Routine Versus Aggressive Upstream Rhythm Control for Prevention of Early Atrial Fibrillation in Heart Failure: Background, Aims and Design of the RACE 3 Study.

Routine versus aggressive upstream rhythm control for prevention of early atrial fibrillation in heart failure: background, aims and design of the RACE 3 study.

Neth Heart J. 2013 May 23;
Alings M, Smit MD, Moes ML, Crijns HJ, Tijssen JG, Brügemann J, Hillege HL, Lane DA, Lip GY, Smeets JR, Tieleman RG, Tukkie R, Willems FF, Vermond RA, Van Veldhuisen DJ, Van Gelder IC

BACKGROUND: Rhythm control for atrial fibrillation (AF) is cumbersome because of its progressive nature caused by structural remodelling. Upstream therapy refers to therapeutic interventions aiming to modify the atrial substrate, leading to prevention of AF. OBJECTIVE: The Routine versus Aggressive upstream rhythm Control for prevention of Early AF in heart failure (RACE 3) study hypothesises that aggressive upstream rhythm control increases persistence of sinus rhythm compared with conventional rhythm control in patients with early AF and mild-to-moderate early systolic or diastolic heart failure undergoing electrical cardioversion. DESIGN: RACE 3 is a prospective, randomised, open, multinational, multicenter trial. Upstream rhythm control consists of angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers, mineralocorticoid receptor antagonists, statins, cardiac rehabilitation therapy, and intensive counselling on dietary restrictions, exercise maintenance, and drug adherence. Conventional rhythm control consists of routine rhythm control therapy without cardiac rehabilitation therapy and intensive counselling. In both arms, every effort is made to keep patients in the rhythm control strategy, and ion channel antiarrhythmic drugs or pulmonary vein ablation may be instituted if AF relapses. Total inclusion will be 250 patients. If upstream therapy proves to be effective in improving maintenance of sinus rhythm, it could become a new approach to rhythm control supporting conventional pharmacological and non-pharmacological rhythm control. HubMed – rehab


OPTImal CArdiac REhabilitation (OPTICARE) following Acute Coronary Syndromes: Rationale and design of a randomised, controlled trial to investigate the benefits of expanded educational and behavioural intervention programs.

Neth Heart J. 2013 May 23;
Sunamura M, Ter Hoeve N, van den Berg-Emons HJ, Haverkamp M, Redekop K, Geleijnse ML, Stam HJ, Boersma E, van Domburg RT

The majority of cardiac rehabilitation (CR) referrals consist of patients who have survived an acute coronary syndrome (ACS). Although major changes have been implemented in ACS treatment since the 1980s, which highly influenced mortality and morbidity, CR programs have barely changed and only few data are available on the optimal CR format in these patients. We postulated that standard CR programs followed by relatively brief maintenance programs and booster sessions, including behavioural techniques and focusing on incorporating lifestyle changes into daily life, can improve long-term adherence to lifestyle modifications. These strategies might result in improved (cardiac) mortality and morbidity in a cost-effective fashion. In the OPTImal CArdiac REhabilitation (OPTICARE) trial we will assess the effects of two advanced and extended CR programs that are designed to stimulate permanent adaption of a heart-healthy lifestyle, compared with current standard CR, in ACS patients. We will study the effects in terms of cardiac risk profile, levels of daily physical activity, quality of life and health care consumption. HubMed – rehab


Management of Complications of Pulmonary Agenesis in an Adult Patient.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 988A
Lineberry O, Murphy PJ, Piquette C, Bailey K

SESSION TYPE: Miscellaneous Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM – 02:30 PMINTRODUCTION: Complete unilateral pulmonary agenesis is an extremely rare congenital condition, characterized by complete absence of bronchi, parenchyma, vessels and pleural cavity in the affected lung. Fifty percent of infants born with pulmonary aplasia are stillborn or die within the first five years of life. We present a patient with right pulmonary agenesis complicated by ASD that has survived to adulthood.CASE PRESENTATION: A 21 year-old female presents with new onset of hypoxic respiratory failure and dyspnea after diagnosis of community-acquired pneumonia. She has a right pulmonary agenesis, dextrocardia and ASD. Initial diagnosis in the first week of life and ASD surgical repair at 7 months of age, complicated with chronic hypoxic respiratory failure and tracheostomy till age of 5. She also has severe pulmonary hypertension. She was lost to follow up until the current presentation. She was not on supplemental oxygen until current hospitalization. Community-acquired pneumonia treated with Moxifloxacin 10 days course, discharged on 6 L/min of oxygen at rest. Physical exam: BMI 45, vesicular breath sounds over left chest and transmitted breath sounds over right chest, normal S1 and loud S2 over right hemithorax. Echocardiogram: dextrocardia, estimated RV pressure of 89 mmHg with moderate mitral regurgitation. PFT shows obstruction with FEV1/FVC 68%, FEV1 0.81 L (28.7%) and FVC 1.2 L (37.9 %). Chest roenterogram: homogenously opaque right hemithorax with mediastinal shift and hyperlucency of left lung field. CT chest: left lung emphysema, right mediastinal shift, right lung agenesis and heart in right hemithorax.DISCUSSION: There is no specific therapy for pulmonary agenesis. We took a symptomatic approach to therapy, treating her obstructive lung disease with Albuterol, Tiotropium, and Mometasone, pulmonary rehabilitation with improved functional status. Planned left and right cardiac catheterization to evaluate for any remediable anatomic cardiovascular problems that may not be evident by ECHO but may contribute to pulmonary hypertension and assess responsiveness to pulmonary vasodilators.CONCLUSIONS: Lung aplasia is often associated with acute respiratory distress and a high mortality rate early in life. This case highlights the fact that children with complicated congenital pulmonary diseases are increasingly living into adulthood. As adult pulmonologists, we must be more aware of these diseases and their pathophysiological changes to be able to adequately diagnose and treat our patients.1) Skandalakis JE, Gray SW, Symbas P: The trachea and the lungs. In: Skandalakis JE, Gray SW, editors. Embryology for Surgeons. 2nd ed. Baltimore, MD: Williams and Wilkins; 1994. p 429-32.2) Krivchenya DU, Rudenko EO, Lysak SV, Dubrovin AG, Khursin VN, Krivchenya TD. Lung aplasia: Anatomy, history, diagnosis and surgical management. Eur J Pediatr Surg 2007;17:244-50.3) Kumar B, Kandpal DK, Sharma C, Sinha DD. Right lung agenesis. Afr J Paediatr Surg 2008;5:102-4DISCLOSURE: The following authors have nothing to disclose: Olena Lineberry, P.Jim Murphy, Craig Piquette, Kristina BaileyNo Product/Research Disclosure InformationUNMC, Omaha, NE. HubMed – rehab


Lung Function Decline and Predictors in Older People From the English Longitudinal Study of Aging.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 784A
Yohannes A, Tampubolon G

SESSION TYPE: Physiology/PFTs/ Rehabilitation IPRESENTED ON: Sunday, October 21, 2012 at 01:15 PM – 02:45 PMPURPOSE: Lung function declines with age. However, the rate of decline in forced expiratory volume in 1 second (FEV1), in the healthy population and predictors of this change in elderly community-dwellers without established disease is unknown.METHODS: We analysed data from 4656 adult participants aged 50 years and older from the English Longitudinal Study of Ageing, with full spirometry, in four years follow-up. A random-coefficient model was used to assess potential predictors of both FEV1 and their changes over time.RESULTS: The mean (±SE) rate of change in FEV1 was a decline of 47± 14 ml per year and 95% confidence interval [CI, 20 to 74]. The rate of decline in mean FEV1 in smokers was 299 ml per year [CI, 238 to 339] compared to non-smokers. Participants with cardiovascular disease had decline in mean FEV1 was 45 ml per year [CI, 11 to 79], history of breathlessness using the Medical Research Council scale was 78 ml per year [CI, 61 to 95] and history of phlegm was 85 ml per year [CI 42 to 128]. Participants with self-reported good health have increased in mean FEV1 92 ml per year [CI 54 to 128] compared to poorer health status and those with high haemoglobin with greater FEV1 6 ml per year [CI, 1 to 11] compared with low haemoglobin. In addition, participants with low C-reactive protein showed a decline in mean FEV1 by 5 ml per year [CI, 3 to 7] and low in Fibrinogen count showed a decline in mean FEV1 by 2 ml per year (not statistically significant) [CI, 28 to -24].CONCLUSIONS: The rate of decline in FEV1 in elderly healthy participants was high, with increased rates of decline in current smokers, those with history of breathlessness and mucous secretion.CLINICAL IMPLICATIONS: The rate of lung function decline in older people without established lung disease was very high. Current smokers should be advised to stop smoking and attend smoking cessation class in the community.DISCLOSURE: The following authors have nothing to disclose: Abebaw Yohannes, Gindo TampubolonNo Product/Research Disclosure InformationManchester Metropolitan University, Manchester, United Kingdom. HubMed – rehab


Pulmonary-Specific Intermountain Risk Score: Derivation and Validation of Risk Scores for Mortality Among Patients Undergoing Pulmonary Function Testing.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 785A
Horne B, Hegewald M, Muhlestein J, Huggins E, May H, Bair T, Anderson J

SESSION TYPE: Physiology/PFTs/ Rehabilitation IPRESENTED ON: Sunday, October 21, 2012 at 01:15 PM – 02:45 PMPURPOSE: Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) are known predictors of coronary heart disease and mortality. Previously we created and validated risk scores using all risk information in the basic metabolic profile (BMP) and the complete blood count (CBC). This study created and tested risk scores for mortality combining BMP, CBC, and pulmonary function testing (PFT) data.METHODS: Of those patients evaluated by PFT between October, 2002, and October, 2011, 70% (females: n=2,056; males: n=1,754) were included in deriving risk scores using the FVC, body mass index, age, and laboratory factors (similar models using the FEV1 instead of FVC were also created). Sex-specific risk scores included BMP and PFT data (pulmonary BMP Risk Score, pBRS) or BMP, CBC, and PFT (pulmonary Intermountain Risk Score, pIMRS). Cox regression was used to determine multivariable contributions of independent variables to the risk of all-cause mortality following PFT. A scalar risk score was then created using the regression beta-coefficients for each variable. The other 30% of PFT patients were held aside as an internal independent set of patients for validating the risk scores (females: n=887, males: n=741).RESULTS: In the derivation and validation samples, females averaged 59.4±15.4 years and 58.6±14.9 years of age, respectively, and males were 60.2±15.2 years and 60.5±15.0 years of age. For pBRS in females, 6.9% of patients died (derivation) and 7.9% (validation), and areas under the curve (AUC) were 0.815 and 0.806, respectively. Mortality among males was 12.1% in derivation and 10.1% in validation patients, with AUCs of 0.734 and 0.731, respectively, for pBRS. CBC data were available on half of patients, with pIMRS AUCs of 0.835 and 0.757 for females in derivation and validation, and AUCs of 0.755 and 0.699 among males, respectively. Risk scores utilizing FEV1 instead of FVC had slightly better AUCs for males.CONCLUSIONS: Risk scores encapsulating the risk of mortality using PFT and laboratory variables are highly predictive in both females and males, but especially among females. Simple to compute using electronic resources and relatively inexpensive compared to most risk scores, these laboratory-based tools may assist in risk stratification for pulmonary patients undergoing PFT.CLINICAL IMPLICATIONS: Clinical risk stratification for PFT patients may be enhanced through the use of risk scores utilizing the BMP and CBC laboratory measurements.DISCLOSURE: Benjamin Horne: Grant monies (from industry related sources): GlaxoSmithKline clinical research supportMatthew Hegewald: Grant monies (from industry related sources): GlaxoSmithKline clinical research supportJoseph Muhlestein: Grant monies (from industry related sources): GlaxoSmithKline clinical research supportElizabeth Huggins: Grant monies (from industry related sources): GlaxoSmithKline clinical research supportHeidi May: Grant monies (from industry related sources): GlaxoSmithKline clinical research supportTami Bair: Grant monies (from industry related sources): GlaxoSmithKline clinical research supportJeffrey Anderson: Grant monies (from industry related sources): GlaxoSmithKline clinical research supportNo Product/Research Disclosure InformationIntermountain Heart Institute, Salt Lake City, UT. HubMed – rehab