Feasibility and outcomes from using a commitment device and text message reminders to increase adherence to time-restricted eating: A randomized trial.

BACKGROUND: Obesity is strongly associated with cardiovascular disease, particularly through its effects on blood pressure. Though maintaining a negative caloric balance leads to weight loss, many patients struggle to adhere to low calorie diets over the long term. Time-restricted eating, a subtype of intermittent fasting (IF), may be an easier dietary pattern for patients to initiate and maintain. We tested the feasibility of a bidirectional texting strategy to help patients with obesity and hypertension initiate and maintain time-restricted eating, and whether a commitment device, a pledge to behave in a certain way in the future while making nonadherence costlier, would increase adherence beyond bidirectional texting. METHODS: Patients with obesity and hypertension seen in cardiology clinics were provided education on time-restricted eating and randomized to a commitment device versus attention control. Attention control consisted of daily bidirectional text messages asking whether patients adhered to IF and weekly text messages asking participants to send their weight and blood pressure. The commitment device involved the same text messages as attention control, plus a commitment contract, setting of implementation intentions with respect to details of time-restricted eating, and involvement of a support partner who received weekly updates on the participant's adherence to time-restricted eating. The intervention lasted 12 weeks, followed by a 6-week follow-up period. The primary outcome was days per week adherent to time-restricted eating over the 18-week study period, measured by daily self-report. We also compared change from baseline weight and blood pressure between randomized groups. RESULTS: A total of 37 patients were randomized and started the study-20 to attention control and 17 to the commitment device. Mean age was 60 years old, and mean BMI was 38.4 kg/m2. Over the 18-week study period, the mean ± standard deviation (SD) number of days per week adherent to time-restricted eating was 4.7 ± 1.9 in the control arm and 5.4 ± 1.7 in the intervention arm (P = .23). Mean systolic blood pressure declined from 135 to 128 mm Hg among all participants (P = .006) with no difference between groups in change from baseline blood pressure (P = .74). Weight decreased from 229 to 223 pounds among all participants (P = .25) with no significant difference between groups in change from baseline weight (P = .84). CONCLUSIONS: A bidirectional texting strategy was feasible for helping patients with obesity and hypertension initiate and adhere to time-restricted eating. Adding a commitment device to bidirectional texting did not increase adherence to time-restricted eating compared with attention control, nor were there significant between group changes in blood pressure or weight, but these comparisons were underpowered. A larger randomized trial of the effect of this scalable intervention, compared with usual care, on blood pressure and weight among patients with obesity and hypertension is warranted. CLINICAL TRIALS REGISTRATION: clinicaltrials.gov; unique identifier: NCT04836312.

Collegiate Wrestler With a Bicuspid Aortic Valve and Aortic Dilation.

Bicuspid aortic valve and aortopathy are generally considered contraindications to isometric exercise. For athletes with mild disease at low risk of adverse events, a shared decision-making approach for continued sports participation is reasonable. We present a case of a collegiate wrestler with bicuspid aortic valve and aortopathy to illustrate shared decision making. (Level of Difficulty: Intermediate.).

Myocarditis and Other Cardiovascular Complications of the mRNA-Based COVID-19 Vaccines.

Cardiovascular complications following the receipt of mRNA-based (Pfizer-BioNTech and Moderna) coronavirus disease 2019 (COVID-19) vaccines have not yet been described. In this case series, we describe two patients with clinically suspected myocarditis, one patient with stress cardiomyopathy, and two patients with pericarditis after receiving an mRNA-based COVID-19 vaccine. The two patients with clinically suspected myocarditis were otherwise healthy young men who presented with acute substernal chest pressure and/or dyspnea after receiving the second dose of the vaccine and were found to have diffuse ST elevations on electrocardiogram (ECG), elevated cardiac biomarkers and inflammatory markers, and mildly reduced left ventricular (LV) function on echocardiography. Both patients met the modified Lake Louise Criteria for acute myocarditis by cardiac magnetic resonance imaging. We subsequently discuss a case of a 60-year-old woman with known coronary artery disease (CAD) and previously normal LV function, who presented with new exertional symptoms, ECG changes, and apical akinesis following the second dose of the vaccine, and was diagnosed with a stress cardiomyopathy. Finally, we describe two patients with pericarditis who presented with chest pain, elevated inflammatory markers, and pericardial effusions after receiving the vaccine. Overall, this case series describes the first reported cases of myocarditis, stress cardiomyopathy, and pericarditis after receiving an mRNA-based COVID-19 vaccine.

Statins in the prevention of heart failure after myocardial infarction.

Statin therapy has demonstrated clear reductions in the risk of death and recurrent cardiac events in patients with acute coronary syndrome (ACS) and coronary artery disease. Heart failure after myocardial infarction (MI) is associated with increased in-hospital mortality and worse long-term prognosis. Some controversy exists about the effects of statin therapy on heart failure, although the favorable effects of statin therapy likely reduce the risk of heart failure development after MI and ACS. This article reviews data on statin therapy and the incidence of heart failure after MI, discussing mechanisms, safety, and outcomes.

Imaging studies in patients with heart failure: current and evolving technologies.

Technological advances continue to expand the clinical role of echocardiography in the intensive care unit, particularly in patients with heart failure. It has many advantages over tomographic techniques such as echo cardiac magnetic resonance imaging and cardiac computed tomography, can provide rapid bedside cardiac assessment, and facilitate emergent decision-making for critically ill patients. Image quality problems in the intensive care setting have largely been overcome by the use of harmonic imaging, contrast opacification, and when indicated, transesophageal echocardiography. Newer techniques promise to advance the scope and prognostic power of echocardiography, and to expand the portability and availability of this tool.

Management of lipids in the prevention of cardiovascular events.

Lipid-modifying therapy has been proven to significantly reduce cardiovascular events and total mortality. Most of the data have come from statin trials. Statin therapy is generally well-tolerated and safe, and for patients who are at higher than average risk of cardiovascular disease, the benefit of lipid-modifying therapy far exceeds the risk. Careful risk assessment is a critical component of effective lipid-modifying therapy. In the foreseeable future, low-density lipoprotein cholesterol (LDL-C) will remain the primary therapeutic target, and combination therapy is likely to become the norm. The major questions are how low to treat and how to achieve increasingly aggressive targets in lipid-lowering therapy. Many patients on LDL-lowering therapy continue to have abnormalities of the triglyceride-high-density lipoprotein (TG-HDL) axis, so additional drug therapy is often considered for such patients. In this review, we briefly discuss new developments in cardiovascular risk assessment, then discuss recent developments in treatment to reduce LDL, and finally discuss current concepts regarding therapy targeting the TG-HDL axis.

Determinants of the cost-effectiveness of statins.

OBJECTIVE: To examine the cost-effectiveness of statins in relation to different measures of effectiveness, differences in efficacy among individual statins, and the risk of coronary heart disease. Efficacy is defined here as the magnitude of the effect produced by a given amount of drug, as demonstrated in placebocontrol trials; i.e., the effectiveness per unit dose. DATA SYNTHESIS: Treatment guidelines categorize patients by their risk of coronary events and set lower target cholesterol levels for patients at higher risk. Statins vary in their efficacy. If effectiveness is expressed as percent lowering in low-density lipoprotein cholesterol (LDL-C) and relatively little cholesterol lowering is required.as in low-risk patients.even statins of low efficacy provide adequate cholesterol lowering, and drug price is the determining factor of costeffectiveness. For patients at high risk.the primary target group, which has been expanded in recent guidelines.high-efficacy statins are required to meet the more aggressive cholesterol goals, and efficacy is the important determinant of cost-effectiveness. When effectiveness is expressed in terms of life-years saved, the cost-effectiveness of statins as a class for treatment of high-risk patients compares favorably with the cost-effectiveness of generally accepted medical treatments. CONCLUSION: In order to optimize cost-effectiveness, the level of effectiveness required to treat the specific patient or patient group must be considered. Statin efficacy is the major determinant of cost-effectiveness when greater cholesterol lowering is required, i.e., for high-risk patients, who make up the primary target group. Statin price is the more important factor if only limited cholesterol lowering (e.g., 35% or less reduction in LDL) is required.

Exercise and coronary artery disease: assessing causes and managing risks.

Exercise has many benefits, but it is not completely risk-free. Many factors can contribute to cardiac events during exercise, including coronary artery disease (CAD) and nonatherosclerotic causes such as anomalous coronary arteries, myocardial bridging, and vasculitis. Myocardial infarction and sudden cardiac death are the two major problems in older patients with CAD, but most exercise-related deaths in young patients result from hypertrophic cardiomyopathy and coronary artery anomalies. Preexercise screening that includes a careful history, medical examination, and, for some, exercise testing, can stratify risk and mitigate potential problems during exercise.