Showing papers by "Richard V. Milani published in 2006"

Adverse Psychological and Coronary Risk Profiles in Young Patients With Coronary Artery Disease and Benefits of Formal Cardiac Rehabilitation

Abstract: Background: Recent data indicate that young patients with coronary artery disease (CAD) have a poor longterm prognosis. Although the benefits of formal cardiac rehabilitation and exercise training programs are well established, most of these data come from middle-aged and older patients. Methods: We assessed baseline behavioral data, quality of life, and risk profiles in 635 consecutive patients with CAD before and after cardiac rehabilitation and exercise training, and specifically assessed data in 104 young patients (mean±SD age, 48±6 years; range, 22-54 years) compared with 260 elderly patients (mean±SD age, 75±3 years; range, 70-85 years). Results: Compared with older patients, young patients had higher body mass indexes (12.2%,P.001), total cholesterol–high-density lipoprotein ratio (14.6%, P.01), and triglycerides level (27.2%,P.01), and a lower highdensity lipoprotein cholesterol level (�8.8%, P=.045). Young patients also had higher scores for anxiety and hostility (51.5% and 94.4%, respectively; P.001 for both), a considerably higher prevalence of anxiety (27.9% vs 13.5%; P.01) and hostility (12.5% vs 4.6%; P.01) symptoms, and slightly more depression symptoms (23.1% vs 18.8%) compared with elderly patients. Following cardiac rehabilitation and exercise training, young patients had improvements in body mass index (�1.7%, P.01), percentage body fat (�4.4%, P.001), highdensity lipoprotein cholesterol level (10.2%, P.001), high-sensitivity C-reactive protein level (�33.3%,P.01), peak oxygen consumption (11.3%,P.001), resting heart rate (�4.5%,P=.01), and resting systolic pressure (�2.3%, P=.049), and marked improvements in scores for depression (�58.5%), anxiety (�46.0%), hostility (�45.7%), somatization (�33.8%), and quality of life (15.8%) (P.001 for all). Young patients also had greater than 50% to greater than 80% reductions in the prevalence of anxiety (P.001), hostility (P.01), and depression (P.001). Conclusion: These data demonstrate the adverse psychological and CAD risk profiles that are present in young patients with CAD following major CAD events, and are consistent with substantial benefit of formal cardiac rehabilitation and exercise training programs in younger adults.

Left ventricular geometry and survival in patients with normal left ventricular ejection fraction

Abstract: In hypertensive populations, left ventricular (LV) geometry, which is characterized by hypertrophy, predicts cardiovascular outcome. The left ventricle can also alter its shape by concentric remodeling (CR) in the absence of LV hypertrophy, a feature that is detected by echocardiography. This study assessed the prevalence and prognostic significance of various forms of LV geometry and changes in LV geometry over time in patients with normal LV systolic function. Retrospective analysis of a large clinical population (n = 35,602) that was referred for echocardiography was done, with all-cause mortality as the primary outcome. Abnormal LV geometry was identified in 46% of patients, with CR present in 35% (n = 12,362) and LV hypertrophy in 11% (n = 3,958). Patients with abnormal LV geometry were older and more obese compared with subjects with normal LV geometry. There was a strong relation between abnormal LV geometry and mortality, and patients with CR and LV hypertrophy exhibited considerably higher relative risk for all-cause mortality compared with subjects with normal LV geometry (relative risk [RR] 1.99, 95% confidence interval [CI] 1.88 to 2.18, p <0.0001; RR 2.13, 95% CI 1.89 to 2.40, p <0.0001, respectively). Subjects with CR who reverted to a normal geometric pattern had improved survival (RR 0.64, 95% CI 0.42 to 0.97, p = 0.03) compared with those who progressed to LV hypertrophy (RR 1.54, 95% CI 1.01 to 2.47, p = 0.05). In conclusion, CR, a form of cardiac adaptation, is frequently noted in patients with normal LV ejection fractions and confers a risk of death similar to that of LV hypertrophy. Normalization of CR is associated with better survival, whereas transition to LV hypertrophy increases mortality.

Understanding the Basics of Cardiopulmonary Exercise Testing

Abstract: Cardiopulmonary exercise testing adds important additional information to that provided by the standard exercise test. In particular, cardiopulmonary exercise testing provides precise determination of aerobic capacity, the causes of dyspnea with exertion, and prognosis in patients with systolic heart failure. This review provides basic, practical information about cardiopulmonary exercise testing for the clinician.

Fish Oils Produce Anti-inflammatory Effects and Improve Body Weight in Severe Heart Failure

Abstract: Background Fish oils have been shown to reduce production of tumor necrosis factor-alpha (TNF-α) in healthy subjects. We sought to evaluate the effects of fish oils on pro-inflammatory cytokines and body weight in patients with advanced heart failure. Methods Fourteen patients (New York Heart Association [NYHA] Class III to IV heart failure) were randomized in a double-blinded trial to active therapy with 8 g of n-3 fatty acids (Group A, n = 7) or placebo (Group B, n = 7) for 18 weeks. TNF-α and interleukin-1 (IL-1) production were measured by radioimmunoassay after endotoxin stimulation of peripheral blood mononuclear cells. Results Placebo-treated patients had a 44% increase in TNF-α (from 1.28 to 1.84 pg/ml; p = 0.07) but no significant change in IL-1 (from 0.68 to 0.78 pg/ml) production. n-3 fatty acids resulted in a 59% reduction in TNF-α (from 1.64 to 0.68 pg/ml; p = 0.02) and 39% decrease in IL-1 (from 1.98 to 1.21 pg/ml; p = 0.09) production. There was an inverse correlation between change in TNF-α production and change in percent body fat ( r = −0.6; p = 0.02). Conclusions Fish oils decrease TNF-α production in heart failure and improve body weight. Fish oil therapy may represent a novel therapeutic approach in late-stage heart failure characterized by cardiac cachexia.

Left ventricular geometry and mortality in patients > 70 years of age with normal ejection fraction

Abstract: Numerous studies have indicated that left ventricular (LV) hypertrophy predicts morbidity and mortality, including studies in older patients. The prognostic impact of other LV geometric patterns, including concentric remodeling (CR), compared with LV hypertrophy has not been studied in a large cohort of older patients. Echocardiographic and clinical data were studied in 9,771 consecutive patients aged >70 years with ejection fractions ≥50% who were followed for 3.1 years to determine the impact of LV geometric patterns. CR was the most prevalent pattern (43%), and 16% met criteria for LV hypertrophy. Although patients with CR had significantly lower LV mass indexes than patients with normal structure as well as those with LV hypertrophy, their mortality was 35% higher than that of normal subjects (15.5% vs 11.5%, p 70 years with normal systolic function, being present in 59% of this population, with CR (43%) by far the most common LV geometric pattern. Patients aged >70 years with CR have significantly increased mortality compared with similarly aged patients with either normal structure or eccentric LV hypertrophy, with similar increased mortality to those with concentric LV hypertrophy.

Comparison of Cardiac and Peripheral Arterial Stiffening and Ventriculovascular Uncoupling in Patients With Uncomplicated Hypertension Versus Patients With Hypertension After Heart Transplantation

Abstract: Despite normal ejection fractions, patients who undergo heart transplantation (HT) have low peak aerobic capacity and reduced arterial compliance, suggesting "ventriculovascular uncoupling." To what extent this is related to post-transplantation hypertension versus the unique characteristics of the donor-recipient relation remains poorly understood. Echocardiograms were retrospectively reviewed from 126 normal subjects, 309 patients with uncomplicated hypertension (UH), and 58 consecutive patients with HT >1 year after the procedure who were stable without evidence of rejection. Left ventricular (LV) end-systolic elastance (Ees), a measure of LV systolic performance; effective arterial elastance (Ea), a measure of vascular stiffness; and Ea/Ees, a parameter describing ventriculovascular coupling, were obtained. Compared with normal subjects, tandem increases in Ea (+24% and +85%, all p values <0.0001) and Ees (+23% and +33%, all p values <0.0001) were observed in patients with UH and HT, respectively, with patients with HT having significantly higher values than those with UH (both p values <0.05). Although the Ea/Ees ratio remained similar between normal subjects and patients with UH, patients with HT exhibited increases in the Ea/Ees ratio (all p values <0.01) and reduced stroke volume indexes (-20% and -22%, respectively, all p values <0.05). These changes were associated with a doubling of LV concentric remodeling in patients with HT compared with those with UH (67% vs 34%, p <0.0001). In conclusion, HT is associated with increases in Ees, Ea, and the Ea/Ees ratio, suggesting ventriculovascular uncoupling and maximal LV stroke work. These aberrations, which determine cardiovascular performance in the setting of HT, are not simply explained by vascular age or post-transplantation hypertension but may adversely affect functional capacity.

Abstract 73: Lipid Mediators as Novel Biomarkers and Surrogate Indicators of Neurologic Recovery after Cardiac Arrest in a Hypothermic Swine Model

Abstract: Background: Prognostic tools to predict neurologic outcome are essential so that relevant care can be given to patients awakening from coma, and futile intensive care be avoided in patients with severe hypoxic ischemic encephalopathy. There is a need for biomarkers as surrogate indicators of ischemic brain injury or recovery. We studied lipid mediators (Neuroprotectin D1, (NPD1), DHA, PGE-2, and PGD-2) that would reflect the status of anti-inflammatory signaling in endothelial cells and/or brain parenchyma. Methods: Swine who had return of spontaneous circulation (ROSC) after cardiac arrest, with CPR, and up to 3 shocks were randomized to receive 20 hours of hypothermia with Life Recovery Systems (LRS) Thermosuita,,¢ at 34A° C (n=6) or as normothermic controls (n = 8). Serial blood samples were obtained at intervals up to 48 hrs. Results: The time required to reach the target cooling temperature was 9.0 min. Normal neurologic function was regained in all 6 hypothermic animals but in only 1 of 8 normothe...

Preventive cardiology and non-invasive cardiology research at the ochsner clinic foundation.

Abstract: Cardiovascular diseases (CVD), including coronary heart disease (CHD), stroke, and heart failure (HF) remain the leading cause of morbidity and mortality in all of western civilization and certainly this is the case in southern Louisiana. In this manuscript, we briefly review some of the preventive cardiology and non-invasive research performed at the Ochsner Heart and Vascular Institute in New Orleans, particularly data from our cardiac rehabilitation and exercise training (CRET) programs, clinical data from our cardiopulmonary laboratory regarding heart failure (HF) prognosis, as well as retrospective data from our cardiovascular informations systems (CVIS), which has allowed us to link a large volume of non-invasive data with subsequent prognosis.