Comparison of ethanol septal reduction therapy with surgical myectomy for the treatment of hypertrophic obstructive cardiomyopathy

AbstractOBJECTIVESThis study was designed to compare the hemodynamic efficacy of nonsurgical septal reduction therapy (NSRT) by intracoronary ethanol with standard therapy (surgical myectomy) for the treatment of hypertrophic obstructive cardiomyopathy (HOCM).BACKGROUNDNonsurgical septal reduction therapy has gained interest as a new treatment modality for patients with drug-refractory symptoms of HOCM; however, its benefits in comparison to surgery are unknown.METHODSForty-one consecutive NSRT patients at Baylor College of Medicine with one-year follow-up were compared with age- and gradient-matched septal myectomy patients at the Mayo Clinic. All patients had left ventricular outflow obstruction with a resting gradient ≥40 mm Hg and none had concomitant procedures.RESULTSThere were no baseline differences in New York Heart Association class, severity of mitral regurgitation, use of cardiac medications or exercise capacity. One death occurred during NSRT because of dissection of the left anterior descending artery. At one year, all improvements in both groups were similar. After surgical myectomy, more patients were on medications (p < 0.05) and there was a higher incidence of mild aortic regurgitation (p < 0.05). After NSRT, the incidence of pacemaker implantation for complete heart block was higher (22% vs. 2% in surgery; p = 0.02). However, seven of the nine pacemakers in the NSRT group were implanted before a modified ethanol injection technique and the use of contrast echocardiography.CONCLUSIONSNonsurgical septal reduction therapy resulted in a significantly higher incidence of complete heart block, but the risk was reduced with contrast echocardiography and slow ethanol injection. Surgical myectomy resulted in a significantly higher incidence of mild aortic regurgitation. Nonsurgical septal reduction therapy, guided by contrast echocardiography, is an effective procedure for treating patients with HOCM. The hemodynamic and functional improvements at one year are similar to those of surgical myectomy

Physical health status assessed during hospitalization for acute coronary syndrome predicts mortality 12 months later

Objective: Self-report measures of health status predict mortality in several groups of patients with cardiovascular disease, although overlap with symptoms of depression may reduce or eliminate this relationship. The association between self-reported health status and mortality has not been examined in patients hospitalized for acute coronary syndrome (ACS). The objective was to investigate whether the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the SF12 predicted 12-month all-cause mortality after controlling for cardiac risk factors and symptoms of depression. Methods: The SF-12 and Beck Depression Inventory were administered 2-5 days after admission to 800 ACS patients from 12 coronary care units. Logistic regression was used to assess the relationship of the PCS and MCS with mortality 12 months later, controlling for age, sex, cardiac diagnosis (acute myocardial infarction vs. unstable angina), Killip class, history of myocardial infarction, and in-hospital depressive symptoms. Results: Lower scores on the SF-12 PCS (worse health) were associated with a significantly higher risk of mortality [odds ratio (OR)=0.94, 95% confidence interval (CI)=0.92-0.97, P<.OOI]. MCS scores failed to reach significance (OR=0.98, CI=0.95-1.00, P=.053). The PCS significantly predicted mortality even after controlling for other cardiac risk factors and depressive symptoms (OR=0.96, CI=0.93-0.99, P=.008), equivalent to a 34% increase in risk per lO-point (I SD) decrement in PCS scores. Conclusion: The brief SF-12 PCS presents an attractive option for improving risk stratification among hospitalized ACS patients.This research was conducted with funds from the Heart and Stroke Foundation of Ontario and the Samuel Lunenfeid Foundation of Toronto, Ontario, awarded to Dr. Stewart and Dr. Abbey. Dr. Thombs is supported by a New Investigator Award from the Canadian Institutes of Health Research and an Etablissement de Jeunes Chercheurs award from the Fonds de la Recherche en Sante Quebec. Dr. Grace receives funding from the Canadian Institutes of Health Research, and Dr. Ziegeistein is supported by grant number R24AT00464l from the National Center for Complementary & Alternative Medicine and by the Miller Family Scholar Program.This research was conducted with funds from the Heart and Stroke Foundation of Ontario and the Samuel Lunenfeid Foundation of Toronto, Ontario, awarded to Dr. Stewart and Dr. Abbey. Dr. Thombs is supported by a New Investigator Award from the Canadian Institutes of Health Research and an Etablissement de Jeunes Chercheurs award from the Fonds de la Recherche en Sante Quebec. Dr. Grace receives funding from the Canadian Institutes of Health Research, and Dr. Ziegeistein is supported by grant number R24AT00464l from the National Center for Complementary & Alternative Medicine and by the Miller Family Scholar Program

BETTER HEALTH: Durham -- protocol for a cluster randomized trial of BETTER in community and public health settings

Abstract Background The Building on Existing Tools to Improve Chronic Disease Prevention and Screening (BETTER) cluster randomized trial in primary care settings demonstrated a 30% improvement in adherence to evidence-based Chronic Disease Prevention and Screening (CDPS) activities. CDPS activities included healthy activities, lifestyle modifications, and screening tests. We present a protocol for the adaptation of BETTER to a public health setting, and testing the adaptation in a cluster randomized trial (BETTER HEALTH: Durham) among low income neighbourhoods in Durham Region, Ontario (Canada). Methods The BETTER intervention consists of a personalized prevention visit between a participant and a prevention practitioner, which is focused on the participant’s eligible CDPS activities, and uses Brief Action Planning, to empower the participant to set achievable short-term goals. BETTER HEALTH: Durham aims to establish that the BETTER intervention can be adapted and proven effective among 40–64 year old residents of low income areas when provided in the community by public health nurses trained as prevention practitioners. Focus groups and key informant interviews among stakeholders and eligible residents of low income areas will inform the adaptation, along with feedback from the trial’s Community Advisory Committee. We have created a sampling frame of 16 clusters composed of census dissemination areas in the lowest urban quintile of median household income, and will sample 10 clusters to be randomly allocated to immediate intervention or six month wait list control. Accounting for the clustered design effect, the trial will have 80% power to detect an absolute 30% difference in the primary outcome, a composite score of completed eligible CDPS actions six months after enrollment. The prevention practitioner will attempt to link participants without a primary care provider (PCP) to a local PCP. The implementation of BETTER HEALTH: Durham will be evaluated by focus groups and key informant interviews. Discussion The effectiveness of BETTER HEALTH: Durham will be tested for delivery in low income neighbourhoods by a public health department. Trial Registration: NCT03052959, registered February 10, 2017