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Van Wagoner D.R.,Cleveland ClinicOH | Nattel S.,Montreal Heart Institute
Circulation Journal | Year: 2015

Atrial fibrillation (AF) is the most common clinically relevant arrhythmia, but the methods available for treating AF and its complications (of which the most important is thrombogenesis), as well as for assessing AF risk and underlying pathophysiology, are largely limited. Emerging evidence suggests a significant role of inflammation in the pathogenesis of AF. That evidence includes elevated serum levels of inflammatory biomarkers in AF subjects, the expression of inflammatory markers in cardiac tissues of AF patients and animal models of AF, and beneficial effects of anti-inflammatory drugs in experimental AF paradigms. Inflammation is suggested to be linked to various pathological processes, such as oxidative stress, apoptosis, and fibrosis, that promote AF substrate formation. Inflammation has also been associated with endothelial dysfunction, platelet activation, and coagulation cascade activation, leading to thrombogenesis. Thus, inflammation may contribute to both the occurrence/maintenance of AF and its thromboembolic complications. Here, we review the evidence for a role of inflammation and inflammatory biomarkers in the risk management and treatment of AF. We also summarize the current knowledge of inflammationdependent cellular and molecular mechanisms in AF pathophysiology and their potential as therapeutic targets. © 2015, Japanese Circulation Society. All rights reserved.

Pandey A.,University of Texas Southwestern Medical Center | Parashar A.,Cleveland ClinicOH | Agarwal S.,Johns Hopkins University | Garg J.,Lehigh Valley Health Network | And 4 more authors.
Circulation: Heart Failure | Year: 2015

Background-Heart failure with preserved ejection fraction (HFPEF) is common and characterized by exercise intolerance and lack of proven effective therapies. Exercise training has been shown to be effective in improving cardiorespiratory fitness (CRF) in patients with systolic heart failure. In this meta-analysis, we aim to evaluate the effects of exercise training on CRF, quality of life, and diastolic function in patients with HFPEF. Methods and Results-Randomized controlled clinical trials that evaluated the efficacy of exercise training in patients with HFPEF were included in this meta-analysis. Primary outcome of the study was change in CRF (measured as change in peak oxygen uptake). Effect of exercise training on quality of life (estimated using Minnesota living with heart failure score), and left ventricular systolic and diastolic function was also assessed. The study included 276 patients who were enrolled in 6 randomized controlled trials. In the pooled data analysis, patients with HFPEF undergoing exercise training had significantly improved CRF (mL/kg per min; weighted mean difference, 2.72; 95% confidence interval, 1.793.65) and quality of life (weighted mean difference, -3.97; 95% confidence interval, -7.21 to -0.72) when compared with the control group. However, no significant change was observed in the systolic function (EF-weighted mean difference, 1.26; 95% confidence interval, -0.13% to 2.66%) or diastolic function (E/A-weighted mean difference, 0.08; 95% confidence interval, -0.01 to 0.16) with exercise training in patients with HFPEF. Conclusions-Exercise training in patients with HFPEF is associated with an improvement in CRF and quality of life without significant changes in left ventricular systolic or diastolic function. © 2015 American Heart Association, Inc.

Bangalore S.,New York University | Bhatt D.L.,Harvard University | Steg P.G.,AP HP | Weber M.A.,New York University | And 6 more authors.
Circulation: Cardiovascular Quality and Outcomes | Year: 2014

Background-The long-term efficacy of β-blockers in patients with and without myocardial infarction (MI) is controversial. Methods and Results-This is post hoc analysis from the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial of 4772 patients with prior MI, 7804 patients with known atherothrombosis, and 2101 patients with risk factors alone but without heart failure. Primary outcome was a composite of nonfatal MI, stroke, or cardiovascular mortality. The cohorts were divided into 2 groups based on baseline β-blocker use. In the propensity score-matched prior MI cohort, after 28 months of follow-up, β-blocker use was associated with a 31% lower risk of the primary outcome (70 [7.1%] versus 100 [10.2%]; hazards ratio, 0.69; 95% confidence interval, 0.50-0.94; P=0.021), driven by a lower risk of recurrent MI (33 [3.4%] versus 48 [4.9%]; hazards ratio, 0.62; 95% confidence interval, 0.39-1.00; P=0.049) with no difference in mortality (52 [5.3%] versus 66 [6.7%]; P=0.20). In the known atherothrombotic disease and the risk factors alone cohorts, β-blocker use was not associated with lower ischemic outcomes, whereas a trend toward a higher risk of stroke (3.5% versus 1.5%; hazards ratio, 2.13; 95% confidence interval, 0.92-4.92; P=0.079) was observed in the risk factors alone cohort. This higher stroke risk was significant in the regression model adjusted to the propensity score (hazards ratio, 2.69; 95% confidence interval, 1.33-5.44; P=0.006) and in the multivariable models. Conclusions-β-blocker use in patients with prior MI but no heart failure was associated with a lower composite cardiovascular outcome driven by lower risk of recurrent MI with no difference in mortality. However, β-blocker use was not associated with lower cardiovascular events in those without MI, with a suggestion of inferior outcome with regard to stroke risk. © 2014 American Heart Association, Inc.

Agarwal S.,Heart and Vascular Institute | Parashar A.,Cleveland ClinicOH | Ellis S.G.,Heart and Vascular Institute | Heupler F.A.,Heart and Vascular Institute | And 3 more authors.
Circulation: Cardiovascular Interventions | Year: 2014

Background-X-ray use in the catheterization laboratory is guided by the principle of as low as reasonably achievable. In accordance with this principle, we reduced the default fluoroscopic frame rate from 10 to 7.5 frames/s and increased the emphasis on the use of low-dose acquisition starting January 1, 2013. We aimed to study the impact of these measures on the total air kerma during diagnostic catheterization (DC) and percutaneous interventions (PCI). Methods and Results-Propensity matching based on age, sex, body surface area, total fluoroscopy time, and total acquisition time was used to select matched patients for 2012 and 2013, further stratified by DC or PCI. The total air kerma was subsequently compared between 2012 and 2013, separately for DC and PCI. Median total air kerma during DC in 2013 was 625 mGy, which was significantly lower than the corresponding values in 2012 (median, 798 mGy; P<0.001). Similarly, median total air kerma during PCI in 2013 was 1675 mGy, which was significantly less than corresponding values in 2012 (median 2463 mGy, P<0.001). On comparison of air kerma rates between corresponding projections in 2 years, we observed a significant reduction in fluoroscopy- and acquisition-based air kerma rates in 2013, after institution of radiation reduction measures in all projections. Conclusions-With reduction in the default fluoroscopic frame rate and a greater use of low-dose acquisition, there has been a marked reduction in the total air kerma and air kerma rates for DC and PCI. © 2014 American Heart Association, Inc.

Wayangankar S.A.,Cleveland ClinicOH | Ellis S.G.,Cleveland ClinicOH
Progress in Cardiovascular Diseases | Year: 2015

Current drug-eluting stents (DES) have shown excellent safety and efficacy in various clinical settings. However, the presence of a permanent metallic scaffold remains an Achilles heel, with concerns for late stent thrombosis and the need for prolonged dual anti-platelet therapy. The bioresorbable vascular scaffold (BRS) has been termed the fourth revolution in interventional cardiology, with an ability to not only treat the coronary lesion, but also restore endothelial function after complete absorption. The absence of a permanent scaffold after months of implantation has the potential to overcome the shortcomings of current metallic DES and markedly impact interventional cardiology practice around the world. This review article focuses on the history, development and clinical studies on various BRS and attempts to predict how this technology could impact future cardiology practice. © 2015 Elsevier Inc.

Sabe M.A.,Cleveland ClinicOH | Jacob M.S.,Cleveland ClinicOH | Taylor D.O.,Cleveland ClinicOH
Cleveland Clinic Journal of Medicine | Year: 2015

The PARADIGM-HF trial (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) found a combination drug containing sacubitril (a neprilysin inhibitor) and valsartan (an angiotensin II receptor blocker) superior to enalapril (an angiotensin-converting enzyme inhibitor) in patients with systolic heart failure. Recently approved by the US Food and Drug Administration, sacubitril-valsartan is the first new drug in over a decade to decrease death rates in patients with systolic heart failure.

Mitchell J.,Cleveland ClinicOH
Online Journal of Nursing Informatics | Year: 2015

The purpose of the study is to determine competence and confidence of newly hired nurses' completion of documentation in the electronic health record (EHR). As a result of the American Recovery and Reinvestment Act (ARRA) of 2009, billions of dollars are directed towards the use of EHRs nationwide. Nurses spend approximately 19% of their time documenting patient care; it is essential for patient safety that documentation is accurate and proficient. The focus of this study is competency of new nurses in EHR documentation; confidence of new graduate nurses in EHR documentation; and the relationship between levels of competence and confidence of new nurses for EHR documentation. Findings suggest that an individual's confidence and competence do not always correspond. Those less competent often identify as having more ability and are unaware of their shortcomings. In addition, new graduate nurses have difficulty learning the necessary tasks of electronic documentation during the first week of orientation. More time and practice is required to improve documentation. The new nurse would benefit from extensive practice and discussion of electronic documentation during their orientation to become competent in a timelier manner. © 2016 Healthcare Information and Management Systems Society (HIMSS).

Alzubaidi M.,Cleveland ClinicOH | Gabbard S.,Digestive Disease Institute
Cleveland Clinic Journal of Medicine | Year: 2015

Gastroesophageal reflux disease (GERD) is chronic, very common, and frequently encountered in internal medicine and subspecialty clinics. It is often diagnosed on clinical grounds, but specialized testing such as endoscopy and pH monitoring may be necessary in certain patients. Although proton pump inhibitors (PPIs) are the mainstay of treatment, clinicians should be aware of their short-term and long-term side effects.

Faiman B.,Cleveland ClinicOH
Clinical Journal of Oncology Nursing | Year: 2016

Background: One of the most common and inadequately managed symptoms that patients with multiple myeloma (MM) experience as a result of cancer treatment is diarrhea. Diarrhea in patients with MM often is severe enough to warrant dose reduction, delays, or discontinuation of chemotherapy. Short-term diarrhea can occur as a side effect of drugs, such as bortezomib (Velcade®) or panobinostat (Farydak®). Late-onset diarrhea from lenalidomide (Revlimid®) can occur 17–24 months after the start of therapy. Treatment of diarrhea is often by dose reduction and discontinuation of the offending drug. However, the symptom fails to entirely resolve with these interventions and dose reductions place the individual at risk for disease progression. Best practices for diarrhea management in MM are poorly understood, but diarrhea symptoms impede patient adherence and undermine quality of life. Objectives: The purpose of this article is to review the etiology of the symptom of diarrhea in people with cancer, specifically MM. Management strategies also are discussed. Methods: A comprehensive review of CINAHL®, MEDLINE®, and PubMed databases was performed using the search terms diarrhea, chemotherapy, multiple myeloma, and cancer. Research studies, guidelines, and papers from peer-reviewed publications were considered. Findings: Although general guidelines from the American Society of Clinical Oncology and Oncology Nursing Society exist that suggest best practices in the management of chemotherapy-induced diarrhea, best practices to identify and manage diarrhea symptoms in patients with MM are lacking. © 2016 by the Oncology Nursing Society.

Tomecki K.J.,Cleveland ClinicOH | Martinez J.D.,University of Monterrey
Seminars in Cutaneous Medicine and Surgery | Year: 2014

In today's world, many people can travel easily and quickly around the globe. Most travel travel-related illnesses include fever, diarrhea, and skin disease, which are relatively uncommon in returning travelers. We review four of the most common emerging infestations and skin infections in the Americas, which are important to the clinical dermatologist, focusing on the clinical presentation and treatment of cutaneous larva migrans, gnathostomiasis, cutaneous amebiasis, and trombiculiasis. © 2014 Frontline Medical Communications.

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