Obesity, Hypertension, and Bariatric Surgery Samson, Rohan; Ayinapudi, Karnika; Le Jemtel, Thierry H. ...
Current hypertension reports,
07/2020, Letnik:
22, Številka:
7
Journal Article
Obese patients with respiratory failure need more intensive care and invasive mechanical ventilation than their non-obese counterparts. We aimed to evaluate the impact of body mass index and obesity ...related conditions on fatal outcome during a hospitalization for COVID-19.
From March 1 to April 30, 2020, 425 consecutive patients with severe acute respiratory syndrome coronavirus 2 were hospitalized at University Medical Center, in New Orleans. Clinical variables, comorbidities, and hospital course were extracted from electronic medical records. Special attention was given to obesity related conditions like hypertension, type 2 diabetes, and dyslipidemia. Severe obesity was defined as a body mass index ≥35–<40 kg/m2 and morbid obesity as body mass index ≥40 kg/m2. Risk of mortality was determined by applying multivariate binary logistic regression modeling to risk factor variables (age, sex, race, and Charlson comorbid score).
Patients were mostly African American (77.9%) and 51.0% were women. Age and Charlson comorbidity index scores averaged 60 (50–71 years) and 3.0 (1.25–5), respectively. In-hospital mortality was greater in morbidly obese than non-morbidly obese patients. Of the 64 severely obese patients, 16 had no obesity related conditions, and 48 had at least one obesity related condition: hypertension (60%), type 2 diabetes mellitus (28%), and dyslipidemia (20%). In-hospital mortality was greater in severely obese patients with than without at least one obesity related condition.
During a hospitalization for COVID-19, severely obese patients with at least one obesity related condition and morbidly obese patients have a high mortality.
Indirect evidence implicates endothelial dysfunction in the pathogenesis of vascular diseases associated with obstructive sleep apnea (OSA). We investigated directly whether dysfunction and ...inflammation occur in vivo in the vascular endothelium of patients with OSA. The effects of continuous positive airway pressure (CPAP) therapy on endothelial function and repair capacity were assessed.
Thirty-two patients with newly diagnosed OSA and 15 control subjects were studied. Proteins that regulate basal endothelial nitric oxide (NO) production (endothelial NO synthase eNOS and phosphorylated eNOS) and inflammation (cyclooxygenase-2 and inducible NOS) and markers of oxidative stress (nitrotyrosine) were quantified by immunofluorescence in freshly harvested venous endothelial cells before and after 4 weeks of CPAP therapy. Vascular reactivity was measured by flow-mediated dilation. Circulating endothelial progenitor cell levels were quantified to assess endothelial repair capacity. Baseline endothelial expression of eNOS and phosphorylated eNOS was reduced by 59% and 94%, respectively, in patients with OSA compared with control subjects. Expression of both nitrotyrosine and cyclooxygenase-2 was 5-fold greater in patients with OSA than in control subjects, whereas inducible NOS expression was 56% greater. Expression of eNOS and phosphorylated eNOS significantly increased, whereas expression of nitrotyrosine, cyclooxygenase-2, and inducible NOS significantly decreased in patients who adhered to CPAP > or = 4 hours daily. Baseline flow-mediated dilation and endothelial progenitor cell levels were lower in patients than in control subjects, and both significantly increased in patients who adhered to CPAP > or = 4 hours daily.
OSA directly affects the vascular endothelium by promoting inflammation and oxidative stress while decreasing NO availability and repair capacity. Effective CPAP therapy is associated with the reversal of these alterations.
Analysis of randomized controlled trials (RCTs) is the cornerstone of evidence-based medicine, therapeutic guidelines and ultimately daily practice. However, 2 issues contribute to cloud the analysis ...of RCTs. Industry-sponsored RCTs aim at capturing as large indications as possible and clinicians rely excessively on P value statistical significance for the evaluation of the findings. To be most valuable to practitioners, analysis of RCTs needs to provide absolute risk reduction, number of patients needed to treat, fragility index along with the estimation of lost to follow-up patients, and outcome postponement (gain in survival time). We analyzed few major cardiovascular RCTs and assessed the robustness of their findings. Our suggested analytic parameters may be further used in future systematic reviews and meta-analyses.
Central illustration. Patient-centred benefit versus risk analysis of early aortic valve replacement (AVR) for asymptomatic severe aortic stenosis. AKI: acute kidney injury; PM: pacemaker; PPM: ...patient prosthesis mismatch.▪
Aortic stenosis, the most common valvular heart disease in Western countries, affects predominantly older people. Prompt aortic valve replacement is undoubtedly indicated in symptomatic patients. Management of asymptomatic patients is nowadays shifting from a conservative approach to early aortic valve replacement, as multimodality imaging is increasingly available. However, multimodality imaging has led to multiple prognostic parameters and complex algorithms, as well as a new staging classification that has left patients and physicians somewhat puzzled. We highlight the value of thorough serial clinical examinations, Doppler echocardiography and exercise testing when caring for a growing aortic stenosis population, including that has no or limited access to multimodality imaging. Evidence for early aortic valve replacement versus conservative management in asymptomatic patients with severe aortic stenosis is biased by the lack of serial stress testing evaluation; 30% of so-called asymptomatic patients were in fact symptomatic, and thus were clear candidates for aortic valve replacement in the above-mentioned studies. Randomized trials of aortic valve replacement versus conservative management that include serial stress testing evaluation are needed to ascertain whether early aortic valve replacement actually improves clinical outcome in asymptomatic patients with severe aortic stenosis. Less interventional medicine and healthcare resource utilization can result in better health.
Le rétrécissement aortique (RA) affecte préférentiellement les sujets âgés, c’est la valvulopathie la plus fréquente dans les pays occidentaux. Chez les patients porteurs d’un RA serré, un remplacement valvulaire aortique (RVA) rapide est indiqué dès l’apparition de symptômes. Le développement de l’imagerie multimodalité tend à modifier la prise en charge des RA asymptomatiques et la surveillance rapprochée laisse place progressivement à une stratégie de RVA précoce. De multiples paramètres pronostiques, des algorithmes complexes et de nouvelles classifications sont régulièrement proposés semant la confusion parmi les patients tout comme chez les médecins. Nous insistons sur la nécessité de répéter de façon périodique et minutieuse l’évaluation clinique, échocardiographique ainsi que les tests d’effort pour dépister les faux asymptomatiques. Cette stratégie assure en toute sécurité le suivi d’une population de RA en expansion, y compris dans les déserts médicaux peu équipés en nouvelles technologies. Pour prouver l’utilité d’un RVA systématique chez les patients ayant un RA serré asymptomatique, des études prospectives sont nécessaires ; elles doivent comparer le pronostic à long terme des procédures précoces (RVA par voie chirurgicale ou percutanée) à celui d’une surveillance clinique incluant des évaluations à l’effort répétées. En l’absence d’un tel suivi, le bras non interventionnel va inclure de faux asymptomatiques (environ 30 %), avec un risque d’évènements graves et donc de biais en faveur de la stratégie de RVA précoce. La qualité des soins n’est pas toujours liée à la quantité d’actes et de gestes interventionnels.
Owing to the overwhelming obesity epidemic, preserved ejection fraction heart failure commonly ensues in patients with severe obesity and the obese phenotype of preserved ejection fraction heart ...failure is now commonplace in clinical practice. Severe obesity and preserved ejection fraction heart failure share congruent cardiovascular, immune, and renal derangements that make it difficult to ascertain whether the obese phenotype of preserved ejection fraction heart failure is the convergence of two highly prevalent conditions or severe obesity enables the development and progression of the syndrome of preserved ejection fraction heart failure. Nevertheless, the obese phenotype of preserved ejection fraction heart failure provides a unique opportunity to assess whether sustained and sizeable loss of excess body weight via metabolic bariatric surgery reverses the concentric left ventricular remodeling that patients with preserved ejection fraction heart failure commonly display.
A Practical Approach to Hybrid Coronary Revascularization Singh, Twinkle; Ayinapudi, Karnika; Motwani, Ayush ...
Cardiology in review,
2020-September/October, 2020 Sep/Oct, 2020-09-00, 20200901, Letnik:
28, Številka:
5
Journal Article
Combined surgical and percutaneous coronary revascularization, ie, hybrid coronary revascularization (HCR) consists of surgical left internal mammary artery (LIMA) bypass to the left anterior ...descending artery (LAD) and percutaneous revascularization of other diseased coronary arteries. Developed as a 1-stage procedure, HCR has not been widely adopted by the cardiovascular community. The recommended minimally invasive approach through a small left thoracotomy incision is technically demanding, and same-day percutaneous revascularization requires a hybrid operating room that is not available in most hospitals. In this review, we consider present HCR protocols, barriers to widespread adoption of HCR, and we give special attention to the surgical approach for the LIMA graft to the LAD and the timing of percutaneous revascularization. We conclude that grafting the LIMA to the LAD through a median sternotomy approach and delaying the percutaneous revascularization may facilitate the widespread use of HCR in patients with multivessel coronary artery disease and a low to intermediate Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score.
BACKGROUND The relative risk for cardiovascular diseases in passive smokers is similar to that of active smokers despite almost a 100-fold lower dose of inhaled cigarette smoke. However, the ...mechanisms underlying the surprising susceptibility of the vascular tissue to the toxins in secondhand smoke (SHS) have not been directly investigated. The aim of this study was to investigate directly vascular endothelial cell function in passive smokers. METHODS Using a minimally invasive method of endothelial biopsy, we investigated directly the vascular endothelium in 23 healthy passive smokers, 25 healthy active smokers, and 23 healthy control subjects who had never smoked and had no regular exposure to SHS. Endothelial nitric oxide synthase (eNOS) function (expression of basal eNOS and activated eNOS phosphorylated eNOS at serine1177 (P-eNOS)) and expression of markers of inflammation (nuclear factor-κB NF-κB) and oxidative stress (nitrotyrosine) were assessed in freshly harvested venous endothelial cells by quantitative immunofluorescence. RESULTS Expression of eNOS and P-eNOS was similarly reduced and expression of NF-κB was similarly increased in passive and active smokers compared with control subjects. Expression of nitrotyrosine was greater in active smokers than control subjects and similar in passive and active smokers. Brachial artery flow-mediated dilation was similarly reduced in passive and active smokers compared with control subjects, consistent with reduced endothelial NO bioavailability. CONCLUSIONS Secondhand smoking increases vascular endothelial inflammation and reduces active eNOS to a similar extent as active cigarette smoking, indicating direct toxic effects of SHS on the vasculature.
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