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Rehabilitation at Home Using Mobile Health for Older Adults Hospitalized for Ischemic Heart Disease: The RESILIENT Randomized Clinical Trial
Dodson, John A; Adhikari, Samrachana; Schoenthaler, Antoinette; Hochman, Judith S; Sweeney, Greg; George, Barbara; Marzo, Kevin; Jennings, Lee A; Kovell, Lara C; Vorsanger, Matthew; Pena, Stephanie; Meng, Yuchen; Varghese, Ashwini; Johanek, Camila; Rojas, Michelle; McConnell, Riley; Whiteson, Jonathan; Troxel, Andrea B
IMPORTANCE/UNASSIGNED:Among older adults with ischemic heart disease, participation in traditional ambulatory cardiac rehabilitation (CR) remains low. While mobile health CR (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments to technology use may limit uptake, and efficacy data are currently lacking. OBJECTIVE/UNASSIGNED:To test whether mHealth-CR improves functional capacity in older adults. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:The RESILIENT phase 2, multicenter, randomized clinical trial recruited patients aged 65 years or older with ischemic heart disease (defined as a hospital visit for myocardial infarction or coronary revascularization) from 5 academic hospitals in New York, Connecticut, and Massachusetts between January 9, 2020, and April 22, 2024. INTERVENTION/UNASSIGNED:Participants were randomized 3:1 to mHealth-CR or usual care. mHealth-CR consisted of commercially available software delivered on a tablet computer, coupled with remote monitoring and weekly exercise therapist telephone calls, delivered over a 3-month duration. As RESILIENT was a trial conducted in a routine care setting to inform decision-making, participants in both arms were also allowed to receive traditional CR at their cardiologist's discretion. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was change from baseline to 3 months in functional capacity, measured by 6-minute walk distance (6MWD). Secondary outcomes were health status (12-Item Short Form Health Survey [SF-12]), residual angina, and impairment in activities of daily living. RESULTS/UNASSIGNED:A total of 400 participants (median age, 71.0 years [range, 65.0-91.0 years]; 291 [72.8%] male) were randomized to mHealth-CR (n = 298) or usual care (n = 102) and included in the intention-to-treat analysis. Of those, 356 participants (89.0%) returned in person for 6MWD assessment at 3 months. For the primary outcome, there was no adjusted difference in 6MWD between participants receiving mHealth-CR vs usual care (15.6 m; 95% CI, -0.3 to 31.5 m; P = .06). Among subgroups, there was an improvement in 6MWD among women (36.6 m; 95% CI, 8.7-64.4 m). There were no differences in any secondary outcomes between groups (eg, adjusted difference in SF-12 physical component scores at 3 months: -1.9 points; 95% CI, -3.9 to 0.2 points). Based on inverse propensity score weighting, there was no effect of mHealth-CR on 6MWD among those who did not attend traditional CR (25.7 m; 95% CI, -8.7 to 60.2 m). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this randomized clinical trial of mHealth-CR vs usual care, mHealth-CR did not significantly increase 6MWD or result in improvements in secondary outcomes. The findings suggest the older adult population may require more age-tailored mHealth strategies to effectively improve outcomes. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03978130.
PMID: 39775808
ISSN: 2574-3805
CID: 5778362
Adult congenital heart disease care in a municipal public health system
Tinsay, Maria Andrea Francesca M; Halpern, Dan G; Feinberg, Jodi L; Vorsanger, Matthew; Keller, Norma; Small, Adam J
Specialty care is associated with improved outcomes for adults with adult CHD and must be extended to the underserved. A retrospective cohort study was performed to describe the provision of care to adult CHD patients in America's largest municipal public health system including patient demographics, diagnostic and therapeutic procedures, and adherence to guideline-recommended surveillance. We identified 229 adult CHD patients aged >18 years through electronic medical records. The most common diagnoses were atrial septal defect, ventricular septal defect, patent ductus arteriosus, and valvular pulmonary stenosis. In total, 65% had moderate or greater anatomic complexity. A large number of patients were uninsured (45%), non-white (96%), and non-English speaking (44%). One hundred forty-six patients (64%) presented with unrepaired primary defects. Fifty eight patients underwent primary repair during the study period; 48 of those repairs were surgical and 10 were transcatheter. Collaboration with an affiliated Comprehensive Care Center was utilised for 28% of patients. A high proportion of patients received adult CHD speciality visits (78%), echocardiograms (66%), and electrocardiograms (56%) at the guideline-recommended frequency throughout the study period. There was no significant difference in the rate of adherence to guideline-recommended surveillance based on insurance status, race/ethnicity, or primary language status. The proportion of patients who had guideline-recommended adult CHD visits, echocardiograms, and electrocardiograms was significantly lower for those with more advanced physiological stages. These results can inform the provision of adult CHD care in other public health system settings.
PMID: 37909409
ISSN: 1467-1107
CID: 5614462
Positional Right Ventricular Obstruction in Pectus Excavatum
Underwood, Katherine; Vorsanger, Matthew; Saric, Muhamed; Skolnick, Adam H
Pectus excavatum is one of the most common congenital chest wall deformities. The degree of sternal depression, which may result in compression of the right heart by the chest wall, is variable. While typically asymptomatic, there are various symptoms that can result from severe pectus excavatum. We report on a patient with severe pectus excavatum leading to dynamic obstruction of the right ventricular outflow tract in the seated position.
PMID: 28214505
ISSN: 1879-1913
CID: 2451732
Diagnosing myocardial infarction in a ventricular paced rhythm [Meeting Abstract]
Vani, A; Yokomizo, L; Vorsanger, M
LEARNING OBJECTIVE #1: Diagnose myocardial infarction (MI) in patients with ventricular-paced rhythms by using the Sgarbossa criteria LEARNING OBJECTIVE #2: Recognize the limitations of the Sgarbossa criteria CASE: A 93 year-old Polish man with complete heart block, treated with a dualchamber pacemaker, presented with acute onset chest pain to the emergency room of our institution. His electrocardiogram (ECG) showed sinus rhythm with atrial sensing and right ventricular pacing. There were >1mm ST segment depressions in leads V3-V5, leads in which the QRS complex was predominantly negative. His initial troponin I level was 1.9 ng/mL. Due to suspicion of an acute coronary plaque rupture, the patient was referred for urgent coronary angiography, which revealed severe stenosis of the distal right coronary artery, mid posterior descending artery, left main coronary artery, mid left anterior descending artery, and the ostial left circumflex artery. An intra-aortic balloon pump was placed to maintain coronary perfusion. The patient subsequently underwent successful coronary artery bypass grafting, with saphenous vein grafts placed on the left anterior descending artery, first obtusemarginal, and posterior descending artery, and was discharged home in stable condition. IMPACT: This case validates the application of the Sgarbossa criteria to the ECG of ventricular-paced patients to diagnose acute MI. It also highlights significant limitations of the Sgarbossa criteria and suggests a need to develop a more comprehensive system to allow for greater sensitivity in diagnosing acute MI in ventricular-paced patients. DISCUSSION: Interpreting the ECG in the setting of a left bundle branch block (LBBB) or ventricular-paced rhythm can be challenging. Depolarization and repolarization through the ventricular myocardial tissue, instead of the specialized conduction system, produces STsegment changes discordant to the major vector of the QRS complex, which may obscure underlying ischemic ST changes. Sgarbossa et al. found that ST elevations >5mm in leads with predominantly negative QRS complexes, ST elevations >1mm in leads with predominantly positive QRS complexes, or ST depressions >1mmin leads V1- V3 were all highly specific for an acute MI, based on a 17 patient cohort from the GUSTO-1 trial. There are significant limitations of the Sgarbossa criteria, however. It has not been validated for use in patients with biventricular pacing and the criteria are specific, but not sensitive. Other scoring systems exist, although they have been validated in patients with a LBBB, not in ventricularpaced patients. Subsequent research with a larger patient cohort is needed, due to the increasing number of ventricular-paced patients in our aging population and the importance of the emergency room ECG to triage patients with acute MI for immediate fibrinolytic therapy or percutaneous coronary intervention
EMBASE:615580810
ISSN: 0884-8734
CID: 2554322
Impact Of A Brief, Blended Curriculum On Point-Of-Care Echocardiography For Internal Medicine Residents [Meeting Abstract]
Adelman, MH; Patrawalla, P; Lee, MH; Barnett, MP; Vorsanger, MH; Barghash, M; Blackstock, U; Kaufman, B; Sauthoff, H; Skolnick, AH
ISI:000400372500108
ISSN: 1535-4970
CID: 2591582
Cardiovascular Effects of the New Weight Loss Agents
Vorsanger, Matthew H; Subramanyam, Pritha; Weintraub, Howard S; Lamm, Steven H; Underberg, James A; Gianos, Eugenia; Goldberg, Ira J; Schwartzbard, Arthur Z
The global obesity epidemic and its impact on cardiovascular outcomes is a topic of ongoing debate and investigation in the cardiology community. It is well known that obesity is associated with multiple cardiovascular risk factors. Although life-style changes are the first line of therapy, they are often insufficient in achieving weight loss goals. Liraglutide, naltrexone/bupropion, and phentermine/topiramate are new agents that have been recently approved to treat obesity, but their effects on cardiovascular risk factors and outcomes are not well described. This review summarizes data currently available for these novel agents regarding drug safety, effects on major cardiovascular risk factors, impact on cardiovascular outcomes, outcomes research that is currently in progress, and areas of uncertainty. Given the impact of obesity on cardiovascular health, there is a pressing clinical need to understand the effects of these agents beyond weight loss alone.
PMID: 27539178
ISSN: 1558-3597
CID: 2219452
INTERVENTIONS TO PROMOTE RESIDENT WELLNESS: A NATIONAL SURVEY OF RESIDENCY PROGRAM DIRECTORS [Meeting Abstract]
Bhagat, Rajiv; Cocks, Patrick M; Vorsanger, Matthew
ISI:000392201600351
ISSN: 1525-1497
CID: 2482062
Transient right bundle branch block: A rare manifestation in cardiac contusion
Subramanyam, Pritha; Devanabanda, Arvind Reddy; Slater, William R; Vorsanger, Matthew
Transient right bundle branch block following blunt cardiac injury is a known but under-recognized manifestation of cardiac contusion. The first case documented in the medical literature occurred in 1952 in a 22-year-old man who was thrown from a motorcycle. Due to their relatively anterior location, the right ventricle and right bundle branch are at particular risk of injury in contusion. We present here a case in which a 24-year-old man suffered a blunt chest trauma leading to a right bundle branch block and elevated troponin levels, consistent with cardiac contusion. His conduction system abnormalities rapidly resolved and he recovered completely, with no clinical sequelae. <Learning objective: Cardiac contusion is a heterogeneous syndrome with widely variable clinical manifestations and severity. Transient right bundle branch block has been described as a self-limited and benign manifestation of cardiac contusion. This case highlights the need for a better understanding of the natural history and predictors of serious complications of cardiac contusion, which can aid in determining appropriate diagnostic studies, risk stratification, and treatment.>.
PMCID:6280947
PMID: 30546623
ISSN: 1878-5409
CID: 3556362
COMPARATIVE SAFETY OF INTRAVENOUS NICARDIPINE INFUSION IN PATIENTS WITH AND WITHOUT SYSTOLIC DYSFUNCTION [Meeting Abstract]
Alviar, Carlos L; Singh, Prabhjot; Vorsanger, Matthew; Volodarskiy, Alexander; Lee, David; Geisler, Benjamin; Roswell, Robert
ISI:000375328801195
ISSN: 1558-3597
CID: 2793582
New Treatment Approaches for Dyslipidemia and its Management
Vorsanger, M; Underberg, J A
The field of lipidology is evolving rapidly. Two novel medications have recently been approved for use in homozygous familial hypercholesterolemia (HoFH); the Apolipoprotein B (Apo B) mRNA antisense oligonucleotide (ASO), mipomersen (Kynamro) and the microsomal triglyceride transfer protein (MTP) inhibitor, lomitapide (Juxtapid). Equally important have been the disappointments in cholesterol research; the halting of further investigation into the cholesteryl ester transfer protein (CETP) inhibitor dalcetrapib, yet two others remain in development. The failure of the combination of extended release niacin and laropiprant to show benefit when combined with statin therapy has lead to the discontinuation of this product in Europe. Perhaps one of the most exciting avenues of future research is into the inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9). 2013 Springer Science+Business Media New York
EMBASE:2013581253
ISSN: 1932-9520
CID: 549762