Sleep Deficiency and Deprivation Leading to Cardiovascular Disease

Sleep plays a vital role in an individual’s mental, emotional, and physiological well-being. Not only does sleep deficiency lead to neurological and psychological disorders, but also the literature has explored the adverse effects of sleep deficiency on the cardiovascular system. Decreased quantity and quality of sleep have been linked to cardiovascular disease (CVD) risk factors, such as hypertension, obesity, diabetes, and dyslipidemia. We explore the literature correlating primary sleep deficiency and deprivation as a cause for cardiovascular disease and cite endothelial dysfunction as a common underlying mechanism

Dyslipidemia and Its Role in the Pathogenesis of Atherosclerotic Cardiovascular Disease: Implications for Evaluation and Targets for Treatment of Dyslipidemia Based on Recent Guidelines

The clinical presentations of atherosclerotic disease are the result of a constellation of diverse metabolic and immunologic mechanisms ultimately set into motion by the formation of fatty acid streaks and the accompanying inflammatory cell activation, endothelial damage, smooth muscle proliferation, vascular fibrosis, and end-organ infarction and necrosis. At the heart of atherosclerosis are the byproducts of lipid metabolism, lipoproteins containing triglycerides, phospholipids, and cholesterol, and the changes they undergo that eventually lead to macrophage activation, foam cell formation, and other downstream atherosclerotic changes. Understanding the functionality of cholesterol, triglycerides, and lipoproteins in the cascade of atherosclerotic pathways has tremendous implications on current guidelines for the evaluation and targets in the management of dyslipidemia, and serves as the foundation for future investigations into targets of atherosclerotic therapies

Diabetes and Coronary Artery Disease – Pathophysiologic Insights and Therapeutic Implications

Cardiovascular disease is the leading cause of morbidity and mortality among people with diabetes worldwide, accounting for 60% of all deaths in diabetics. Despite advances in our pathophysiologic understanding of diabetic co-morbidities and measures to help counter these, diabetics still remain at increased risk for cardiovascular disease complicating our overall approach to management. Diabetics, in particularly type 2, are often fraught with additional risk factors contributing to their overall propensity for developing cardiovascular disease. These include, but are not limited to, obesity, dyslipidemia, poor glycemic control, lack of physical activity, and hypertension. In response to this, research driven guidelines focusing on primary prevention have continued to arise with new clinical targets and goals substantially changing our approach with the diabetic population. It is important to note early on, type 1 diabetics carry a higher risk of cardiovascular disease for which the pathophysiology is only recently being elucidated. The underlying relationship between cardiovascular events and risk factors is, however, not well understood. For this reason, management approaches to risk reduction have been extrapolated from experience in type 2 diabetes mellitus. The purpose of this chapter is to present the conclusions of current literature pertaining to blood pressure and blood glucose control, cholesterol management, aspirin therapy, and lifestyle modification. We present a synthesis of the new guidelines, and clinical targets, including preventative measures for subclinical cardiovascular disease for the contemporary management of patients with diabetes mellitus

Quantitative Three-Dimensional Wall Motion Analysis Predicts Ischemic Region Size and Location

Stress echocardiography is an important screening test for coronary artery disease. Currently, cardiologists rely on visual analysis of left ventricular (LV) wall motion abnormalities, which is subjective and qualitative. We previously used finite-element models of the regionally ischemic left ventricle to develop a wall motion measure, 3DFS, for predicting ischemic region size and location from real-time 3D echocardiography (RT3DE). The purpose of this study was to validate these methods against regional blood flow measurements during regional ischemia and to compare the accuracy of our methods to the current state of the art, visual scoring by trained cardiologists. We acquired RT3DE images during 20 brief (<2min) coronary occlusions in dogs and determined ischemic region size and location by microsphere-based measurement of regional perfusion. We identified regions of abnormal wall motion using 3DFS and by blinded visual scoring. 3DFS predicted ischemic region size well (correlation r 2=0.64 against microspheres, p<0.0001), reducing error by more than half compared to visual scoring (8±9% vs. 19±14%, p<0.05), while localizing the ischemic region with equal accuracy. We conclude that 3DFS is an objective, quantitative measure of wall motion that localizes acutely ischemic regions as accurately as wall motion scoring while providing superior quantification of ischemic region siz

Hypertension Management in the High Cardiovascular Risk Population

The incidence of hypertension is increasing every year. Blood pressure (BP) control is an important therapeutic goal for the slowing of progression as well as for the prevention of Cardiovascular disease. The management of hypertension in the high cardiovascular risk population remains a real challenge as the population continues to age, the incidence of diabetes increases, and more and more people survive acute myocardial infarction. We will review hypertension management in the high cardiovascular risk population: patients with coronary heart disease (CHD) and heart failure (HF) as well as in diabetic patients

Deep Vein Thrombosis of the Left Leg: A Case of May-Thurner Syndrome

A 56-year-old woman presented with gradually worsening shortness of breath associated with dull left leg pain over 5 days. She denied any recent travel, recent surgeries or immobilization. CT pulmonary angiography and CT venography revealed multiple bilateral pulmonary emboli and extensive left pelvic and left lower extremity deep vein thromboses. Contrast-enhanced CT showed that the right common iliac artery crossed the left common iliac vein and compressed it externally, indicative of May–Thurner syndrome. Catheter-directed thrombolysis of the left lower extremity was performed and heparin infusion was started. The patient also underwent left iliac vein balloon angioplasty with stenting and infra-renal inferior vena cava filter placement via the jugular approach to prevent further embolization

Management of Hypertension among Patients with Coronary Heart Disease

Evidence suggests that coronary heart disease (CHD) is the most common outcome of hypertension. Hypertension accelerates the development of atherosclerosis, and sustained elevation of blood pressure (BP) can destabilize vascular lesions and precipitate acute coronary events. Hypertension can cause myocardial ischemia in the absence of CHD. These cardiovascular risks attributed to hypertension can be reduced by optimal BP control. Although several antihypertensive agents exist, the choice of agent and the appropriate target BP for patients with CHD remain controversial. In this succinct paper, we examine the evidence and the mechanisms for the linkage between hypertension and CHD and we discuss the treatment options and the goals of therapy that are consistent with the report of the seventh Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and American Heart Association scientific statement. We anticipate changes in the recommendations of the forthcoming JNC 8

The Role of the Renin-Angiotensin-Aldosterone System in Cardiovascular Disease: Pathogenetic Insights and Clinical Implications

Increased attention has been placed on the activation of the renin-angiotensin-aldosterone system (RAAS) and pathogenetic mechanisms in cardiovascular disease. Multiple studies have presented data to suggest that cardiac and arterial stiffness leading to adverse remodeling of both the heart and vasculature leads to the various pathological changes seen in coronary artery disease, heart failure (with preserved and reduced ejection fractions), hypertension and renal disease. Over-activation of the RAAS is felt to contribute to these structural and endocrinological changes through its control of the Na+/K+ balance, fluid volume, and hemodynamic stability. Subsequently, along these lines, multiple large investigations have shown that RAAS blockade contributes to prevention of both cardiovascular and renal disease. We aim to highlight the known role of the activated RAAS and provide an updated description of the mechanisms by which activation of RAAS promotes and leads to the pathogenesis of cardiovascular disease

Ensuring fidelity: key elements to consider in disseminating a diabetes telemanagement program for underserved Hispanic/Latinos living with type 2 diabetes

BackgroundThe Hispanic/Latino population has greater risk (estimated &gt;50%) of developing type 2 diabetes (T2D) and developing it at a younger age. The American Diabetes Association estimates costs of diagnosed diabetes in 2017 was $327 billion; with medical costs 2.3x higher than patients without diabetes. The purpose of this manuscript is to describe the methodology utilized in a randomized controlled trial aimed at evaluating the efficacy of a diabetes telemanagement (DTM) program for Hispanic/Latino patients with T2D. The intent is to provide information for future investigators to ensure that this study can be accurately replicated.MethodsThis study was a randomized controlled trial with 240 participants. Eligible patients (Hispanic/Latino, aged 18+, living with T2D) were randomized to Comprehensive Outpatient Management (COM) or DTM. DTM was comprised of usual care, including routine clinic visits every three months, as well as: Biometrics (a tablet, blood glucose meter, blood pressure monitor, and scale); Weekly Video Visits (facilitated in the patient’s preferred language); and Educational Videos (including culturally congruent diabetes self-management education and quizzes). COM consisted of usual care including routine clinic visits every three months. For this study, COM patients received a glucometer, glucose test strips, and lancets. Establishing a therapeutic nurse-patient relationship was a fundamental component of our study for both groups. First contact (post-enrollment) centered on ensuring that patients and caregivers understood the program, building trust and rapport, creating a non-judgmental environment, determining language preference, and establishing scheduling availability (including evenings and weekends). DTM were provided with a tablet which allowed for self-paced education through videos and weekly video visits. The research team and Community Advisory Board identified appropriate educational video content, which was incorporated in diabetes educational topics. Video visits allowed us to assess patient involvement, motivation, and nonverbal communication. Communicating in Spanish, and awareness of diverse Hispanic/Latino backgrounds was critical, as using relevant and commonly-used terms can increase adherence and improve outcomes. Shared decision-making was encouraged to make realistic health care choices.ConclusionKey elements discussed above provide a framework for future dissemination of an evidence-based DTM intervention to meet the needs of underserved Hispanic/Latino people living with T2D