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Adoption of all components of a structured surgical implant technique and clinical management strategy (PREVENT recommendations) is associated with low rates of confirmed PT.

Diabetes is associated with abnormal autonomic function and increased mortality. Abnormal heart rate recovery after exercise, a measure of autonomic dysfunction, is also associated with increased mortality. The objective of this study was to determine the association of fasting plasma glucose with abnormal heart rate recovery and its prognostic importance in healthy adults. We studied 5,190 healthy adults who did not have medically treated diabetes (mean age 45 years, 39% women), were enrolled in the Lipid Research Clinics' Prevalence Study, and underwent exercise testing. Heart rate recovery was defined as the change from peak heart rate to that after 2 min of recovery; an abnormal value was <42 bpm. All-cause mortality was assessed over 12 years. A total of 504 participants (10%) had impaired fasting glucose, and 131 (3%) had untreated diabetes. An abnormal heart rate recovery was found in 1,699 (33%). Compared with participants who had normal fasting plasma glucose, abnormal heart rate recovery was more common among those with impaired fasting glucose (42 vs. 31%; relative risk, 1.34; 95% confidence interval [CI], 1.20 -1.50; P < 0.0001) and those with diabetes (50 vs. 31%; relative risk, 1.61; 95% CI, 1.35-1.92; P < 0.0001). Fasting plasma glucose remained an independent predictor of abnormal heart rate recovery even after adjustment for age, sex, and other confounders (P ‫؍‬ 0.0003). An abnormal heart rate recovery added to impaired fasting plasma glucose for the prediction of death. Fasting plasma glucose is strongly and independently associated with abnormal heart rate recovery, even at nondiabetic levels. Diabetes 51:803-807, 2002 D iabetes and impaired fasting glucose are associated with increased mortality, particularly from cardiovascular causes (1-3). Diabetes is frequently complicated by an autonomic neuropathy (4), which can be detected by noting reduced heart rate variability (5,6). The Framingham Heart Study demonstrated a reduction of heart rate variability, along with a sympathetic-parasympathetic imbalance, not only in patients with diabetes but also in individuals with impaired fasting glucose (7).Abnormal heart rate recovery after exercise is an easyto-measure marker of reduced parasympathetic activity (8,9) and has been found to be an independent predictor of mortality in submaximal as well as in symptom-limited exercise stress testing (10 -12). Given the known associations among diabetes, impaired fasting glucose, and autonomic dysfunction, we hypothesized that increasing levels of fasting glucose would be associated with higher rates of abnormal heart rate recovery and that this association would be of prognostic importance. We tested these hypotheses in a healthy, population-based cohort of adults who did not have medically treated diabetes. RESEARCH DESIGN AND METHODSPopulation sample. The study population, derived from the Lipid Research Clinics Prevalence Study, a cross-sectional survey among North Americans assembled to determine the prevalence of dyslipidemia and its association wit...

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Background Destination therapy left ventricular assist devices (DT LVAD) are one of the most invasive medical interventions for end-stage illness. How patients decide whether or not to proceed with device implantation is unknown. We aimed to understand the decision-making processes of patients who either accept or decline DT LVADs. Methods and Results Between October 2012–September 2013, we conducted semi-structured, in-depth interviews to understand patients’ decision-making experiences. Data were analyzed using a mixed inductive and deductive approach. Twenty-two eligible patients were interviewed, 15 with DT LVADs and 7 who declined. We found a strong dichotomy between decision processes with some patients (11 accepters) being “automatic” and others (3 accepters, 7 decliners) being “reflective” in their approach to decision making. The automatic group was characterized by a fear of dying and an overriding desire to live as long as possible: “[LVAD] was the only option I had…that or push up daisies…so I automatically took this”. In contrast, the reflective group went through a reasoned process of weighing risks, benefits, and burdens: “There are worse things than death.” Irrespective of approach, most patients experienced the DT LVAD decision as a highly emotional process and many sought support from their families or spiritually. Conclusion Some patients offered a DT LVAD face the decision by reflecting on a process and reasoning through risks and benefits. For others, the desire to live supersedes such reflective processing. Acknowledging this difference is important when considering how to support patients who are faced with this complex decision.