OBJECTIVES:(1) Characterize the initial clinical characteristics and long-term outcomes of smallpox vaccine-associated hypersensitivity myocarditis and pericarditis (MP) in United States service members. (2) Describe the process of case identification and adjudication using the 2003 CDC nationally defined myocarditis/pericarditis epidemiologic case definitions to include consideration of case-specific diversity and evolving evidence.BACKGROUND:Between 2002 and 2016, 2.546 million service members received a smallpox Vaccinia vaccine. Acute MP is associated with vaccinia, but the long-term outcomes have not been studied.METHODS:Records of vaccinia-associated MP reported to the Vaccine Adverse Event Reporting System by vaccination date were adjudicated using the 2003 MP epidemiologic case definitions for inclusion in a retrospective observational cohort study. Descriptive statistics of clinical characteristics, presentation, cardiac complications, and time course of clinical and cardiac recovery were calculated with comparisons by gender, diagnosis and time to recovery.RESULTS:Out of over 5000 adverse event reports, 348 MP cases who survived the acute illness, including 276 myocarditis (99.6% probable/confirmed) and 72 pericarditis (29.2% probable/confirmed), were adjudicated for inclusion in the long-term follow-up. Demographics included a median age of 24 years (IQR 21,30) and male predominance (96%). Compared to background military population, the myocarditis and pericarditis cohort had a higher percentage of white males by 8.2% (95% CI: 5.6, 10.0) and age <40 years by 4.2% (95% CI: 1.7,5.8). Long-term follow-up documented full recovery in 267/306 (87.3%) with 74.9% recovered in less than a year (median ~3 months). Among patients with myocarditis, the percentage who had a delayed time to recovery at time of last follow-up was 12.8% (95% CI: 2.1,24.7) higher in those with an acute left ventricular ejection fraction (EF) of ≤50% and 13.5% (95% CI: 2.4,25.7) higher in those with hypokinesis. Patient complications included 6 ventricular arrhythmias (2 received implanted defibrillators) and 14 with atrial arrhythmias (2 received radiofrequency ablation). Three of 6 patients (50%) diagnosed with cardiomyopathy had clinical recovery at their last follow-up date.CONCLUSIONS:Hypersensitivity myocarditis/pericarditis following the smallpox vaccine is associated with full clinical and functional ventricular recovery in over 87% of cases (74.9% <1 year). A minority of MP cases experienced prolonged or incomplete recovery beyond 1 year.

Heart failure represents a growing chronic medical condition with major implications on patient morbidity, mortality, and cost to health care systems. In this article, the heart failure syndrome is reviewed from a perspective of diagnosis and management, with updated therapeutic options reflected in major guidelines published since this topic was last reviewed in Primary Care Clinics in Office Practice in 2013. An emphasis is placed on the use of the American Heart Association/American College of Cardiology's staging system as a framework to improve early identification and treatment of patients at risk of symptomatic heart failure.

Heart failure represents a growing chronic medical condition with major implications on patient morbidity, mortality, and cost to health care systems. In this article, the heart failure syndrome is reviewed from a perspective of diagnosis and management, with updated therapeutic options reflected in major guidelines published since this topic was last reviewed in Primary Care Clinics in Office Practice in 2013. An emphasis is placed on the use of the American Heart Association/American College of Cardiology’s staging system as a framework to improve early identification and treatment of patients at risk of symptomatic heart failure.

Background Although myocarditis/pericarditis (MP) has been identified as an adverse event following smallpox vaccine (SPX), the prospective incidence of this reaction and new onset cardiac symptoms, including possible subclinical injury, has not been prospectively defined. Purpose The study's primary objective was to determine the prospective incidence of new onset cardiac symptoms, clinical and possible subclinical MP in temporal association with immunization. Methods New onset cardiac symptoms, clinical MP and cardiac specific troponin T (cTnT) elevations following SPX (above individual baseline values) were measured in a multi-center prospective, active surveillance cohort study of healthy subjects receiving either smallpox vaccine or trivalent influenza vaccine (TIV). Results New onset chest pain, dyspnea, and/or palpitations occurred in 10.6% of SPX-vaccinees and 2.6% of TIV-vaccinees within 30 days of immunization (relative risk (RR) 4.0, 95% CI: 1.7-9.3). Among the 1081 SPX-vaccinees with complete follow-up, 4 Caucasian males were diagnosed with probable myocarditis and 1 female with suspected pericarditis. This indicates a post-SPX incidence rate more than 200-times higher than the pre-SPX background population surveillance rate of myocarditis/pericarditis (RR 214, 95% CI 65-558). Additionally, 31 SPX-vaccinees without specific cardiac symptoms were found to have over 2-fold increases in cTnT (>99th percentile) from baseline (pre-SPX) during the window of risk for clinical myocarditis/pericarditis and meeting a proposed case definition for possible subclinical myocarditis. This rate is 60-times higher than the incidence rate of overt clinical cases. No clinical or possible subclinical myocarditis cases were identified in the TIV-vaccinated group. Conclusions Passive surveillance significantly underestimates the true incidence of myocarditis/pericarditis after smallpox immunization. Evidence of subclinical transient cardiac muscle injury post-vaccinia immunization is a finding that requires further study to include long-term outcomes surveillance. Active safety surveillance is needed to identify adverse events that are not well understood or previously recognized.

Examination of the arteries is an age old medical tradition. Examination of the carotid artery is of unique importance because it is an easily accessible large artery. Through the methods of inspection, palpation, and auscultation, carotid artery examination gives clinicians important diagnostic clues about the health and disease of the patient. Inspection and palpation of the carotid give insight into left ventricular systolic function and distinguish types of valvular heart disease. Auscultation identifies patients with high-risk atherosclerosis. In most cases carotid examination is neither sensitive nor specific, but in the correct clinical context it offers important evidence leading to specific diagnoses and treatment. In this review, we discuss the examination of the carotid artery under normal conditions and describe how abnormalities in the carotid artery examination are indicators of disease.

Background and Purpose-Current guidelines recommend against routine auscultation of carotid arteries, believing that carotid bruits are poor predictors of either underlying carotid stenosis or stroke risk in asymptomatic patients. We investigated whether the presence of a carotid bruit is associated with increased risk for transient ischemic attack, stroke, or death by stroke (stroke death).Methods-We searched Medline (1966 to December 2009) and EMBASE (1974 to December 2009) with the terms "carotid" and "bruit." Bibliographies of all retrieved articles were also searched. Articles were included if they prospectively reported the incidence of transient ischemic attack, stroke, or stroke death in asymptomatic adults. Two authors independently reviewed and extracted data.Results-We included 28 prospective cohort articles that followed a total of 17 913 patients for 67 708 patient-years. Among studies that directly compared patients with and without bruits, the rate ratio for transient ischemic attack was 4.00 (95% CI, 1.8 to 9.0, P<0.0005, n=5 studies), stroke was 2.5 (95% CI, 1.8 to 3.5, P<0.0005, n=6 studies), and stroke death was 2.7 (95% CI, 1.33 to 5.53, P=0.002, n=3 studies). Among the larger pool of studies that provided data on rates, transient ischemic attack rates were 2.6 per 100 patient-years (95% CI, 2.0 to 3.2, P<0.0005, n=24 studies) for those with bruits compared with 0.9 per 100 patient-years (95% CI, 0.2 to 1.6, P=0.02, n=5 studies) for those without carotid bruits. Stroke rates were 1.6 per 100 patient-years (95% CI, 1.3 to 1.9, P<0.0005, n=26 studies) for those with bruits compared with 1.3 per 100 patient-years (95% CI, 0.8 to 1.7, P<0.0005, n=6) without carotid bruits, and death rates were 0.32 (95% CI, 0.20 to 0.44, P<0.005, n=13 studies) for those with bruits compared with 0.35 (95% CI, 0.00 to 0.81, P=0.17, n=3 studies) for those without carotid bruits.Conclusion-The presence of a carotid bruit may increase the risk of cerebrovascular disease. (Stroke. 2010;41:2295-2302.)

Background: Previous studies suggest a potential association between gastroesophageal reflux disease (GERD) and atrial fibrillation.Objective: To explore the potential association between GERD and atrial fibrillation.Materials and Methods: This was a retrospective study created from a database containing all health care encounters for patients who received ambulatory care in the National Capitol Area military health care system between January 1, 2001 and October 28, 2007. The study population included all subjects at least 18 years of age (n = 163 627). Our primary outcomes of interest were International Classification of Diseases, Ninth Revision (ICD-9) diagnoses of atrial fibrillation and GERD.Results: Among 163 627 patients, 7992 (5%) had atrial fibrillation and 47 845 (29%) had GERD. The presence of GERD increased the relative risk (RR) of a diagnosis of atrial fibrillation (RR: 1.39, 95% confidence interval [CI]: 1.33-1.45). In sensitivity analyses, this relationship persisted after adjustment for cardiovascular disease risk factors (RR: 1.19, 95% CI: 1.13-1.25) and diagnoses known to be strongly associated with atrial fibrillation (RR: 1.08, 95% CI: 1.02-1.13).Conclusions: The presence of GERD is associated with an increased risk of a diagnosis of atrial fibrillation.

BACKGROUND:Although carotid bruits are deemed to be markers of generalised atherosclerosis, they are poor predictors of cerebrovascular events. We investigated whether a carotid bruit predicts myocardial infarction and cardiovascular death.METHODS:In this meta-analysis, we searched Medline (1966 to August, 2007) and Embase (1974 to August, 2007) with the terms "carotid" and "bruit". Bibliographies of all the retrieved articles were also searched. Articles were included if they reported the incidence of myocardial infarction or cardiovascular death in adults. Outcome variables were extracted in duplicate and included the rate of myocardial infarction and cardiovascular mortality. Quality of the articles was independently assessed with the Hayden rating scheme. Data were pooled with a random effects model.FINDINGS:Of the 22 articles included, 20 (91%) used prospective cohorts. Our analysis included 17,295 patients with 62 413.5 patient-years of follow-up, with a median sample size of 273 patients (range 38-4736) followed up for 4 years (2-7). The rate of myocardial infarction in patients with carotid bruits was 3.69 (95% CI 2.97-5.40) per 100 patient-years (eight studies) compared with 1.86 (0.24-3.48) per 100 patient-years in those without bruits (two studies). Yearly rates of cardiovascular death were also higher in patients with bruits (16 studies) than in those without (four studies) (2.85 [2.16-3.54] per 100 patient-years vs 1.11 [0.45-1.76] per 100 patient-years). In the four trials in which direct comparisons of patients with and without bruits were possible, the odds ratio for myocardial infarction was 2.15 (1.67-2.78) and for cardiovascular death 2.27 (1.49-3.49).INTERPRETATION:Auscultation for carotid bruits in patients at risk for heart disease could help select those who might benefit the most from an aggressive modification strategy for cardiovascular risk.

The concepts of risk assessment and reduction are the cornerstones of preventive cardiology practice. The Framingham Heart Study is a landmark achievement that has provided valuable insights into coronary heart disease risk prediction. Through this cohort study, risk calculators have been generated to predict the risk of cardiac disease in asymptomatic patients. These risk predictors are practical, clinically relevant, and modestly accurate. Their accuracy is somewhat limited in applicability among certain specific populations, however, and some well-known risk factors are not incorporated. These are recognized limitations of the Framingham Risk Score, but it is important to keep in mind that the Framingham Heart Study is an ongoing project and that there are new risk prediction models forthcoming to incorporate additional risk factors. The emergence of subclinical atherosclerosis testing offers promise to refine the assessment of global risk, specifically identifying subjects assessed as intermediate risk by the standard Framingham Risk Score.

From the Division of Cardiology, Walter Reed Army Medical Center, Washington, DC. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Address correspondence to: Brian A. Hemann, MD, Division of Cardiology, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307 (e-mail: [email protected]).