Rehabilitation Using Mobile Health for Older Adults With Ischemic Heart Disease in the Home Setting (RESILIENT): Protocol for a Randomized Controlled Trial

BACKGROUND: Participation in ambulatory cardiac rehabilitation remains low, especially among older adults. Although mobile health cardiac rehabilitation (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments may limit older adults\u27 uptake, and efficacy data are currently lacking. OBJECTIVE: This study aims to describe the design of the rehabilitation using mobile health for older adults with ischemic heart disease in the home setting (RESILIENT) trial. METHODS: RESILIENT is a multicenter randomized clinical trial that is enrolling patients aged \u3e /=65 years with ischemic heart disease in a 3:1 ratio to either an intervention (mHealth-CR) or control (usual care) arm, with a target sample size of 400 participants. mHealth-CR consists of a commercially available mobile health software platform coupled with weekly exercise therapist sessions to review progress and set new activity goals. The primary outcome is a change in functional mobility (6-minute walk distance), which is measured at baseline and 3 months. Secondary outcomes are health status, goal attainment, hospital readmission, and mortality. Among intervention participants, engagement with the mHealth-CR platform will be analyzed to understand the characteristics that determine different patterns of use (eg, persistent high engagement and declining engagement). RESULTS: As of December 2021, the RESILIENT trial had enrolled 116 participants. Enrollment is projected to continue until October 2023. The trial results are expected to be reported in 2024. CONCLUSIONS: The RESILIENT trial will generate important evidence about the efficacy of mHealth-CR among older adults in multiple domains and characteristics that determine the sustained use of mHealth-CR. These findings will help design future precision medicine approaches to mobile health implementation in older adults. This knowledge is especially important in light of the COVID-19 pandemic that has shifted much of health care to a remote, internet-based setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT03978130; https://clinicaltrials.gov/ct2/show/NCT03978130. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32163

Heart Failure with Transient Left Bundle Branch Block in the Setting of Left Coronary Fistula

Coronary arterial fistulas are rare communications between vessels or chambers of the heart. Although cardiac symptoms associated with fistulas are well described, fistulas are seldom considered in the differential diagnosis of acute myocardial ischemia. We describe the case of a 64-year-old man who presented with left shoulder pain, signs of heart failure, and a new left bundle branch block (LBBB). Cardiac catheterization revealed a small left anterior descending (LAD)-to-pulmonary artery (PA) fistula. Diuresis led to subjective improvement of the patient's symptoms and within several days the LBBB resolved. We hypothesize that the coronary fistula in this patient contributed to transient ischemia of the LAD territory through a coronary steal mechanism. We elected to observe rather than repair the fistula, as his symptoms and ECG changes resolved with treatment of his heart failure

Stage A Heart Failure Is Not Adequately Recognized in US Adults: Analysis of the National Health and Nutrition Examination Surveys, 2007-2010.

Stage A heart failure (HF) is defined as people without HF symptoms or structural heart disease, but with predisposing conditions for HF. This classification is used to identify high risk patients to prevent progression to symptomatic HF. While guidelines exist for managing HF risk factors, achievement of treatment goals in the United States (US) population is unknown.We examined all adults with Stage A HF (≥20 years, N =4,470) in the National Health and Nutrition Examination Surveys (NHANES) 2007-2010, a nationally representative sample. Stage A HF was defined by coronary heart disease (CHD), hypertension, diabetes mellitus, or chronic kidney disease. We evaluated whether nationally accepted guidelines for risk factor control were achieved in Stage A patients, including sodium intake, body mass index, hemoglobin A1c (HbA1c), cholesterol, and blood pressure (BP). Pharmacologic interventions and socioeconomic factors associated with guideline compliance were also assessed.Over 75 million people, or 1 in 3 US adults, have Stage A HF. The mean age of the Stage A population was 56.9 years and 51.5% were women. Seventy-two percent consume ≥2g sodium/day and 49.2% are obese. Of those with CHD, 58.6% were on a statin and 51.8% were on a beta-blocker. In people with diabetes, 43.6% had HbA1c ≥7%, with Mexican Americans more likely to have HbA1c ≥7% . Of those with hypertension, 30.8% had a systolic BP ≥140 or diastolic BP ≥90 mm Hg. Having health insurance was associated with controlled blood pressure, both in those with hypertension and diabetes. In CHD patients, income ≥$20,000/year and health insurance were inversely associated with LDL ≥100mg/dL with prevalence ratio (PR) of 0.58 (P=0.03) and 0.56 (P=0.03), respectively.One-third of the US adult population has Stage A HF. Prevention efforts should focus on those with poorly controlled comorbid disease

Socioeconomic Factors Associated with Treatment among US Adults with Stage A HF.

<p>*Model 1: adjusted for age, sex, race</p><p>^†Model 2: Model 1 plus adjustment for health insurance, education, income</p><p>^‡<i>P</i> ≤ 0.05</p><p>Abbreviations: HF, heart failure; CHD, coronary heart disease; MI, myocardial infarction; ACE, angiotensin converting enzyme; ARB, angiotensin receptor antagonists; Statin, HMG-CoA reductase inhibitors; Beta-blocker, beta-adrenergic blocking agent</p><p>Socioeconomic Factors Associated with Treatment among US Adults with Stage A HF.</p

Socioeconomic Factors Associated with Uncontrolled Risk Factors in US Adults with Stage A HF.

<p>*Model 1: Adjusted for age, sex, race</p><p>^†Model 2: Model 1 plus adjustment for health insurance, education, income</p><p>^‡<i>P</i> ≤ 0.05</p><p>^§<i>P</i> ≤ 0.01</p><p>^||Note LDL only measured in subgroup of total population, proportions are based on the total of individuals with measured values.</p><p>Abbreviations: HF, heart failure; BMI, body mass index; CHD, coronary heart disease; MI, myocardial infarction; LDL, low density lipoprotein cholesterol; HbA1c, hemoglobin A1c; SBP, systolic blood pressure; DBP, diastolic blood pressure</p><p>Socioeconomic Factors Associated with Uncontrolled Risk Factors in US Adults with Stage A HF.</p

Demographic factors (age, sex, race/ethnicity) associated with poor risk factor control in US adults with stage A heart failure (HF).

<p>Factors examined were (A) sodium intake ≥2,000 mg/d in any adult with stage A HF, (B) body mass index ≥30 kg/m² in any adult with stage A HF, (C) low density lipoprotein cholesterol (LDL) ≥100 mg/dL (≥2.59 mmol/L) in participants with a history of coronary heart disease or myocardial infarction, (D) LDL ≥70 mg/dL (≥1.81 mmol/L) in participants with a history of coronary heart disease or myocardial infarction, (E) hemoglobin A1c ≥7% in participants with a history of diabetes, (F) systolic blood pressure (SBP)≥140 mm Hg or diastolic blood pressure (DBP)≥90 mm Hg in participants with diabetes, (G) SBP≥140 mm Hg or DBP≥90 mm Hg in participants with hypertension, and (H) SBP≥140 mm Hg or DBP≥90 mm Hg in participants with kidney disease. Diamonds represent the reference groups. Circles represent the prevalence ratios. Horizontal capped lines represent the 95% confidence interval.</p

Control of Risk Factors and Medication Use in US Adults≥20 with Stage A HF.

<p>*The US total population is limited to adults age 20 years and older with Stage A HF who do not have a clinical diagnosis of HF</p><p>^†Note LDL only measured in subgroup of total population, proportions are based on the total of individuals with measured values</p><p>Abbreviations: HF, heart failure; CHD, coronary heart disease; MI, myocardial infarction; LDL, low density lipoprotein cholesterol; HbA1c, hemoglobin A1c; SBP, systolic blood pressure; DBP, diastolic blood pressure; ACE, angiotensin converting enzyme; ARB, angiotensin receptor antagonists; Statin, HMG-CoA reductase inhibitors; Beta-blocker, beta-adrenergic blocking agent</p><p>Control of Risk Factors and Medication Use in US Adults≥20 with Stage A HF.</p

Population Characteristics of US Adults ≥20 With and Without Stage A HF, 2007–2010.

<p>Abbreviations: HF, heart failure; GFR, glomerular filtration rate; MI, myocardial infarction; CHD, coronary heart disease</p><p>Population Characteristics of US Adults ≥20 With and Without Stage A HF, 2007–2010.</p

Dose-Response Association of Uncontrolled Blood Pressure and Cardiovascular Disease Risk Factors with Hyperuricemia and Gout

<div><p>Background</p><p>First-line therapy of hypertension includes diuretics, known to exert a multiplicative increase on the risk of gout. Detailed insight into the underlying prevalence of hyperuricemia and gout in persons with uncontrolled blood pressure (BP) and common comorbidities is informative to practitioners initiating antihypertensive agents. We quantify the prevalence of hyperuricemia and gout in persons with uncontrolled BP and additional cardiovascular disease (CVD) risk factors.</p> <p>Methods and Findings</p><p>We performed a cross-sectional study of non-institutionalized US adults, 18 years and older, using the National Health and Nutrition Examination Surveys in 1988–1994 and 1999–2010. Hyperuricemia was defined as serum uric acid >6.0 mg/dL in women; >7.0 mg/dL in men. Gout was ascertained by self-report of physician-diagnosed gout. Uncontrolled BP was based on measured systolic BP≥140 mmHg and diastolic BP≥90 mmHg. Additional CVD risk factors included obesity, reduced glomerular filtration rate, and dyslipidemia. The prevalence of hyperuricemia was 6–8% among healthy US adults, 10–15% among adults with uncontrolled BP, 22–25% with uncontrolled BP and one additional CVD risk factor, and 34–37% with uncontrolled BP and two additional CVD risk factors. Similarly, the prevalence of gout was successively greater, at 1–2%, 4–5%, 6–8%, and 8–12%, respectively, across these same health status categories. In 2007–2010, those with uncontrolled BP and 2 additional CVD risk factors compared to those without CVD risk factors had prevalence ratios of 4.5 (95% CI 3.5–5.6) and 4.5 (95% CI: 3.1–6.3) for hyperuricemia and gout respectively (<i>P</i><0.01).</p> <p>Conclusions</p><p>Health care providers should be cognizant of the incrementally higher prevalence of hyperuricemia and gout among patients with uncontrolled BP and additional CVD risk factors. With one in three people affected by hyperuricemia among those with several CVD risk factors, physicians should consider their anti-hypertensive regimens carefully and potentially screen for hyperuricemia or gout.</p> </div

Population Characteristics of US Adults Aged 18 Years and Older According to NHANES Survey Period, 1988–1994 &1990–2010.

<p>Abbreviations: BP, blood pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure; HTN, hypertension; HDL, high density lipoprotein; GFR, glomerular filtration rate; NA, not available.</p>*<p>Weighted number.</p>†<p>The unweighted number (for means) or numerator (for prevalences) corresponding with each variable category.</p>‡<p>In order to account for a change in NHANES race/ethnicity definitions in 2005–2010, we placed Hispanic in the “Other” to be consistent with NHANES 1988–2004.</p>§<p>Defined as >6.0 mg/dL (360 µmol/L) in women and >7.0 mg/dL (420 µmol/L) in men.</p>∥<p>Gout medications included allopurinol, probenecid, colchicine, sulfinpyrazone, alloxanthine.</p