Citations

AbstractBackgroundQRS fragmentation (fQRS) during baseline ventricular conduction, a myocardial fibrosis marker, is associated with increased risk of ventricular tachyarrhythmias but may not manifest unless ventricular activation change is provoked. We examined the association of fQRS during right ventricular (RV) pacing with death and ventricular tachyarrhythmia in patients with left ventricular (LV) dysfunction undergoing electrophysiology study (EPS).Methods and resultsStudy participants had LV dysfunction (ejection fraction < 50%) undergoing EPS from January 2002 to May 2014 at Mayo Clinic in Rochester, Minnesota. fQRS during RV stimulation involved >2 notches on R/S waves identified in ≥2 contiguous standard electrocardiographic leads representing anterior, inferior, or lateral ventricular segments. Primary outcomes were ventricular tachyarrhythmias that were symptomatic or required intervention and total and cardiac deaths. In all, 528 patients participated (mean age, 65 years; male sex, 80%). Of them, 312 (59%) had ischemic cardiomyopathy and mean (SD) left ventricular ejection fraction (LVEF) of 33.2% (9.5%); 457 (87%) had implantable cardiac devices (implanted defibrillator, n = 380). Mean (SD) follow‐up was 3.2 (3.0) years. fQRS during RV pacing was observed in 292 patients (60%) in any ventricular segment. Patients with fQRS during RV pacing had 2.5 higher rate of ventricular tachyarrhythmia events than patients with no fQRS (hazard ratio [95% CI], 2.45 [1.5–4.2]; P < 0.01), after correcting for baseline ventricular conduction defect and QRS duration, LVEF, inducible sustained ventricular tachycardia, diabetes mellitus, chronic kidney disease, and ischemic cardiomyopathy.ConclusionsRV stimulation can unmask fQRS, and it is associated with increased risk of ventricular tachyarrhythmia in LV dysfunction.

Background: Intima-media thickness (IMT) has been proposed as a measurement of subclinical atherosclerosis and has been associated with cardiovascular disease (CVD). Epicardial adipose tissue (EAT) is a fat depot between the pericardium and myocardium and has been associated with coronary atherosclerosis. The relationship between IMT and EAT thickness has not been reported before. We investigated the relationship between EAT thickness, IMT, CVD risk factors, and ideal cardiovascular health (CVH) metrics using subjects from the Kardiovize Brno 2030 cohort study, a random urban sample population in Central Europe. Methods: We studied 102 individuals (65 males) aged 25–64 years (median = 37 years) with no current or past CVD history. We measured IMT using a vascular ultrasound and EAT thickness using transthoracic echocardiography, and collected data on anthropometric factors, CVD risk factors, and CVH score. Correlation tests and multiple linear regression models were applied. Results: In the age- and gender-adjusted model, we demonstrated that, among CVD risk factors, only BMI was significantly and positively associated with EAT thickness (β = 0.182, SE = 0.082, p = 0.030), while no significant associations with IMT were evident. Although both EAT thickness and IMT were negatively correlated with CVH score (r = −0.45, p < 0.001, and r = −0.38, p < 0.001, respectively), we demonstrated that overall CVH score (β = −0.262; SE = 0.077; p = 0.001), as well as BMI (β = −1.305; SE = 0.194; p < 0.001) and blood pressure CVH metrics (β = −0.607; SE = 0.206; p = 0.004) were significantly associated with EAT thickness but not with IMT. Conclusions: Our study is important as it demonstrated for the first time that CVH is associated with EAT thickness. Interestingly, this relationship seems to be dependent on BMI and blood pressure rather than on the other CVH metrics. However, outcome-driven studies are required to confirm these findings.

Abstract BACKGROUND A decrease in diastolic blood pressure (DBP) with exercise is considered normal, but the significance of an increase in DBP has not been validated. Our aim was to determine the relationship of DBP increasing on a stress test regarding comorbidities and mortality. METHODS Our database was reviewed from 1993 to 2010 using the first stress test of a patient. Non-Minnesota residence, baseline cardiovascular (CV) disease, rest DBP &lt;60 or &gt;100 mm Hg, and age &lt;30 or ≥80 were exclusion criteria. DBP response was classified: normal if peak DBP–rest DBP &lt; 0, borderline 0–9, and abnormal ≥10 mm Hg. Mortality was determined from Mayo Clinic records and Minnesota Death Index. Logistic regression was used to determine the relationship of DBP response to the presence of comorbidities. Cox regression was used to determine total and CV mortality risk by DBP response. All analyses were adjusted for age, sex, and resting DBP. RESULTS Twenty thousand seven hundred sixty patients were included (51 ± 11 years, female n = 7,314). Rest/peak averaged DBP 82 ± 8/69 ± 15 mm Hg in normal vs. 79 ± 9/82 ± 9 mm Hg in borderline vs. 76 ± 9/92 ± 11 mm Hg in abnormal DBP response. There were 1,582 deaths (8%) with 557 (3%) CV deaths over 12 ± 5 years of follow-up. In patients with borderline and abnormal DBP response, odds ratios for obesity, hypertension, diabetes, and current smoking were significant, while hazard ratios for total and CV death were not significant compared with patients with normal DBP response. CONCLUSIONS DBP response to exercise is significantly associated with important comorbidities at the time of the stress test but does not add to the prognostic yield of stress test.

Background Prognosis based on body fat percentage ( BF %) in patients with coronary artery disease has not been extensively studied. We tested the hypothesis that patients with coronary artery disease and increased BF % have a higher risk for major adverse cardiovascular events ( MACEs ) and that fat‐free mass is associated with better prognosis. Methods and Results We included 717 patients referred to cardiac rehabilitation after coronary artery disease events or procedures who underwent air displacement plethysmography to assess BF %; 75% were men, with a mean age 61.4±11.4 years and a mean body mass index of 30±5.4 kg/m 2 . Follow‐up was performed using a record linkage system. Patients were classified in sex‐specific quartiles of BF % and fat‐free mass index. The composite outcome of MACEs included acute coronary syndromes, coronary revascularization, stroke, or death from any cause. After a median follow‐up of 3.9 years, 201 patients had a MACE . After adjusting for covariates, body mass index was not associated with MACEs ( P =0.12). However, the risk of MACEs for those in the highest BF % quartile was nearly double when compared with those in the lowest quartile (hazard ratio, 1.89; 95% confidence interval, 1.30–2.77; P =0.0008). In contrast, fat‐free mass was inversely associated with MACEs . The risk of MACEs for those in the fourth fat‐free mass quartile was lower (adjusted hazard ratio, 0.53; 95% confidence interval, 0.35–0.82; P =0.004), when compared with those in the first quartile. Conclusions In patients with coronary artery disease, there is no obesity paradox when measuring BF % instead of body mass index. BF % is associated with a higher risk of MACEs , whereas fat‐free mass is associated with a lower risk of MACEs . Body mass index was not associated with MACEs .

Abstract Yoga is increasing in popularity in the United States and across the globe. However, most yoga programs are provided outside the worksite; although many companies offer worksite wellness programs, at present there is limited documentation regarding the potential benefits of participating in a worksite yoga program. Therefore, the purpose of this project was to examine the potential effect of a worksite yoga program on self-acceptance, quality of life, and perceived stress. A prospective cohort pilot study that examined a structured worksite yoga program was designed and tailored to individuals new to yoga. The 8-week Yoga Foundations program was conducted at an academic medical center's worksite wellness center with 86 subjects. Outcome measures were the 36-item Self-Acceptance Scale; a six-item quality-of-life measure that assesses overall, social, mental, physical, emotional, and spiritual well-being; and the ten-item Perceived Stress Scale. Participants demonstrated significant improvement in their overall self-acceptance (p &lt; 0.001), quality of life (p &lt; 0.001), and perceived stress (p &lt; 0.001) levels. They also highly rated the yoga instructors and the weekly format of the program. Participation in a Yoga Foundations program was associated with improvements in self-acceptance, quality of life and stress levels in worksite wellness center members. Future studies should use randomized designs and examine other wellness domains to learn more about the potential benefits of worksite yoga programs.

Background Heart rate ( HR ) recovery has been investigated in specific patient cohorts, but there is less information about the role of HR recovery in general populations. We investigated whether HR recovery has long‐term prognostic significance in primary prevention. Methods and Results Exercise tests performed between 1993 and 2010 on patients aged 30 to 79 years without cardiovascular disease were included. Mortality was determined from Mayo Clinic records and Minnesota Death Index. Total, cardiovascular , and non‐cardiovascular mortality was reported according to HR recovery <13 bpm using Cox regression. 19 551 patients were included, 6756 women (35%), age 51±10 years. There were 1271 deaths over follow‐up of 12±5 years. HR recovery declined after age 60, and was also lower according to diabetes mellitus, hypertension, obesity, current smoking, and poor cardiorespiratory fitness but not sex or β‐blockers. Adjusting for these factors, abnormal HR recovery was a significant predictor of total (hazard ratio [95% confidence interval]=1.56 [1.384–1.77]), cardiovascular (1.95 [1.57–2.42]), and non‐cardiovascular death (1.41 [1.22–1.64]). Hazard ratios for cardiovascular death according to abnormal HR recovery were significant in all age groups (30–59, 60–69, 70–79), in both sexes, in patients with and without hypertension, obesity, and diabetes mellitus, but not in patients taking β‐blockers, current smokers, and patients with normal cardiorespiratory fitness. Conclusions HR recovery is a powerful prognostic factor predicting total, cardiovascular, and non‐cardiovascular death in a primary prevention cohort. It performs consistently well according to sex, age, obesity, hypertension, and diabetes mellitus but shows diminished utility in patients taking β‐blockers, current smokers, and patients with normal cardiorespiratory fitness.

BackgroundReplacing sitting with standing is one of several recommendations to decrease sedentary time and increase the daily energy expenditure, but the difference in energy expenditure between standing versus sitting has been controversial. This systematic review and meta-analysis aimed to determine this difference.Designs and methodsWe searched Ovid MEDLINE, Ovid Embase Scopus, Web of Science and Google Scholar for observational and experimental studies that compared the energy expenditure of standing versus sitting. We calculated mean differences and 95% confidence intervals using a random effects model. We conducted different predefined subgroup analyses based on characteristics of participants and study design.ResultsWe identified 658 studies and included 46 studies with 1184 participants for the final analysis. The mean difference in energy expenditure between sitting and standing was 0.15 kcal/min (95% confidence interval (CI) 0.12–0.17). The difference among women was 0.1 kcal/min (95% CI 0.0–0.21), and was 0.19 kcal/min (95% CI 0.05–0.33) in men. Observational studies had a lower difference in energy expenditure (0.11 kcal/min, 95% CI 0.08–0.14) compared to randomised trials (0.2 kcal/min, 95% CI 0.12–0.28). By substituting sitting with standing for 6 hours/day, a 65 kg person will expend an additional 54 kcal/day. Assuming no increase in energy intake, this difference in energy expenditure would be translated into the energy content of about 2.5 kg of body fat mass in 1 year.ConclusionsThe substitution of sitting with standing could be a potential solution for a sedentary lifestyle to prevent weight gain in the long term. Future studies should aim to assess the effectiveness and feasibility of this strategy.

Background Participation in cardiac rehabilitation ( CR ) is an essential component of care for patients with coronary artery disease. However, little is known about its benefit on cardiovascular outcomes in patients with diabetes mellitus ( DM ) who have undergone percutaneous coronary intervention. The aim of our study was to evaluate the impact of CR in this high‐risk group of patients. Methods and Results We performed a retrospective analysis of all patients with DM who underwent percutaneous coronary intervention in Olmsted County (Minnesota) between 1994 and 2010, assessing the impact of CR participation on clinical outcomes. CR participation was significantly lower in patients with DM (38%, 263/700) compared with those who did not have DM (45%, 1071/2379; P =0.004). Using propensity score adjustment, we found that in patients with DM , CR participation was associated with significantly reduced all‐cause mortality (hazard ratio, 0.56; 95% confidence interval, 0.39–0.80; P =0.002) and composite end point of mortality, myocardial infarction, or revascularization (hazard ratio, 0.77; 95% confidence interval, 0.60–0.98; P =0.037), during a median follow‐up of 8.1 years. In patients without DM , CR participation was associated with a significant reduction in all‐cause mortality (hazard ratio, 0.67; 95% confidence interval, 0.55–0.82; P <0.001) and cardiac mortality (hazard ratio, 0.67; 95% confidence interval, 0.47–0.95; P =0.024). Conclusions CR participation after percutaneous coronary intervention is associated with lower all‐cause mortality rates in patients with DM , to a similar degree as for those without DM . However, CR participation was lower in patients with DM , suggesting the need to identify and correct the barriers to CR participation for this higher‐risk group of patients.