Three Vessel Disease with Left Main Involvement: A Rare Manifestation of Takayasu’s Arteritis

Background: Takayasu’s arteritis is a chronic vasculitis of unknown etiology affecting large vessels. Coronary involvement is rare and myocardial infarction as a presenting symptom has only been described in case reports. Case: We report a case of a 19 year old female diagnosed with Takayasu’s arteritis 2 years prior who came in due to chest pain and heart failure symptoms. ECG showed diffuse ischemia with ST elevation of the inferior wall. Coronary angiogram showed 3 vessel disease with left main involvement. Patient was started on high dose steroids. She then developed an acute stroke in the right posterior cerebral artery territory. She improved with Methylprednisolone pulse therapy and oral methotrexate. She was discharged on Prednisone, Methotrexate and cardiac medications and is stable on follow up. Diagnostics: Coronary angiogram showed ostioproximal stenosis of the distal left main segment, the proximal left anterior descending artery and the proximal left circumflex artery, with the right coronary artery being totally occluded. Two dimensional echocardiogram showed an ejection fraction of 38 percent with multisegmental wall motion abnormalities. CT aortogram showed segmental narrowing of the infrarenal abdominal aorta with multiple ostioproximal stenosis of several aortic branches with extensive collateral formation. MRI showed acute infarction in the right thalamus,right medial temporal and occipital lobes and right cerebellar hemisphere and vermis Conclusion: Takayasu’s arteritis can present with a myriad of vascular complications. The reported incidence of coronary involvement is low. This case highlights the progressive and unpredictable nature of this disease. A high index of clinical suspicion, as well as a meticulous search for the extent of disease severity allows the clinician to individualize treatment options for these patient

Nature of Cardiac Rehabilitation Around the Globe

BackgroundCardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region.MethodsIn this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models.Findings111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ± 2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p

Cardiac Rehabilitation Availability and Density around the Globe

BackgroundDespite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density.MethodsA survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed.FindingsCR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N?=?1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p

Correlation between severity of ultrasonographic nonalcoholic fatty liver disease and cardiometabolic risk among Filipino wellness patients

Introduction: Nonalcoholic fatty liver disease (NAFLD) is a prevalent condition which is known to be related to factors that predispose to the development of coronary artery disease as well as development of metabolic syndrome. The study aimed to determine the association between ultrasound-based grading of hepatic steatosis with metabolic profile and estimated cardiovascular risk using the Framingham Risk Score (FRS). Methods: This was a cross-sectional study on 100 Filipino patients without established cardiovascular disease who underwent a general wellness health evaluation. Cases with NAFLD diagnosed on the basis of ultrasound grading were analyzed. Comparison of demographics and metabolic parameters between grades of hepatic steatosis was performed using Kruskal Wallis test. FRS was used to assess cardiovascular risk with Spearman rank test for correlation with the degree of NAFLD. Results: Mean age was 47 ± 9.6 years, with 70% males. Mean body mass index (BMI) was 28.7 ± 5.1. Most patients had grade I NAFLD (53%), 34% were grade II, and 13% were grade III. BMI (P =0.034), liver enzymes (alanine aminotransferase [ALT], P = 0.001; aspartate aminotransferase [AST], P = 0.00), triglycerides (P = 0.047), and fasting blood sugar [FBS] (P = 0.049) were associated with fatty liver grade. No association was noted with total cholesterol (P = 0.569), high density lipoprotein (HDL) (P = 0.220), and low density lipoprotein (LDL) (P = 0.792). Using the FRS 43% were stratified as low (20% risk). Severity of fatty liver was directly correlated with the FRS (Spearman rank 0.741, P = 0.009). Conclusion: Ultrasound-based grading of the severity of NAFLD is associated with abnormalities in the metabolic profile of patients. The FRS is correlated with increasing severity of NAFLD based on ultrasound. These findings suggest that the presence of NAFLD may be a marker for the presence of increased cardiovascular risk and may help identify patients who may benefit from more aggressive therapies to prevent development of adverse cardiovascular events

Physician factors affecting cardiac rehabilitation referral among cardiac specialists: The Philippine Heart Center CRAVE study (Cardiac Rehabilitation Attitudes and Viewpoints on Engagement)

Background: Cardiac rehabilitation (CR), despite numerous evidence of a positive impact on morbidity and mortality, still remains underutilized due to multifactorial reasons. Physician endorsement has been shown to be a very powerful predictor of CR referral. The objective of the study was to describe physicians′ attitudes and preferences regarding referral of patients to CR. Methods: A cross-sectional survey of a stratified random sample of 160 physicians specializing in cardiology was conducted at the Philippine Heart Center. One hundred and four physicians responded (65% response rate) to a survey that investigated clinical factors and perceptions affecting referral. Included in the survey was a hypothetical case scenario that elicited open-ended responses affecting physician management preferences. Results: About 78.9% of the physicians stated that they would refer the hypothetical case to CR although there were varied responses in their management practices. The most important factor affecting CR referral was financial limitation, followed by geographic location and issues on program accessibility and benefit. While there is general agreement regarding knowledge of the indications of CR, there is a disparity in the responses with regard to actual referral and management preferences. Conclusions: Financial considerations, accessibility, perceived benefit, and health-care system-related aspects are some of the identified factors that affect physician preferences toward referral to CR. Assessment of physician attitudes and factors affecting CR referral practices provides insight regarding potential targets of improvement to ensure adequate CR referral and provision

Nature of cardiac rehabilitation around the globe

Abstract Background: Cardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region. Methods: In this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models. Findings: 111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ± 2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p &lt; 0.001), dietitians (n = 739, 80.2%), and physiotherapists (n = 733, 79.3%). The most commonly-offered core components (mean = 8.7 ± 1.9 program) were: initial assessment (n = 939, 98.8%; most commonly for hypertension, tobacco, and physical inactivity), risk factor management (n = 928, 98.2%), patient education (n = 895, 96.9%), and exercise (n = 898, 94.3%; lower in Western Pacific, p &lt; 0.01). All regions met ≥ 16/20 quality indicators, but quality was &lt; 75% for tobacco cessation and return-to-work counseling (lower in Americas, p = < 0.05). Interpretation: This first-ever survey of CR around the globe suggests CR quality is high. However, there is significant regional variation, which could impact patient outcomes

Cardiac rehabilitation availability and density around the globe

Abstract Background: Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density. Methods: A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed. Findings: CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p &lt; 0.001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35–1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04–1.06), and significantly lower with private (OR = 0.92, 95%CI = 0.91–0.93) or public (OR = 0.83, 95%CI = 0.82–0.84) funding compared to hybrid sources. Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25–Q75 = 150–390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally. Interpretation: CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation