Pericardial fat volume is highly associated with paroxysmal and persistent AF independent of traditional risk factors including left atrial enlargement. Whether pericardial fat plays a role in the pathogenesis of AF requires future investigation.
Objectives
We sought to determine whether left atrial (LA) dysfunction predicts heart failure (HF) hospitalization in subjects with preserved baseline ejection fraction (EF).
Background
Among patients with preserved EF, factors leading to HF are not fully understood. Cross-sectional studies have demonstrated LA dysfunction at the time of HF, but longitudinal data on antecedent atrial function are lacking.
Methods
We performed resting transthoracic echocardiography in 855 subjects with coronary heart disease and EF≥50%. Left atrial functional index (LAFI) was calculated as [(LA emptying fraction × left ventricular outflow tract-velocity time integral)/(indexed LA end systolic volume)], where LA emptying fraction was defined as (LA end systolic volume - LA end diastolic volume)/LA end systolic volume. We used Cox models to evaluate the association between LAFI and HF hospitalization.
Results
Over a median follow-up of 7.9 years, 106 participants (12.4%) were hospitalized for HF. Rates of HF hospitalization were inversely proportional to quartile of LAFI: Q1: 47 per 1000 person-years; Q2: 18.3; Q3: 9.6; and Q4: 5.3 (p<0.001). Each standard deviation decrease in LAFI was associated with a 2.6-fold increased hazard of adverse cardiovascular outcomes (unadjusted HR: 2.6, 95% CI 2.1–3.3, p<0.001), and the association persisted even after adjustment for clinical risk factors, NT-proBNP, and a wide range of echocardiographic parameters (adjusted HR: 1.5, 95% CI 1.0–2.1, p=0.05).
Conclusions
LA dysfunction independently predicts HF hospitalization in subjects with coronary heart disease and preserved baseline EF. LAFI may be useful for HF risk stratification, and LA dysfunction may be a potential therapeutic target.
Background
We sought to evaluate the prognostic performance of the CHADS2 score for prediction of ischemic stroke/TIA in subjects with coronary heart disease (CHD) without atrial fibrillation (AF).
Methods
In 916 non-anticoagulated outpatients with stable CHD and no AF by baseline electrocardiogram, we calculated CHADS2 scores (congestive heart failure, hypertension, age ≥ 75, diabetes (1 point each), and prior stroke or transient ischemic attack (TIA) (2 points)). The primary outcome was time to ischemic stroke or TIA over a mean follow-up of 6.4 ± 2.3 years.
Results
Over 5821 person-years of follow-up, 40 subjects suffered an ischemic stroke/TIA (rate 0.69 per 100 person-years, 95% CI 0.50-0.94). Compared to subjects with low (0-1) CHADS2 scores, those with intermediate (2-3) and high (4-6) CHADS2 scores had an increased rate of stroke/TIA, even after adjustment for age, tobacco, antiplatelet therapy, statins, and angiotensin inhibitors (CHADS2 score 2-3: HR 2.4, 95% CI 1.1-5.3, p=0.03, CHADS2 score 4-6: HR 4.0, 95% CI 1.5-10.6, p=0.006). Model discrimination (c-statistic = 0.65) was comparable to CHADS2 model fit in published AF-only cohorts.
Conclusions
The CHADS2 score predicts ischemic stroke/TIA in subjects with stable CHD and no baseline AF. The event rate in non-AF subjects with high CHADS2 scores (5-6) was comparable to published rates in AF patients with moderate CHADS2 scores (1-2), a population known to derive benefit from stroke prevention therapies. These findings should inform efforts to determine whether stroke prevention therapies or screening for silent AF may benefit subjects with stable CHD and high CHADS2 scores.
A growing body of evidence supports an association between vitamin D and cardiovascular disease. However, the mechanisms underlying this association are unknown. From 2000 to 2002, we identified 946 participants with stable cardiovascular disease in San Francisco, California, and followed them prospectively for cardiovascular events (heart failure, myocardial infarction, stroke, or cardiovascular death). We then examined the extent to which the association was attenuated by adjustment for poor health behaviors, comorbid health conditions, and potential biological mediators. During a median follow-up period of 8.0 years (through August 24, 2012), 323 subjects (34.1%) experienced a cardiovascular event. Following adjustment for sociodemographic factors, season of blood measurement, health behaviors, and comorbid conditions, 25-hydroxyvitamin D levels under 20 ng/mL remained independently associated with cardiovascular events (hazard ratio = 1.30, 95% confidence interval: 1.01, 1.67). However, after further adjustment for potential biological mediators, the independent association was no longer present (hazard ratio = 1.11, 95% confidence interval: 0.85, 1.44). Parathyroid hormone, a potentially modifiable biological factor downstream from 25-hydroxyvitamin D, was responsible for the majority of this attenuation. These findings highlight the need for randomized controlled trials to determine whether vitamin D supplementation in persons with deficiency could be beneficial for the primary or secondary prevention of cardiovascular events.
BACKGROUND: Undocumented immigrants with endstage kidney disease (ESKD) who rely on emergency-only hemodialysis (dialysis only after an emergency department evaluation) face psychosocial distress. Emergencyonly hemodialysis (EOHD) is likely burdensome for primary caregivers as well. OBJECTIVE: To understand the experience of primary caregivers of undocumented immigrants with ESKD who rely on emergency-only hemodialysis. DESIGN, SETTING, AND PARTICIPANTS: A qualitative, semi-structured interview study to assess the experiences of primary caregivers of undocumented immigrants with ESKD at a safety-net hospital in Denver, Colorado from June 28 to November 15, 2018. Applied thematic analysis was used to analyze interviews. MAIN OUTCOMES AND MEASURES: Themes and subthemes. RESULTS: Twenty primary caregiver participants had a mean (SD) age of 46 (17), 13 (65%) were female, 7 (35%) were in an adult child caregiver role, and 13 (65%) were spouses. Five themes and 17 subthemes (in parentheses) were identified: (1) Caregiver role (providing emotional, physical, and economic support, advocacy and care navigation), (2) Caregiver burden (anxiety related to patient and personal death, emotional exhaustion and personal illness, struggle with finances, self-care and redefining relationship), (3) Unpredictable EOHD (acute episodes of illness that trigger emergency, stress when patient is denied dialysis, impact on work and sleep, and emotional relief after a session of EOHD), (4) Effect on children (dropping out or missing school, psychosocial distress, children assuming caregiver responsibilities, and juggling multi-generational caregiving of children), (5) Faith and appreciation (comfort in God and appreciation of healthcare). CONCLUSIONS AND RELEVANCE: Caregivers of undocumented immigrants with ESKD who rely upon EOHD experience caregiver burden and distress. The impact of EOHD on caregivers should be considered when assessing the consequences of excluding undocumented immigrants from public insurance programs.
Access to hemodialysis for undocumented immigrants with end stage renal disease (ESRD) is widely variable across the United States and highly dependent upon state policy. Some states have enacted policies to provide coverage for standard dialysis to undocumented immigrants, while other states do not provide coverage. Patients living in some states which do not provide coverage rely on emergency federal coverage through the Emergency Medical Treatment and Active Labor Act. However, this act requires that patients present with an acute, life‐threatening condition in order to receive dialysis, which is then referred to as “emergency‐only hemodialysis” (EoHD). Because EoHD requires patients to present in life‐threatening condition, patients who rely on EoHD suffer from debilitating physical symptoms and psychosocial distress. Undocumented immigrants who receive EoHD also have staggeringly higher mortality rates than those who receive standard hemodialysis. Moreover, in comparison with standard dialysis, EoHD results in greater health care utilization and higher health care costs. Therefore, EoHD represents a very low value care practice, providing substandard care at a greater cost. Policy change is urgently needed to provide undocumented immigrants with ESRD access to the standard of care; that is, three‐times weekly standard hemodialysis or peritoneal dialysis.
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