Widmer, R. Jay

Introduction: Survivorship needs to be comprehensively evaluated amongst older adults. We examined follow-up mortality in patients referred to cardiac catheterization laboratory by prospectively examining frailty. Methods: Frailty in 923 patients ≥55 years was determined using Rockwood’s deficit index. The frailty deficit was based on symptoms, signs, disabilities, diseases, and laboratory measurements. The number of deficits was expressed as a proportion of the total measured deficits. Frailty index was grouped into <0.10 (control), 0.10-<0.20, 0.20-<0.30, 0.30+ and age- and gender-adjusted follow-up mortality was determined using a Cox proportional hazards model. Results: There were 180 (20%) with frailty index <0.10, 348 (38%) in 0.10-<0.20, 215 (23%) in 0.20-<0.30 and 177 (19%) with an index of 0.30 or higher. Patients with a frailty index of 0.30+ were significantly older than those with an index <0.10 (75 ± 10 vs 67 ± 8 years; p<0.001) and more likely to be women (50% vs 20%; p<0.001). Patients with frailty index ≥0.20 and ≥0.30 had a significantly higher mortality risk (HR 3.95, 95% CI 1.51-10.3 and HR: 10.3, 95% CI 4.11-25.7, respectively) on follow-up which remained significant following adjustment for age and gender (HR 3.20, 95% CI 1.21-8.45 and HR: 7.99, 95% CI 3.13-20.4). Conclusions: Among older adults refereed to catheterization laboratory, frailty deficit index predicts follow-up mortality.

Background: Digital health applications are increasingly ubiquitous, however the effectiveness remains mixed. Using a large working age cohort we sought to evaluate use of a digital health intervention (DHI) in people with uncontrolled hypertension and their changes in blood pressure control. Methods: We analyzed usage of DHI and change in blood pressure control and other CVD risk factors over one year in 9,724 participants of a work health program across 81 organizations in 42 states. Patients were selected from a larger cohort based on a previous ICD-9 diagnosis of hypertension. Patients with uncontrolled hypertension, systolic blood pressure (SBP) greater than 140 mmHg, at the initial visit were included. Application users, defined as at least one login, were compared to non-users. Changes in blood pressure, weight, and lipids were compared at one year. Results: Users and non-users were similar in age, weight, blood pressure and lipids at baseline, though users were more likely to be female. At one year users had 16.44 mmHg reduction in SBP and 7.16 mmHg reduction in diastolic blood pressure (DBP), both statistically significantly more than non-users (Table 1). Both users and non-users had an improvement in LDL from baseline, while non-users also had an improvement in BMI and TG from baseline. Discussion: These results show that the use of a DHI is associated with improved systolic and diastolic blood pressure control compared to a workplace health program alone.

Introduction: Cardiovascular disease (CVD) is the leading cause of morbidity/mortality in the US. Despite being a class 1A evidence-based recommendation, secondary prevention efforts in the period following cardiac rehabilitation (CR) lack a proven and successful intervention. A previously validated digital health intervention (DHI) delivered Mayo Clinic’s CR, including educational material, tracking CVD indices, and diet/exercise adherence, for 3 months after usual CR. Hypothesis: We hypothesized DHI use would improve CVD risk factors and rehospitalizations/ emergency department (ED) visits. Methods: Patients undergoing usual Mayo Clinic CR were recruited to use the application following usual CR (n=17) and compared to a similar cohort undergoing standard post-CR care, but not assigned to the application (n=11). DHI patients performed daily informational tasks, entered their own risk factor information (weight, blood pressure (BP), glucose, lipids, physical activity, and diet) at baseline and for three months post-CR. Changes in risk factors, re-hospitalizations/ED visits were assessed after three months. Results: There were no differences in baseline demographics between the two groups. There was no difference in weight change between the two groups during the three months of usual CR, yet in the three months following usual CR the DHI group had significant reductions in weight (-2.5±3.8 kg, p=0.04) and systolic BP (-12.6±12.4 mmHg, p=0.001) compared to the control group. The DHI group also showed significantly lower rate of rehospitalizations/ED visits (-28%, p=0.04, Figure). Conclusions: A DHI post-CR program can enhance secondary prevention strategies compared to standard post-CR care by augmenting weight and BP reduction and reducing the healthcare burden of repeat CVD events. This study thus supports development and implementation of DHI programs.

Abstract The development of novel, non-invasive techniques and standardization of protocols to assess microvascular dysfunction have elucidated the key role of microvascular changes in the evolution of cardiovascular (CV) damage, and their capacity to predict an increased risk of adverse events. These technical advances parallel with the development of novel biological assays that enabled the ex vivo identification of pathways promoting microvascular dysfunction, providing novel potential treatment targets for preventing cerebral-CV disease. In this article, we provide an update of diagnostic testing strategies to detect and characterize microvascular dysfunction and suggestions on how to standardize and maximize the information obtained from each microvascular assay. We examine emerging data highlighting the significance of microvascular dysfunction in the development CV disease manifestations. Finally, we summarize the pathophysiology of microvascular dysfunction emphasizing the role of oxidative stress and its regulation by epigenetic mechanisms, which might represent potential targets for novel interventions beyond conventional approaches, representing a new frontier in CV disease reduction.

Importance. Obesity is a worsening epidemic worldwide. Effective and accessible weight loss programs to combat obesity on a large scale are warranted, but a need for frequent face-to-face care might impose a limitation. Objective. To evaluate whether individuals following a weight loss program based on a mobile application, wireless scale, and nutritional program but no face-to-face care can achieve clinically significant weight loss in a large cohort. Design. Retrospective observational analysis. Setting. China from October 2016 to December 2017. Participants. Mobile application users with a minimum of 2 weights (baseline and ≥35 days). Intervention. A commercial (Weijian Technologies) weight loss program consisting of a dietary replacement, self-monitoring using a wireless home scale, and frequent guidance via mobile application. Main Outcome. Mean weight change around 42, 60, 90, and 120 days after program initiation with subgroup analysis by gender, age, and frequency of use. Results. 251,718 individuals, with a mean age of 37.3 years (SD: 9.86) (79% female), were included with a mean weight loss of 4.3 kg (CI: ±0.02) and a mean follow-up of 120 days (SD: 76.8 days). Mean weight loss at 42, 60, 90, and 120 d was 4.1 kg (CI: ±0.02), 4.9 kg (CI: ±0.02), 5.6 kg (CI: ±0.03), and 5.4 kg (CI: ±0.04), respectively. At 120 d, 62.7% of participants had lost at least 5% of their initial weight. Both genders and all usage frequency tertiles showed statistically significant weight loss from baseline at each interval (P<0.001), and this loss was greater in men than in women (120 d: 6.5 vs. 5.2 kg; P<0.001). The frequency of recording (categorized as high-, medium-, or low-frequency users) was associated with greater weight loss when comparing high, medium, and low tertile use groups at all time intervals investigated (e.g., 120 d: −8.6, −5.6, and −2.2 kg, respectively; P<0.001). Conclusions. People following a commercially available hybrid weight loss program using a mobile application, wireless scale, and nutritional program without face-to-face interaction on average achieved clinically significant short- and midterm weight loss. These results support the implementation of comparable technologies for weight control in a large population.

Abstract Objectives The aim of this study was to describe management of recurrent pulmonary vein stenosis (PVS) and determine if stenting is superior to balloon angioplasty (BA) in preventing subsequent restenosis. Background PVS is a serious complication of atrial fibrillation ablation. BA and stenting are effective therapies; however, restenosis frequently occurs. Here we report management of recurrent stenosis. Methods This was a prospective observational study performed from 2000 to 2014. Results One hundred and thirteen patients with severe PVS underwent intervention in 88 veins treated with BA and 81 treated with stenting. Forty‐two patients experienced restenosis. Restenosis was more common in veins treated with BA (RRR 53% [95% CI 32–70%, p = .008]). A second intervention was performed in 41 patients. In the 34 vessels treated with initial BA, 24 were treated for restenosis with a stent and 10 were treated with a second BA. The recurrence rate was 46% in those treated with BA followed by stenting and 50% in those treated with two BA procedures. In the 22 veins treated with initial stenting, 9 were treated with another stent and 13 were treated with BA. The recurrence rate was 44% in those treated with a second stent and 46% for those treated with a stent followed by BA. The risk of a third stenosis was the same among all groups (Analysis of variance [ANOVA] p = .99). Limited sample size precluded analysis of outcome by stent size. Conclusions Restenosis occurred in 44% of patients overall. Management is challenging; stenting does not appear to be superior to BA.

Background: We aimed to test the hypothesis that peripheral endothelial dysfunction induced by mental stress may predict cardiovascular events after acute coronary syndrome beyond traditional cardiovascular disease risk factors. Methods: This was a prospective study in which 417 patients who had acute coronary syndrome were enrolled in two sites at the US and Qatar. Cardiovascular disease risk factors such as past medical history, blood pressure, heart rate, peripheral endothelial dysfunction, and response to three different mental stress examinations (Stroop Color Word, Arithmetic, and Spiral Omnibus) as assessed by ratio of reactive hyperemia tonometry (EndoPAT) with stress over EndoPAT at rest were obtained at baseline. Major adverse cardiac events were then recorded at 1 year after the index event. Results: There were no differences in baseline peripheral endothelial dysfunction or vascular response to mental stress between the US vs. Qatar patients. Women were more likely to experience major adverse cardiac events in the year following acute coronary syndrome (relative risk 2.42, 95% confidence interval 1.53–3.84, P = 0.044), and had a significantly lower mental stress ratio compared to women who did not (1.0 ± 0.17 vs. 1.20 ± 0.17, P = 0.04). In multivariate analyses stratified by sex, baseline peripheral endothelial dysfunction (EndoPAT < 1.7) (χ2 = 8.0, P = 0.005) and mental stress ratio (χ2 = 7.7, P = 0.006), were independently predictive of major adverse cardiac events in women, but not men. Conclusion: The current study demonstrates that in women both baseline endothelial function and vascular function in response to mental stress ratio are predictive of worse cardiovascular disease outcomes 1 year after acute coronary syndrome. The study may suggest an important mechanism for adverse clinical outcomes in women following acute coronary syndrome.

Purpose To study the effect of a planned social media promotion strategy on access of online articles in an established academic medical journal. Method This was a single-masked, randomized controlled trial using articles published in Mayo Clinic Proceedings , a large-circulation general/internal medicine journal. Articles published during the months of October, November, and December 2015 (n = 68) were randomized to social media promotion (SoMe) using Twitter, Facebook, and LinkedIn or to no social media promotion (NoSoMe), for 30 days (beginning with the date of online article publication). Journal website visits and full-text article downloads were compared for 0–30 and 31–60 days following online publication between SoMe versus NoSoMe using a Wilcoxon rank-sum test. Results Website access of articles from 0 to 30 days was significantly higher in the SoMe group (n = 34) compared with the NoSoMe group (n = 34): 1,070 median downloads versus 265, P < .001. Similarly, full-text article downloads from 0–30 days were significantly higher in the SoMe group: 1,042 median downloads versus 142, P < .001. Compared with the NoSoMe articles, articles randomized to SoMe received a greater number of website visits via Twitter (90 vs 1), Facebook (526 vs 2.5), and LinkedIn (31.5 vs 0)—all P < .001. Conclusions Articles randomized to SoMe were more widely accessed compared with those without social media promotion. These findings show a possible role, benefit, and need for further study of a carefully planned social media promotion strategy in an academic medical journal.