Evaluation of an exercise field test using heart rate monitors to assess cardiorespiratory fitness and heart rate recovery in an asymptomatic population.

PurposeMeasures of cardiorespiratory fitness (CRF) and heart rate recovery (HRR) can improve risk stratification for cardiovascular disease, but these measurements are rarely made in asymptomatic individuals due to cost. An exercise field test (EFT) to assess CRF and HRR would be an inexpensive method for cardiovascular disease risk assessment in large populations. This study assessed 1) the predictive accuracy of a 12-minute run/walk EFT for estimating CRF ([Formula: see text]) and 2) the accuracy of HRR measured after an EFT using a heart rate monitor (HRM) in an asymptomatic population.MethodsFifty subjects (48% women) ages 18-45 years completed a symptom-limited exercise tolerance test (ETT) (Bruce protocol) and an EFT on separate days. During the ETT, [Formula: see text] was measured by a metabolic cart, and heart rate was measured continuously by a HRM and a metabolic cart.ResultsEFT distance and sex independently predicted[Formula: see text]. The average absolute difference between observed and predicted [Formula: see text] was 0.26 ± 3.27 ml·kg-1·min-1 for our model compared to 7.55 ± 3.64 ml·kg-1·min-1 for the Cooper model. HRM HRR data were equivalent to respective metabolic cart values during the ETT. HRR at 1 minute post-exercise during ETT compared to the EFT had a moderate correlation (r=0.75, p<0.001).ConclusionA more accurate model to estimate CRF from a 12-minute run/walk EFT was developed, and HRR can be measured using a HRM in an asymptomatic population outside of clinical settings

Implementation of High-Sensitivity Cardiac Troponin: Challenges From the International Experience.

ObjectiveImplementation of the newly approved high-sensitivity cardiac troponin (hs-cTn) in the United States presents a challenge for clinical practice. Sex-specific cutoffs, clinical protocols, and workflows will likely require modifications before implementation.MethodsWe conducted a cross-sectional survey of international physicians and laboratorians already utilizing hs-cTn for the evaluation of acute myocardial infarction.ResultsTwenty-two of 54 (41%) eligible participants completed the survey, representing 9 countries and 18 hospitals. All reported successful hs-cTn implementation and diagnostic utility (mean 8.6 + 1.2 out of 10 for best implementation). The major perceived benefit was more rapid evaluation of acute myocardial infarction (14/19, 74%), and the most frequently cited limitation was an increase in the number of measurable hs-cTn values that required further evaluation (8/18, 44%). Institutions using the hs-cTnI assay favored sex-specific cutoffs (5/6, 83%), whereas institutions employing the hs-cTnT assay favored a combined cutoff (12/12, 100%). Timing of serial hs-cTn measurements varied, with 0-3 hours (8/17, 47%) most frequent, followed by 0-2 hours (4/17, 24%), 0-1 hour (3/17, 18%), and other (2/17, 12%).ConclusionsOur survey of hs-cTn implementation at international institutions reveals satisfaction with new assays but reflects important variations in clinical practice. The use of sex-specific vs. combined cutoffs and timing of serial hs-cTn measurements varies across institutions and are subjects that United States centers must define without consensus from international practices

Contrast-enhanced transesophageal echocardiography predicts neo-intimal coverage of device post-left atrial appendage closure

Background: Left atrial appendage (LAA) closure (LAAC) is a viable alternative to anticoagulation for stroke prevention in non-valvular atrial fibrillation. However, device-associated thrombosis (DAT) is known as a complication of LAAC as observed within the first few weeks after implantation. A noninvasive method is needed to predict the progress for endothelialization surveillance. The aim of the study was to develop a noninvasive visual contrast-enhanced transesophageal echocardiography (cTEE) method for monitoring the communication between left atrium (LA) and LAA post-LAAC by cTEE-score evaluating the contrast enhancement in LAA. Methods: A total of 29 healthy dogs were studied by LAAC at < 24 h and 1, 2, 3 and 6-months. The LAAC procedure was assessed by TEE with color Doppler flow imaging (CDFI) and contrast imaging. The cTEE score was calculated based on the differential contrast opacification of LA and LAA cavities, the CDFI on the width of peri-device color flow, and that of histology on the level of occluder surface endothelialization in postmortem histological examination. Spearman’s correlation analysis was used to correlate these scores. Results: The correlation between cTEE and histology scores was superior to that between CDFI and histology scores. The trend of average cTEE score was tracked with that of histology, while that of CDFI was far from that of histology. The correlation coefficient of CDFI and histology scores was not significant (p > 0.05). Conclusions: The noninvasive visual cTEE is feasible and reliable to monitor communication between the LA and LAA post-LAAC. cTEE is superior to CDFI as a tool in predicting the progress for endothelialization surveillance

Management of Hypertension: JNC 8 and Beyond

Hypertension is a leading risk factor for cardiovascular disease, the leading cause of death and morbidity in our society and on a global scale. Major components of cardiovascular disease include stroke, coronary artery disease, heart failure, and chronic kidney disease, in all of which hypertension plays a major role. The risk of these complications increases directly and linearly with systolic blood pressure starting at 115 mmHg. Although usually asymptomatic, hypertension is readily detectable on physical examination and is amenable to both lifestyle modification and pharmacologic treatment in most patients. However, large proportions of the hypertensive population remain undetected and undertreated. Numerous guidelines have been issued during the past few decades to promote detection and optimal therapy. Despite the increase in risk with systolic blood pressure greater than 115 mmHg, the generally accepted threshold for diagnosis and treatment has been systolic blood pressure greater than 139 mmHg and diastolic blood pressure greater than 80 mmHg because until recently treatment to lower levels has been associated with an unfavorable relation between clinical benefit and harm. In the past several years, new guidelines, advisories, commentaries, and clinical trials have provided evidence for a potential change in current recommendations for the management of hypertension. In this regard, the long-awaited eighth report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended patients older than 60 years be treated to a systolic blood pressure of less than 150 mmHg, which has generated considerable controversy and caution. The striking findings of the Systolic Blood Pressure Intervention Trial (SPRINT) have received considerable attention because of the demonstration that intensive therapy to a target systolic blood pressure below 120 mmHg decreases cardiovascular mortality and morbidity more than less intensive treatment to a target systolic blood pressure below 140 mmHg, but this approach is not fully generalizable because the trial excluded patients younger than 50 years and those with diabetes and prior stroke. This article addresses major issues in the management of hypertension, including those in the seventh and eight reports of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and subsequent studies, considering maintenance of prior standards as well as the potential application of important new findings