Risk for sudden cardiac death associated with marathon running.
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Death, Sudden, Cardiac↗
Biomedical subjects
M W Rich
Publications and source records attributed to M W Rich.
A trial of increased access to primary care.
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Continuity of Patient Care↗
Effect of a multidisciplinary intervention on medication compliance in elderly patients with congestive heart failure.
PURPOSE: The objectives of this investigation were to prospectively assess medication compliance rates in elderly patients with congestive heart failure, to identify factors associated with reduced compliance, and to evaluate the effect of a multidisciplinary treatment approach on medication adherence. PATIENTS AND METHODS: A total of 156 patients > or = 70 years of age (mean, 79.4 +/- 6.0; 67% female, 65% nonwhite) hospitalized with congestive heart failure were evaluated prospectively. Prior to discharge, patients were randomized to the study intervention (n = 80) or conventional care (n = 76). The intervention consisted of comprehensive patient education, dietary and social service consultations, medication review, and intensive postdischarge follow-up. Detailed data were collected on all prescribed medications at the time of discharge, and compliance was assessed by pill counts 30 +/- 2 days later. RESULTS: The overall compliance rate during the first 30 days after discharge was 84.6 +/- 15.1% (range, 23.1-100%). Compliance was 87.9 +/- 12.0% in patients randomized to the study intervention, compared with 81.1 +/- 17.2% in the control group (P = 0.003). A compliance rate of > or = 80% was achieved by 85.0% of the treatment group versus 69.7% of the control group (P = 0.036). By multivariate analysis, assignment to the treatment group was the strongest independent predictor of compliance (P = 0.008). Other variables included in the model were Caucasian race (P = 0.044) and not living alone (P = 0.09). CONCLUSIONS: A multidisciplinary treatment strategy is associated with improved medication compliance during the first 30 days following hospital discharge in elderly patients with congestive heart failure. Improved compliance may contribute to improved outcomes in these patients.
Aged↗
Iatrogenic congestive heart failure in older adults: clinical course and prognosis.
OBJECTIVE: To determine the prevalence, risk factors, clinical course, and prognosis of iatrogenic congestive heart failure in older patients. DESIGN AND SETTING: Prospective observational study at a university teaching hospital. PARTICIPANTS: A total of 401 patients 70 years of age or older hospitalized with congestive heart failure. The mean age was 80 +/- 6 years; 59% were female, and 65% were white. MEASUREMENTS: Comprehensive data, including an assessment of the etiology and precipitating factors leading to the development of heart failure, were collected at the time of diagnosis. Iatrogenic heart failure was defined as heart failure precipitated by medications or excessive fluid administration, or occurring as a procedural complication. All patients were followed for 1 year, and the primary outcome measure was total mortality. RESULTS: Using strict criteria, 28 patients (7.0%) were considered to have iatrogenic heart failure. Compared with noniatrogenic patients (n = 373), iatrogenic cases had less severe premorbid cardiac disease but more marked noncardiac disability and longer hospital stays (29 +/- 24 vs 13 +/- 12 days, P < .001). Hospital mortality was 32% in iatrogenic heart failure patients compared with 9% in noniatrogenic cases (P < .001). Cumulative mortality at 1 year was 68% in iatrogenic patients versus 39% in noniatrogenic patients (P < .01). Using a Cox proportional hazards model, iatrogenic congestive heart failure was associated with a relative mortality risk during follow-up of 2.5 (95% confidence interval 1.5-4.3) after adjusting for age, sex, prior history of heart failure, New York Heart Association class, diabetes mellitus, systolic blood pressure, hemoglobin, blood urea nitrogen, and serum albumin. CONCLUSIONS: Frail, debilitated older patients are at increased risk for developing iatrogenic heart failure, even in the absence of clinically evident cardiac disease. In this population, iatrogenic heart failure serves as a marker for poor short- and long-term prognosis, but further study is required to determine the optimal approach to management of these patients.
Aged↗
Management of acute myocardial infarction in the elderly.
The prevalence of myocardial infarction (MI) is high among the elderly population. Many of the physiological and morphological changes attributable to 'normal' aging predispose older adults to cardiovascular instability. The incidence of both MIs and their associated morbidity and mortality increase with aging. Older MI patients may therefore derive substantial benefit from appropriately selected therapeutic intervention. In fact, given the high morbidity and mortality associated with MI in the elderly, aggressive therapeutic strategies may be particularly warranted. There are a number of age-related cardiovascular changes that contribute to the increasing incidence of MI as adults age. However, age itself is not a contraindication to aggressive therapy. Common MI management options include invasive and pharmaceutical strategies. The relative advantages of angioplasty and thrombolytics must be considered. Other drugs used in the treatment of MI include beta-blockers, ACE inhibitors, nitrates, aspirin, anticoagulants, magnesium, antiarrhythmics and calcium antagonists. Significant peri-infarction complications, including heart failure, hypotension, arrhythmias, myocardial rupture and cardiogenic shock, often occur in older adults. Age-specific management strategies for these complications are reviewed.
Acute Disease↗
Drug-induced lupus. The list of culprits grows.
More than 70 medications have been implicated as a cause of drug-induced lupus. The condition most commonly manifests with arthralgias and fever. The most important laboratory feature is an elevated antinuclear antibody titer, which often corresponds to the presence of antihistone antibodies. Fortunately, the course of drug-induced lupus is more benign than that of idiopathic systemic lupus erythematosus. Clinical resolution generally occurs after withdrawal of the offending agent. The patient described here exemplifies the importance of maintaining a heightened awareness of this uncommon disorder. For him, delayed diagnosis of drug-induced lupus resulted in prolonged discomfort, restriction of daily activities, and unnecessary therapeutic intervention.
Aged↗
Therapy for acute myocardial infarction.
Acute myocardial infarction occurs with increasing frequency with advancing age, and older patients with acute MI are at increased risk of a variety of complications including congestive heart failure, arrhythmias and conduction disturbances, myocardial rupture, cardiogenic shock, and death. Older patients thus comprise a high-risk subgroup of the MI population who consequently may derive substantial benefit from appropriately selected therapeutic interventions. At the same time, many interventions are associated with increased risks in the elderly, so that individualization of treatment is essential in all patients. Optimal therapy is thus based on a careful risk-benefit assessment of the available treatment options in conjunction with information on patient preferences and other relevant factors. Though many therapeutic trials of patients with acute MI have either excluded elderly patients or enrolled too few older subjects to permit definitive conclusions, sufficient data are available to make specific recommendations in several areas. As shown in Table 6, therapies of proven value in the acute-phase treatment of elderly patients with MI include aspirin and thrombolysis. Intravenous beta blockers are likely to be of benefit as well, and long-term oral beta blockade after MI is clearly beneficial. ACE inhibitors are of proven value in the long-term management of patients with left ventricular dysfunction (ejection fraction less than 40%), but initiation of an ACE inhibitor should probably be delayed for 48 to 72 hours in most cases. The role of other agents including nitrates, magnesium, diltiazem, and verapamil requires further clarification, but anti-arrhythmic drugs and dihydropyridine calcium antagonists should generally be avoided in the absence of specific indications for their use. Finally, though the role of catheterization and revascularization in elderly patients with acute MI requires additional study, current data indicate that age alone should not be considered a contraindication to these procedures. As the age of the population continues to rise, the number of older patients at risk of acute MI also increases. Though progressively more sophisticated interventions may ultimately result in sizable reductions in post-MI morbidity and mortality, given the high risk of adverse outcomes in this population the best treatment is prevention. Thus, the greatest potential for the future, as well as the greatest challenge, is to develop more effective strategies for preventing atherosclerosis and for conquering the epidemic of coronary heart disease.
Adrenergic beta-Antagonists↗
A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure.
BACKGROUND: Congestive heart failure is the most common indication for admission to the hospital among older adults. Behavioral factors, such as poor compliance with treatment, frequently contribute to exacerbations of heart failure, a fact suggesting that many admissions could be prevented. METHODS: We conducted a prospective, randomized trial of the effect of a nurse-directed, multidisciplinary intervention on rates of readmission within 90 days of hospital discharge, quality of life, and costs of care for high-risk patients 70 years of age or older who were hospitalized with congestive heart failure. The intervention consisted of comprehensive education of the patient and family, a prescribed diet, social-service consultation and planning for an early discharge, a review of medications, and intensive follow-up. RESULTS: Survival for 90 days without readmission, the primary outcome measure, was achieved in 91 of the 142 patients in the treatment group, as compared with 75 of the 140 patients in the control group, who received conventional care (P = 0.09). There were 94 readmissions in the control group and 53 in the treatment group (risk ratio, 0.56; P = 0.02). The number of readmissions for heart failure was reduced by 56.2 percent in the treatment group (54 vs. 24, P = 0.04), whereas the number of readmissions for other causes was reduced by 28.5 percent (40 vs. 29, P not significant). In the control group, 23 patients (16.4 percent) had more than one readmission, as compared with 9 patients (6.3 percent) in the treatment group (risk ratio, 0.39; P = 0.01). In a subgroup of 126 patients, quality-of-life scores at 90 days improved more from base line for patients in the treatment group (P = 0.001). Because of the reduction in hospital admissions, the overall cost of care was $460 less per patient in the treatment group. CONCLUSIONS: A nurse-directed, multidisciplinary intervention can improve quality of life and reduce hospital use and medical costs for elderly patients with congestive heart failure.
Aged↗
Association of depression with reduced heart rate variability in coronary artery disease.
Decreased heart rate (HR) variability is an independent risk factor for mortality in cardiac populations. Clinical depression has also been associated with adverse outcomes in patients with coronary artery disease (CAD). This study tests the hypothesis that depressed patients with CAD have decreased HR variability compared with nondepressed CAD patients. Nineteen patients with angiographically documented CAD and either major or minor depression were compared with a sample of nondepressed CAD patients according to age, sex, and smoking status. All patients underwent 24-hour Holter monitoring, and the standard deviation of all normal-to-normal intervals was used as the primary index of HR variability. HR variability was significantly lower in depressed than nondepressed patients (90 +/- 35 vs 117 +/- 26 ms; p < or = 0.01), even after adjusting for relevant covariates. Thus, decreased HR variability may help explain the increased risk for cardiac mortality and morbidity in depressed CAD patients.
Aged↗
Prognosis of patients > or = 70 years of age with non-Q-wave acute myocardial infarction compared with younger patients with similar infarcts and with patients > or = 70 years of age with Q-wave acute myocardial infarction.
In this study, 70 patients > or = 70 years of age admitted to the coronary care unit with non-Q-wave acute myocardial infarction (AMI) were followed prospectively for 1 year, and the clinical course in these patients was compared with that in 61 patients < 70 years with non-Q-wave AMI and 56 patients > or = 70 years with Q-wave AMI. Compared with the younger patients with non-Q-wave AMI, older patients were more likely to develop atrial fibrillation (23% vs 8%; p < 0.05) and congestive heart failure (53% vs 30%; p < 0.01), and less likely to receive thrombolytic therapy (9% vs 28%; p < 0.01), cardiac catheterization (41% vs 72%; p < 0.01), and coronary angioplasty (20% vs 39%; p < 0.05). Hospital mortality did not differ significantly between older and younger non-Q-wave AMI patients (10% vs 3%), but 1-year mortality was higher in the elderly (36% vs 16%; p = 0.02). Elderly patients with Q-wave AMI had more in-hospital complications, including death (25% vs 10%; p < 0.05), than elderly patients with non-Q-wave AMI. In contrast, postdischarge mortality was higher in elderly patients with non-Q-wave AMI, so that total mortality at 1 year was similar in the 2 groups. Overall, elderly patients with non-Q-wave AMI accounted for 62% of all deaths occurring during the first year after discharge (relative risk 2.6 compared with other groups; p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Age Factors↗
Stability of index of heart rate variability in patients with congestive heart failure.
Stability of indexes of heart rate variability (HRV) has not been established for patients with congestive heart failure (CHF). We therefore measured Holter-derived HRV indexes in 17 stable patients with class II or III CHF (mean age 52 +/- 9 yr; 5 men and 12 women) on two occasions 2 weeks apart. Stability was determined via paired t tests and intraclass correlation coefficients (ICCs). ICCs for time domain indexes of HRV were > or = 0.86 for 24 hours, > or = 0.73 for daytime, and > or = 0.72 for nighttime indexes reflecting longer-term variability. After log transformation, ICCs for the short-term 24-hour measures PNN50 (percentage of N-N intervals > 50 msec different from preceding interval) and RMSSD (the root mean square of successive differences) were 0.85 and 0.67. ICCs for frequency domain indexes of HRV were 0.86 to 0.91. We compared HRV indexes, serum norepinephrine (NE) levels, and respiratory sinus arrhythmia induced by paced breathing, also considered measures of autonomic tone. NE correlated weakly with average R-R interval, and all indexes of HRV reflecting longer-term variation (r = -0.32 to r = -0.50). ICC was 0.78 for NE. Respiratory sinus arrhythmia was highly repeatable (ICC = 0.70) but did not correlate significantly with NE or any measure of HRV. We conclude that time and frequency domain indexes of HRV are stable over time in CHF patients without intervening events.
Adult↗
Major depression and medication adherence in elderly patients with coronary artery disease.
Little is known about the effects of depression on adherence to medical treatment regimens in older patients with chronic medical illnesses. Poor adherence may explain the increased risk of medical morbidity and mortality found in depressed medical patients. Ten of 55 patients over the age of 64 with coronary artery disease met the criteria for major depression from the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987). All patients were prescribed a twice-per-day regimen of low dose aspirin to reduce their risk for myocardial infarction. Medication adherence was assessed for 3 weeks by an unobtrusive electronic monitoring device. Depressed patients adhered to the regimen on 45% of days, but nondepressed patients, on 69% (p < .02). Thus, major depression is associated with poor adherence to a regimen of prophylactic aspirin after the diagnosis of coronary artery disease.
Aged↗
A randomized comparison of intravenous amrinone versus dobutamine in older patients with decompensated congestive heart failure.
OBJECTIVE: To compare the hemodynamic effects of amrinone and dobutamine in patients 75 years of age or older who have severe congestive heart failure requiring invasive hemodynamic monitoring and inotropic support. DESIGN: Prospective, randomized, double-blind clinical trial. SETTING: Coronary care unit of a university teaching hospital. PARTICIPANTS: Fourteen patients > or = 75 years of age (mean 80.3 +/- 5.7 years) with refractory New York Heart Association class IV congestive heart failure. All patients had a cardiac index < 2.5 L/min/M2 (mean 1.8 +/- 0.3 L/min/M2), pulmonary capillary wedge pressure > or = 18 mm Hg (mean 26 +/- 10 mm Hg), and left ventricular ejection fraction < 40% (mean 26 +/- 10%). INTERVENTION: Patients were randomly assigned to treatment with 2-hour infusions of amrinone (n = 7) or dobutamine (n = 7) at fixed dosages of 5 and 10 micrograms/kg/min. MEASUREMENTS: Complete hemodynamic data were obtained at baseline and after each 2-hour medication infusion. Transthoracic two-dimensional echocardiography was performed at baseline and after the 10 micrograms/kg/min medication dose. The primary analysis compared the effects of the two drugs on cardiac index and stroke volume index at each of the two dosages. RESULTS: Both amrinone and dobutamine had salutary hemodynamic effects, as indicated by improvements in cardiac index, stroke volume index, pulmonary capillary wedge pressure, and systemic vascular resistance (all P < .05 except effect of amrinone on stroke index and wedge pressure). Although the overall hemodynamic effects of amrinone and dobutamine were similar, stroke volume index was higher with dobutamine at the 10 micrograms/kg/min dose (35 +/- 7 ml/M2 vs 26 +/- 6 mL/M2; P = .045). Two dobutamine patients were withdrawn from the study after the 5 micrograms/kg/min dose due to adverse effects (tachycardia, increased ventricular ectopy). One additional patient in each group was noted to have ventricular arrhythmias not requiring termination of the protocol. CONCLUSIONS: Both amrinone and dobutamine are efficacious in improving hemodynamics in older patients with severe congestive heart failure caused by left ventricular contractile dysfunction. Despite the effect of aging on beta-adrenergic responsiveness, dobutamine is at least as effective as amrinone but may be associated with a higher incidence of arrhythmic side effects.
Aged↗
Can hydrochlorothiazide cause lupus?
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Adult↗
Respiratory dyskinesia. An underrecognized phenomenon.
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Aged↗
'Streptococcus milleri' septicemia in a patient with colorectal carcinoma.
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Adenocarcinoma↗
Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study.
OBJECTIVE: To determine the feasibility and potential impact of a non-pharmacologic multidisciplinary intervention for reducing hospital readmissions in elderly patients with congestive heart failure. DESIGN: Prospective, randomized clinical trial, with 2:1 assignment to the study intervention or usual care. SETTING: 550-bed secondary and tertiary care university teaching hospital. PATIENTS AND PARTICIPANTS: 98 patients > or = 70 years of age (mean 79 +/- 6 years) admitted with documented congestive heart failure. INTERVENTIONS: Comprehensive multidisciplinary treatment strategy consisting of intensive teaching by a geriatric cardiac nurse, a detailed review of medications by a geriatric cardiologist with specific recommendations designed to improve medication compliance and reduce side effects, early consultation with social services to facilitate discharge planning, dietary teaching by a hospital dietician, and close follow-up after discharge by home care and the study team. MEASUREMENTS AND MAIN RESULTS: All patients were followed for 90 days after initial hospital discharge. The primary study endpoints were rehospitalization within the 90-day interval and the cumulative number of days hospitalized during follow-up. The 90-day readmission rate was 33.3% (21.7%-44.9%) for the patients receiving the study intervention (n = 63) compared with 45.7% (29.2%-62.2%) for the control patients (n = 35). The mean number of days hospitalized was 4.3 +/- 1.1 (2.1-6.5) for the treated patients vs 5.7 +/- 2.0 (1.8-9.6) for the usual-care patients. In a prospectively defined subgroup of patients at intermediate risk for readmission (n = 61), readmissions were reduced by 42.2% (from 47.6% to 27.5%; p = 0.10), and the average number of hospital days during follow-up decreased from 6.7 +/- 3.2 days to 3.2 +/- 1.2 days (p = NS). CONCLUSIONS: These pilot data suggest that a comprehensive, multidisciplinary approach to reducing repetitive hospitalizations in elderly patients with congestive heart failure may lead to a reduction in readmissions and hospital days, particularly in patients at moderate risk for early rehospitalization. Further evaluation of this treatment strategy, including an assessment of the cost-effectiveness, is warranted.
Aged↗
Ventricular tachycardia and psychiatric depression in patients with coronary artery disease.
PURPOSE: The purpose of this study was to examine the relationship between psychiatric depression and ventricular arrhythmias in patients with coronary artery disease (CAD). The hypothesis was that depressed patients with CAD would have a higher prevalence of ventricular tachycardia (VT) than nondepressed patients with CAD. PATIENTS AND METHODS: One hundred three patients who were found to have significant CAD by elective diagnostic cardiac catheterization were administered a standardized psychiatric interview and underwent 24-hour Holter monitoring. RESULTS: Twenty-one patients (20%) met the criteria for either major or minor depression. There were no significant differences between depressed and nondepressed patients with CAD in severity of CAD or in ventricular function. Five (23.8%) of the depressed patients and three (3.7%) of the nondepressed patients exhibited episodes of VT during 24 hours of Holter monitoring (p < 0.008). This difference remained significant even after controlling for relevant covariates. CONCLUSIONS: We conclude that there is a higher prevalence of VT among patients with CAD and depression than among those CAD patients without depression. This may help to explain the increased risk for cardiac mortality in depressed patients with CAD.
Aged↗