) and left ventricular (LV) mass in Hispanic patients. This population also tends to have a higher incidence of kidney disease, with progression to dialysis. We analyzed the change in LV mass in 982 Hispanic patients with MetS and used these data to anticipate the progression of renal dysfunction. Glomerular filtration rate (GFR) was calculated using the formula described by the Chronic Kidney Disease Epidemiology Collaboration. Echocardiographic data were collected using 2-dimensionally guided M-mode echocardiography measures. The data collected were then analyzed using linear regression analyses. Results showed a lower average GFR in individuals classified as having a severe change in LV mass in comparison to those with milder change in LV mass (P < 0.0001). This relation was also demonstrated when those with severe change in LV mass were compared with the control group (P < 0.0001). In those ≥54 years old, the presence of MetS and LV mass were negatively correlated with GFR (regression coefficient [RC] = 14.76, P < 0.063; RC = 0.11, P < 0.0001 respectively). In patients <54 years old, no statistically significant association between the presence of MetS and GFR was seen. However, LV mass was once again negatively correlated with GFR (RC = 0.15, P < 0.0001). In conclusion, results demonstrated the association between the MetS, change in LV mass, and chronic kidney disease progression.

Spindle-cell sarcoma involving the major pulmonary arteries.

Primary pulmonary vasculature tumors are exceptionally rare, with only a few reported cases. Signs and symptoms of such neoplasms vary but include dyspnea, cough, and chest pain. This condition is associated with a high mortality rate and is easily misdiagnosed as a pulmonary artery embolism. We pre-sent a case of pulmonary artery sarcoma that demonstrates the value of cardiac magnetic resonance imaging for accurate diagnosis.

Ultrasound-Assisted Catheter-Directed Thrombolysis: A Novel and Promising Endovascular Therapeutic Modality for Intermediate-Risk Pulmonary Embolism.

Intermediate-risk pulmonary embolism (PE), also known as submassive PE, occurs in a substantial group of patients and carries a significant mortality risk. With adequate risk stratification, catheter-directed techniques could be used as a therapeutic approach in the intermediate-risk PE. Ultrasound-assisted catheter-directed thrombolysis (UCDT) represents a novel endovascular technique with good clinical and safety outcomes. Ultrasound-assisted catheter-directed thrombolysis can achieve reduction in the thrombus burden and improvement of pulmonary hemodynamics and right ventricular (RV) dysfunction and/or dilatation, without major procedure-related complications, major bleeding, or hemorrhagic strokes. This narrative review will focus on the major studies involving the efficacy and safety of UCDT in the intermediate-risk PE population. Prospective, randomized clinical trials with long-term follow-up and a large sample size are needed for further evaluation of mortality benefit and to further define which subgroup of patients may benefit from this novel endovascular technique.

Diffuse large B-cell non-Hodgkin's lymphoma and osteosclerotic myeloma with features of POEMS syndrome.

Multiple myeloma is a clonal hematopoietic neoplasm characterized by the proliferation of malignant plasma cells and associated end-organ damage, most notably lytic lesions in the bones. Osteosclerotic myeloma is an unusual variant of the disease in which the skeletal involvement is characterized by sclerotic lesions instead of classical lytic lesions. The disease can be associated with paraneoplastic symptoms, which have been given the acronym POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes). In addition to clonal plasma cell dyscrasias, some cases of POEMS syndrome are associated with Castleman's disease, and in 11% to 30% of the cases both Castleman's disease and clonal plasma cell proliferation are present. POEMS syndrome has rarely been described in patients with non-Hodgkin's lymphoma.

Rumpel-Leede phenomenon presenting as a hypertensive urgency.

Rumpel-Leede (R-L) phenomenon is the rare event in which the small dermal capillaries of an extremity rupture in response to application of a compressive device to that extremity, such as when inflating a cuff during noninvasive blood pressure monitoring or when applying a tourniquet to draw blood. This capillary rupture results in formation of a petechial rash distal to the compressive device. R-L phenomenon is believed to occur most often in patients with underlying vascular disease, such as diabetes mellitus or thrombocytopenia. R-L phenomenon is most often benign, though it may rarely be associated with pain and discomfort. There is no treatment for this condition apart from treatment of the underlying vascular disease or thrombocytopenia. We report a 57-year-old woman who presented with hypertensive urgency and experienced R-L phenomenon during blood pressure cuff inflation.