In this study, more than 6000 men, some with and some without cardiovascular disease, underwent treadmill exercise testing and were followed for six years. Exercise capacity, as measured in metabolic ...equivalents, was a strong predictor of overall mortality, whether or not there was clinical evidence of cardiovascular disease.
More than 6000 men underwent exercise testing and were followed for six years. Exercise capacity was a strong predictor of overall mortality.
During the past two decades, exercise capacity and activity status have become well-established predictors of cardiovascular and overall mortality.
1
,
2
The fact that exercise capacity is a strong and independent predictor of outcomes supports the value of the exercise test as a clinical tool; it is noninvasive, is relatively inexpensive, and provides a wealth of clinically relevant diagnostic and prognostic information.
3
,
4
However, recent guidelines
4
and commentaries on the topic
5
,
6
have identified several areas related to the prognostic usefulness of exercise testing that are in need of further study. For example, the majority of previous studies have not clearly . . .
Although myocarditis/pericarditis (MP) has been identified as an adverse event following smallpox vaccine (SPX), the prospective incidence of this reaction and new onset cardiac symptoms, including ...possible subclinical injury, has not been prospectively defined.
The study's primary objective was to determine the prospective incidence of new onset cardiac symptoms, clinical and possible subclinical MP in temporal association with immunization.
New onset cardiac symptoms, clinical MP and cardiac specific troponin T (cTnT) elevations following SPX (above individual baseline values) were measured in a multi-center prospective, active surveillance cohort study of healthy subjects receiving either smallpox vaccine or trivalent influenza vaccine (TIV).
New onset chest pain, dyspnea, and/or palpitations occurred in 10.6% of SPX-vaccinees and 2.6% of TIV-vaccinees within 30 days of immunization (relative risk (RR) 4.0, 95% CI: 1.7-9.3). Among the 1081 SPX-vaccinees with complete follow-up, 4 Caucasian males were diagnosed with probable myocarditis and 1 female with suspected pericarditis. This indicates a post-SPX incidence rate more than 200-times higher than the pre-SPX background population surveillance rate of myocarditis/pericarditis (RR 214, 95% CI 65-558). Additionally, 31 SPX-vaccinees without specific cardiac symptoms were found to have over 2-fold increases in cTnT (>99th percentile) from baseline (pre-SPX) during the window of risk for clinical myocarditis/pericarditis and meeting a proposed case definition for possible subclinical myocarditis. This rate is 60-times higher than the incidence rate of overt clinical cases. No clinical or possible subclinical myocarditis cases were identified in the TIV-vaccinated group.
Passive surveillance significantly underestimates the true incidence of myocarditis/pericarditis after smallpox immunization. Evidence of subclinical transient cardiac muscle injury post-vaccinia immunization is a finding that requires further study to include long-term outcomes surveillance. Active safety surveillance is needed to identify adverse events that are not well understood or previously recognized.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Peripheral edema Cho, Shaun; Atwood, J.Edwin
The American journal of medicine,
11/2002, Letnik:
113, Številka:
7
Journal Article
Recenzirano
Peripheral edema often poses a dilemma for the clinician because it is a nonspecific finding common to a host of diseases ranging from the benign to the potentially life threatening. A rational and ...systematic approach to the patient with edema allows for prompt and cost-effective diagnosis and treatment. This article reviews the pathophysiologic basis of edema formation as a foundation for understanding the mechanisms of edema formation in specific disease states, as well as the implications for treatment. Specific etiologies are reviewed to compare the diseases that manifest this common physical sign. Finally, we review the clinical approach to diagnosis and treatment strategies.
Summary Background Although carotid bruits are deemed to be markers of generalised atherosclerosis, they are poor predictors of cerebrovascular events. We investigated whether a carotid bruit ...predicts myocardial infarction and cardiovascular death. Methods In this meta-analysis, we searched Medline (1966 to August, 2007) and Embase (1974 to August, 2007) with the terms “carotid” and “bruit”. Bibliographies of all the retrieved articles were also searched. Articles were included if they reported the incidence of myocardial infarction or cardiovascular death in adults. Outcome variables were extracted in duplicate and included the rate of myocardial infarction and cardiovascular mortality. Quality of the articles was independently assessed with the Hayden rating scheme. Data were pooled with a random effects model. Findings Of the 22 articles included, 20 (91%) used prospective cohorts. Our analysis included 17 295 patients with 62 413·5 patient-years of follow-up, with a median sample size of 273 patients (range 38–4736) followed up for 4 years (2–7). The rate of myocardial infarction in patients with carotid bruits was 3·69 (95% CI 2·97–5·40) per 100 patient-years (eight studies) compared with 1·86 (0·24–3·48) per 100 patient-years in those without bruits (two studies). Yearly rates of cardiovascular death were also higher in patients with bruits (16 studies) than in those without (four studies) (2·85 2·16–3·54 per 100 patient-years vs 1·11 0·45–1·76 per 100 patient-years). In the four trials in which direct comparisons of patients with and without bruits were possible, the odds ratio for myocardial infarction was 2·15 (1·67–2·78) and for cardiovascular death 2·27 (1·49–3·49). Interpretation Auscultation for carotid bruits in patients at risk for heart disease could help select those who might benefit the most from an aggressive modification strategy for cardiovascular risk. Funding None.
CONTEXT In the United States, the annual incidence of myocarditis is estimated
at 1 to 10 per 100 000 population. As many as 1% to 5% of patients with
acute viral infections involve the myocardium. ...Although many viruses have
been reported to cause myopericarditis, it has been a rare or unrecognized
event after vaccination with the currently used strain of vaccinia virus (New
York City Board of Health). OBJECTIVE To describe a series of probable cases of myopericarditis following
smallpox vaccination among US military service members reported since the
reintroduction of vaccinia vaccine. DESIGN, SETTING, PARTICIPANTS Surveillance case definitions are presented. The cases were identified
either through sentinel reporting to US military headquarters surveillance
using the Defense Medical Surveillance System or reports to the Vaccine Adverse
Event Reporting System using International Classification
of Diseases, Ninth Revision. The cases occurred among individuals vaccinated
from mid-December 2002 to March 14, 2003. MAIN OUTCOME MEASURE Elevated serum levels of creatine kinase (MB isoenzyme), troponin I,
and troponin T, usually in the presence of ST-segment elevation on electrocardiogram
and wall motion abnormalities on echocardiogram. RESULTS Among 230 734 primary vaccinees, 18 cases of probable myopericarditis
after smallpox vaccination were reported (an incidence of 7.8 per 100 000
over 30 days). No cases of myopericarditis following smallpox vaccination
were reported among 95 622 vaccinees who were previously vaccinated.
All cases were white men aged 21 years to 33 years (mean age, 26.5 years),
who presented with acute myopericarditis 7 to 19 days following vaccination.
A causal relationship is supported by the close temporal clustering (7-19
days; mean, 10.5 days following vaccination), wide geographic and temporal
distribution, occurrence in only primary vaccinees, and lack of evidence for
alternative etiologies or other diseases associated with myopericarditis.
Additional supporting evidence is the observation that the observed rate of
myopericarditis among primary vaccinees is 3.6-fold (95% confidence interval,
3.33-4.11) higher than the expected rate among personnel who were not vaccinated.
The background incidence of myopericarditis did not show statistical significance
when stratified by age (20-34 years: 2.18 expected cases per 100 000;
95% confidence interval CI, 1.90-2.34), race (whites: 1.82 per 100 000;
95% CI, 1.50-2.01), and sex (males: 2.28 per 100 000; 95% CI, 2.04-2.54). CONCLUSION Among US military personnel vaccinated against smallpox, myopericarditis
occurred at a rate of 1 per 12 819 primary vaccinees. Myopericarditis
should be considered an expected adverse event associated with smallpox vaccination.
Clinicians should consider myopericarditis in the differential diagnosis of
patients presenting with chest pain 4 to 30 days following smallpox vaccination
and be aware of the implications as well as the need to report this potential
adverse advent.
The purpose of this study was to determine quality of life (QOL) and exercise performance (EP) in patients with persistent atrial fibrillation (AF) converted to sinus rhythm (SR) compared with those ...remaining in or reverting to AF.
Restoration of SR in patients with AF improving QOL and EP remains controversial.
Patients with persistent AF were randomized double-blind to amiodarone, sotalol, or placebo. Those not achieving SR at day 28 were cardioverted and classified into SR or AF groups at 8 weeks (n = 624) and 1 year (n = 556). The QOL (SF-36), symptom checklist (SCL), specific activity scale (SAS), AF severity scale (AFSS), and EP were assessed.
Favorable changes were seen in SR patients at 8 weeks in physical functioning (p < 0.001), physical role limitations (p = 0.03), general health (p = 0.002), and vitality (p < 0.001), and at 1 year in general health (p = 0.007) and social functioning (p = 0.02). Changes in the scores for SCL severity (p = 0.01), functional capacity (p = 0.003), and AFSS symptom burden (p < 0.001) at 8 weeks and in SCL severity (p < 0.01) and AF symptom burden (p < 0.001) at 1 year showed significant improvements in SR versus AF. Symptomatic patients were more likely to have improvement. The EP in SR versus AF was greater from baseline to 8 weeks (p = 0.01) and to 1 year (p = 0.02). The EP correlated with physical functioning and functional capacity except in the AF group at 1 year.
In patients with persistent AF, restoration and maintenance of SR was associated with improvements in QOL measures and EP. There was a strong correlation between QOL measures and EP.
Smallpox is a devastating viral illness that was eradicated after an aggressive, widespread vaccination campaign. Routine U.S. childhood vaccinations ended in 1972, and routine military vaccinations ...ended in 1990. Recently, the threat of bioterrorist use of smallpox has revived the need for vaccination. Over 450,000 U.S. military personnel received the vaccination between December 2002 and June 2003, with rates of non-cardiac complications at or below historical levels. The rate of cardiac complications, however, has been higher than expected, with two confirmed cases and over 50 probable cases of myopericarditis after vaccination reported to the Department of Defense Smallpox Vaccination Program. The practicing physician should use the history and physical, electrocardiogram, and cardiac biomarkers in the initial evaluation of a post-vaccination patient with chest pain. Echocardiogram, cardiac catheterization, magnetic resonance imaging, nuclear imaging, and cardiac biopsy may be of use in further workup. Treatment is with non-steroidal anti-inflammatory agents, four to six weeks of limited exertion, and conventional heart failure treatment as necessary. Immune suppressant therapy with steroids may be uniquely beneficial in myopericarditis related to smallpox vaccination, compared with other types of myopericarditis. If a widespread vaccination program is undertaken in the future, many more cases of post-vaccinial myopericarditis could be seen. Practicing physicians should be aware that smallpox vaccine-associated myopericarditis is a real entity, and symptoms after vaccination should be appropriately evaluated, treated if necessary, and reported to the Vaccine Adverse Events Reporting System.
Background Therapy for chronic atrial fibrillation (AF) focuses on rate versus rhythm control, but little is known about the effects of common therapeutic interventions on exercise tolerance in AF. ...Methods Six hundred fifty-five patients with chronic AF underwent maximal exercise testing at baseline and 8 weeks, 6 months, and 1 year after randomization to sotalol, amiodarone, or placebo therapy and attempted direct current cardioversion. Analyses of baseline determinants of exercise capacity, predictors of change in exercise capacity at 6 months and 1 year, and the short- and long-term effects of cardioversion on exercise capacity were made. Results Age, obesity, and presence of symptoms accompanying AF were inversely associated with baseline exercise capacity, but these factors accounted for only 10% of the variance in exercise capacity. Patients most likely to benefit from cardioversion were those most limited initially, younger, not obese or hypertensive, and with an uncontrolled ventricular rate at baseline. Conversion to sinus rhythm (SR) resulted in significant reductions in resting (≈25 beat/min) and peak exercise (≈40 beat/min) heart rates at 6 months and 1 year ( P < .001). Successful cardioversion improved exercise capacity by 15% at 8 weeks, and these improvements were maintained throughout the year. This improvement was observed both among those who maintained SR and those with intermittent AF. Conclusion Cardioversion resulted in a sustained improvement in exercise capacity over the course of 1 year, and this improvement was similar between those in SR and those with SR and recurrent AF. Patients most likely to improve with treatment tended to be younger and nonobese and have the greatest limitations initially.
Current guidelines recommend against routine auscultation of carotid arteries, believing that carotid bruits are poor predictors of either underlying carotid stenosis or stroke risk in asymptomatic ...patients. We investigated whether the presence of a carotid bruit is associated with increased risk for transient ischemic attack, stroke, or death by stroke (stroke death).
We searched Medline (1966 to December 2009) and EMBASE (1974 to December 2009) with the terms "carotid" and "bruit." Bibliographies of all retrieved articles were also searched. Articles were included if they prospectively reported the incidence of transient ischemic attack, stroke, or stroke death in asymptomatic adults. Two authors independently reviewed and extracted data.
We included 28 prospective cohort articles that followed a total of 17 913 patients for 67 708 patient-years. Among studies that directly compared patients with and without bruits, the rate ratio for transient ischemic attack was 4.00 (95% CI, 1.8 to 9.0, P<0.0005, n=5 studies), stroke was 2.5 (95% CI, 1.8 to 3.5, P<0.0005, n=6 studies), and stroke death was 2.7 (95% CI, 1.33 to 5.53, P=0.002, n=3 studies). Among the larger pool of studies that provided data on rates, transient ischemic attack rates were 2.6 per 100 patient-years (95% CI, 2.0 to 3.2, P<0.0005, n=24 studies) for those with bruits compared with 0.9 per 100 patient-years (95% CI, 0.2 to 1.6, P=0.02, n=5 studies) for those without carotid bruits. Stroke rates were 1.6 per 100 patient-years (95% CI, 1.3 to 1.9, P<0.0005, n=26 studies) for those with bruits compared with 1.3 per 100 patient-years (95% CI, 0.8 to 1.7, P<0.0005, n=6) without carotid bruits, and death rates were 0.32 (95% CI, 0.20 to 0.44, P<0.005, n=13 studies) for those with bruits compared with 0.35 (95% CI, 0.00 to 0.81, P=0.17, n=3 studies) for those without carotid bruits.
The presence of a carotid bruit may increase the risk of cerebrovascular disease.
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