BackgroundLimited data exist regarding cardiac manifestations of Chagas disease in migrants living in non-endemic regions.MethodsA retrospective cohort analysis of 109 patients with Chagas disease seen at Boston Medical Center (BMC) between January 2016 and January 2023 was performed. Patients were identified by screening and testing migrants from endemic regions at a community health center and BMC. Demographic, laboratory, and cardiac evaluation data were collected.ResultsMean age of the 109 patients was 43 years (range 19-76); 61% were female. 79% (86/109) were diagnosed with Chagas disease via screening and 21% (23/109) were tested given symptoms or electrocardiogram abnormalities. Common symptoms included palpitations (25%, 27/109) and chest pain (17%, 18/109); 52% (57/109) were asymptomatic. Right bundle branch block (19%, 19/102), T-wave changes (18%, 18/102), and left anterior fascicular block (11%, 11/102) were the most common electrocardiogram abnormalities; 51% (52/102) had normal electrocardiograms. Cardiomyopathy stage was ascertained in 94 of 109 patients: 51% (48/94) were indeterminate stage A and 49% (46/94) had cardiac structural disease (stages B1-D). Clinical findings that required clinical intervention or change in management were found in 23% (25/109), and included cardiomyopathy, apical hypokinesis/aneurysm, stroke, atrial or ventricular arrhythmias, and apical thrombus.ConclusionsThese data show high rates of cardiac complications in a cohort of migrants living with Chagas disease in a non-endemic setting. We demonstrate that Chagas disease diagnosis prompts cardiac evaluation which often identifies actionable cardiac disease and provides opportunities for prevention and treatment.

A 29-year-old man presented to our institution with acute, severe substernal chest pain. An ECG on arrival revealed 3mm ST-elevations in the lateral leads with reciprocal depressions in the inferior leads. Troponin-I was above assay (>50 ng/mL). Emergent coronary angiography showed normal coronary arteries, and left ventriculogram showed no wall motion abnormalities. A transthoracic echocardiogram showed normal biventricular size, wall thickness, and ejection fraction (EF). This was his fifth episode of chest pain over the past 10 years, consistent with prior presentations of ST-elevation myocardial infarction and angiographically normal coronary arteries. A prior cardiac magnetic resonance imaging (MRI, 6 years before the current presentation) revealed increased T2 signal intensity and subepicardial late gadolinium enhancement (LGE) in the septum, inferior, and inferolateral walls, suggestive of nonischemic acute myocardial injury. A repeat cardiac MRI during the current presentation showed mildly reduced biventricular systolic function (LVEF 52%, RVEF 36%), and again showed increased T2 signal intensity and subepicardial LGE involving the septum, inferior and inferolateral walls. The anterior and anterolateral walls were also now involved. Endomyocardial biopsy (EMB) showed focal interstitial fibrosis with no evidence of active myocarditis. On telemetry he was noted to have runs of non-sustained ventricular tachycardia (NSVT). Serologic evaluation was negative for parvovirus, cytomegalovirus, and Chagas disease. Erythrocyte sedimentation rate and C-reactive protein levels were normal. Genetic testing was performed at our newly established cardiovascular genetics program, which showed a pathogenic truncating mutation in the desmoplakin gene (DSP). DSP cardiomyopathy (CM) is an LV-predominant arrhythmogenic CM, which can present with episodic myocardial injury, and has a high disposition for ventricular arrhythmias with subepicardial LGE pattern often proceeding LV systolic dysfunction. A primary prevention implantable cardioverter-defibrillator was placed given extent of LGE and NSVT burden in the context of DSP variant. This case illustrates the importance of genetic testing in identifying rare CM phenotypes.

Purpose of Review The goal of the narrative review is to provide an overview of the epidemiology of frailty in cardiovascular disease and cardiovascular mortality and discuss applications of frailty in cardiovascular care of older adults. Recent Findings Frailty is highly prevalent in older adults with cardiovascular disease and is a robust, independent predictor of cardiovascular death. There is a growing interest in using frailty to inform management of cardiovascular disease either through pre- or post-treatment prognostication or by delineating treatment heterogeneity in which frailty serves to distinguish patients with differential harms or benefits from a given therapy. Summary Frailty can enable more individualized treatment in older adults with cardiovascular disease. Future studies are needed to standardize frailty assessment across cardiovascular trials and enable implementation of frailty assessment in cardiovascular clinical practice.

Background As the number of adults with congenital heart disease increases because of therapeutic advances, cardiac rehabilitation (CR) is increasingly being used in this population after cardiac procedures or for reduced exercise tolerance. We aim to describe the adherence and exercise capacity improvements of patients with adult congenital heart disease (ACHD) in CR. Methods and Results This retrospective study included patients with ACHD in CR at New York University Langone Rusk Rehabilitation from 2013 to 2020. We collected data on patient characteristics, number of sessions attended, and functional testing results. Pre‐CR and post‐CR metabolic equivalent task, exercise time, and maximal oxygen uptake were assessed. In total, 89 patients with ACHD (mean age, 39.0 years; 54.0% women) participated in CR. Referral indications were reduced exercise tolerance for 42.7% and post–cardiac procedure (transcatheter or surgical) for the remainder. Mean number of sessions attended was 24.2, and 42 participants (47.2%) completed all 36 CR sessions. Among participants who completed the program as well as pre‐CR and post‐CR functional testing, metabolic equivalent task increased by 1.3 (95% CI, 0.7–1.9; baseline mean, 8.1), exercise time increased by 66.4 seconds (95% CI, 21.4–111.4 seconds; baseline mean, 536.1 seconds), and maximal oxygen uptake increased by 2.5 mL/kg per minute (95% CI, 0.7–4.2 mL/kg per minute; baseline mean, 20.2 mL/kg per minute). Conclusions On average, patients with ACHD who completed CR experienced improvements in exercise capacity. Efforts to increase adherence would allow more patients with ACHD to benefit.

Prediabetes affects at least 1 in 3 adults in the U.S. and 1 in 5 in Europe. Although guidelines advocate aggressive management of lipid parameters in diabetes, most guidelines do not address treatment of dyslipidemia in prediabetes despite the increased atherosclerotic cardiovascular disease (ASCVD) risk. Several criteria are used to diagnose prediabetes: impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and HbA1c of 5.7-6.4%. Individuals with prediabetes have a greater risk of diabetes, a higher prevalence of dyslipidemia with a more atherogenic lipid profile and an increased risk of ASCVD. In addition to calculating ASCVD risk using traditional methods, an OGTT may further stratify risk. Those with 1-hour plasma glucose >= 8.6 mmol/L (155 mg/dL) and/ or 2-hour >= 7.8 mmol/L (140 mg/dL) (IGT) have a greater risk of ASCVD. Diet and lifestyle modification are fundamental in prediabetes. Statins, ezetimibe and PCSK9 inhibitors are recommended in people requiring pharmacotherapy. Although high-intensity statins may increase risk of diabetes, this is acceptable because of the greater reduction of ASCVD. The LDL-C goal in prediabetes should be individualized. In those with IGT and/or elevated 1-hour plasma glucose, the same intensive approach to dyslipidemia as recommended for diabetes should be considered, particularly if other ASCVD risk factors are present.

HomeCirculationVol. 144, No. 6Summoning STRENGTH to Question the Placebo in REDUCE-IT Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessArticle CommentaryPDF/EPUBSummoning STRENGTH to Question the Placebo in REDUCE-IT John A. Bostrom, MD, Joshua A. Beckman, MD, MS and Jeffrey S. Berger, MD John A. BostromJohn A. Bostrom https://orcid.org/0000-0002-4501-4831 Leon H. Charney Division of Cardiology, Department of Medicine, Grossman School of Medicine, Langone Center for Prevention of Cardiovascular Disease, New York University (J.A. Bostrom, J.S.B.), New York, NY. , Joshua A. BeckmanJoshua A. Beckman https://orcid.org/0000-0001-8332-8439 Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN (J.A. Beckman). and Jeffrey S. BergerJeffrey S. Berger Correspondence to: Jeffrey S. Berger, MD, 530 1st Avenue, HCC, Suite 4F, New York, NY 10016. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8216-4647 Leon H. Charney Division of Cardiology, Department of Medicine, Grossman School of Medicine, Langone Center for Prevention of Cardiovascular Disease, New York University (J.A. Bostrom, J.S.B.), New York, NY. Originally published9 Aug 2021https://doi.org/10.1161/CIRCULATIONAHA.121.054539Circulation. 2021;144:407–409The initial use of placebo medications in the late 18th century was not in the context of clinical trials. Placebos—or remedies given without curative intent—were often used by physicians aiming to satisfy a patient's demand for an evaluation and treatment. The use of a placebo as a comparator with an established treatment can be traced to John Haygarth. Skeptical of claims that widely popular "metallic tractors"—a pair of rods made of copper, zinc, and gold—could cure ailments ranging from gout to boils using electricity and magnetism, he designed what is regarded as one of the first placebo-controlled trials. Fashioning sham tractors out of wood, he treated 5 patients with either metallic or wood tractors. Equal results were obtained by both the true and false tractors; after the results were disseminated, metallic tractors soon fell out of favor.Randomized, placebo-controlled trials are now considered the gold standard in clinical trial evidence. Ideally, placebos are indistinguishable from the active treatment and are inert substances. It is imperative that a placebo does not cause harm; interventions that worsen risk factors have a greater adverse effect than, conversely, the benefit achieved by improving risk factors by the same magnitude.The data surrounding the utility of omega-3 fatty acid supplementation for the use of cardiovascular disease (CVD) are mixed, and aggregate results suggest no significant benefit. An outlier is REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial), which randomized 8179 participants with diabetes (58%) or established CVD (71%) with elevated triglycerides (median baseline 216 mg/dL) despite background statin therapy to icosapent ethyl (IPE) versus placebo composed of mineral oil. The results were striking: Over a mean follow-up of 4.9 years, the primary end point composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, revascularization, or hospitalization for unstable angina occurred in 17.2% of the treatment group versus 22.0% of the placebo group.1 Treatment with IPE led to a significant 20% reduction in cardiovascular mortality. On the basis of the results of REDUCE-IT, the Food and Drug Administration approved a label claim for CVD event reduction (for purposes of primary or secondary prevention) for IPE in high-risk patients with elevated triglycerides and diabetes.After the significant reduction in cardiovascular events observed in REDUCE-IT, there was anticipation for the completion of the STRENGTH trial (Statin Residual Risk With Epanova in High Cardiovascular Risk Patients With Hypertriglyceridemia). STRENGTH was designed to evaluate another high-dose omega-3 fatty acid supplement, omega-3 carboxylic acid, versus placebo composed of corn oil. Among 13 708 participants at high risk for CVD (56% with established CVD), the trial was terminated early because of futility. The same primary end point used in REDUCE-IT occurred in 12.0% of the treatment group versus 12.2% of the placebo group.2The difference in results between REDUCE-IT and STRENGTH could be a result of the different treatments (pure eicosapentaenoic acid [EPA] versus a combination of EPA and docosahexaenoic acid). However, a closer look offers a perplexing picture. The change in biomarkers of cardiovascular risk, including lipids and inflammation, was similar between the active treatment of both trials (Figure). Although a higher dose of pure EPA was used in REDUCE-IT compared with STRENGTH, the serum levels of EPA in STRENGTH participants rose dramatically in both STRENGTH (+269%) and REDUCE-IT (+394%). In a subgroup analysis of STRENGTH, participants with the highest increase in EPA levels (≥435% change—higher than what was achieved in REDUCE-IT) had no reduction in the primary composite outcome. In contrast with the consistent change in biomarkers among the treatment arms in both studies, significant differences were seen in the placebo arms. In REDUCE-IT, mineral oil was associated with a 10.2% increase in low-density lipoprotein cholesterol (LDL-C), 7.8% increase in apolipoprotein B, and 32% increase in high-sensitivity C-reactive protein. In contrast, the corn oil placebo used in STRENGTH did not increase any of these biomarkers (Figure). The mechanisms underlying the changes in lipid profiles in the mineral oil arm of REDUCE-IT are unclear, although indirect evidence suggests that mineral oil may block the proper absorption of background statin therapy.3Download figureDownload PowerPointFigure. Percent change from baseline of select biomarkers between placebo arms and treatment arms of STRENGTH and REDUCE-IT trials. Apo-B indicates apolipoprotein-B; CA, carboxylic acid; EPA, eicosapentaenoic acid; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; REDUCE-IT, Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial; and STRENGTH, Statin Residual Risk With Epanova in High Cardiovascular Risk Patients With Hypertriglyceridemia.Discrepancies between these placebo arms remind us of the importance of an inert placebo. Although mineral oil has been used as a placebo in as many as 80 studies, a recent comprehensive review highlighted that its effects on lipid levels and inflammatory markers have been mixed.4 The effect of mineral oil placebo has noted a wide range of effect on LDL-C (from –3.0% to +10.5%) and high-sensitivity C-reactive protein (from –15.9% to +33.3%). The majority of studies (10 of 16) reporting high-sensitivity C-reactive protein in mineral oil arms note an absolute increase in high-sensitivity C-reactive protein levels—including a 32% increase in REDUCE-IT and a 17% increase in ANCHOR.3 It should be noted that the absolute difference in LDL-C between the placebo and IPE arms in REDUCE-IT (≈9 mg/dL) would only be estimated to account for a 3.0% relative risk increase in the primary outcome in the placebo group, suggesting that the observed differences in outcomes between arms were driven by an LDL-C–independent mechanism.3 This estimate also supposes a mirror image of harm by raising LDL-C to the benefit of lowering it. This supposition is not supported in the literature: For example, a 5-mm Hg reduction in blood pressure in hypertension is associated with a 2% relative risk reduction in mortality. In contrast, a medication-mediated increase of 5 mm Hg was associated with a 58% relative risk increase in mortality and a significant increase in cardiovascular events.5 Thus, we question the Food and Drug Administration estimate of harm in this case.In light of the discrepancies between large, well-run trials with similar treatments in similar high-risk populations, it may be difficult for physicians and patients to confidently assign a benefit to omega-3 fatty acid supplementation. The differences between the placebo arms in REDUCE-IT and STRENGTH are so striking that a separate trial (ideally comparing IPE with a demonstrated bland placebo) would be helpful to provide a clear answer about the value of omega-3 fatty acid supplements for primary or secondary prevention of CVD. We believe a new trial is necessary for a definitive answer.Sources of FundingNone.Disclosures J.A. Beckman has performed consulting for Amgen, Bayer, Janone, and Janssen; and research for BMS. J.S.B. has received grants from the National Institutes of Health, American Heart Association, and Astra Zeneca; and has performed consulting for Amgen and Janssen. The other author reports no conflicts.Footnoteshttps://www.ahajournals.org/journal/circThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 408.Correspondence to: Jeffrey S. Berger, MD, 530 1st Avenue, HCC, Suite 4F, New York, NY 10016. Email Jeffrey.[email protected]orgReferences1. Bhatt DL, Steg PG, Miller M, Brinton EA, Jacobson TA, Ketchum SB, Doyle RT, Juliano RA, Jiao L, Granowitz C, et al.; REDUCE-IT Investigators. Cardiovascular r isk reduction with icosapent ethyl for hypertriglyceridemia.N Engl J Med. 2019; 380:11–22. doi: 10.1056/NEJMoa1812792CrossrefMedlineGoogle Scholar2. Nicholls SJ, Lincoff AM, Garcia M, Bash D, Ballantyne CM, Barter PJ, Davidson MH, Kastelein JJP, Koenig W, McGuire DK, et al.. Effect of high-dose omega-3 fatty acids vs corn oil on major adverse cardiovascular events in patients at high cardiovascular risk: the STRENGTH randomized clinical trial.JAMA. 2020; 324:2268–2280. doi: 10.1001/jama.2020.22258CrossrefMedlineGoogle Scholar3. Food and Drug Administration. Endocrinology and Metabolic Drugs Advisory Committee (EMDAC) Meeting.November 14, 2019. https://www.fda.gov/media/132767/download. Accessed April 15, 2021.Google Scholar4. Olshansky B, Chung MK, Budoff MJ, Philip S, Jiao L, Doyle RT, Copland C, Giaquinto A, Juliano RA, Bhatt DL. Mineral oil: safety and use as placebo in REDUCE-IT and other clinical studies.Eur Heart J Suppl. 2020; 22(suppl J):J34–J48. doi: 10.1093/eurheartj/suaa117CrossrefMedlineGoogle Scholar5. Barter PJ, Caulfield M, Eriksson M, Grundy SM, Kastelein JJ, Komajda M, Lopez-Sendon J, Mosca L, Tardif JC, Waters DD, et al.; ILLUMINATE Investigators. Effects of torcetrapib in patients at high risk for coronary events.N Engl J Med. 2007; 357:2109–2122. doi: 10.1056/NEJMoa0706628CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Blaum C, Arnold N and Waldeyer C (2022) Kosten-Nutzen-Analyse neuer LipidsenkerCost-benefit analysis of new lipid-lowering agents, Herz, 10.1007/s00059-022-05116-8, 47:3, (236-243), Online publication date: 1-Jun-2022. Harrington R (2022) Trials and Tribulations of Randomized Clinical Trials, Circulation, 146:5, (380-382), Online publication date: 2-Aug-2022. August 10, 2021Vol 144, Issue 6Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.121.054539PMID: 34370544 Originally publishedAugust 9, 2021 KeywordsUS Food and Drug Administrationrandomized controlled trialsmineral oilfish oilsplacebosPDF download Advertisement SubjectsCardiovascular Disease

This study aims to discuss the mechanisms by which GLP-1 agonists and bariatric surgery improve cardiovascular outcomes in severely obese patients. Recent studies have demonstrated that both GLP-1 agonist use and bariatric surgery reduce adverse cardiovascular outcomes. Improvements in traditional atherosclerosis risk factors in association with weight loss likely contribute, but weight loss–independent mechanisms are also suggested to have roles. We review the clinical and preclinical evidence base for cardiovascular benefit of LP-1 agonists and bariatric surgery beyond traditional risk factors, including improvements in endothelial function, direct impacts on atherosclerotic plaques, and anti-inflammatory effects.

Purpose: Despite known benefits of cardiac rehabilitation (CR), early termination (failure to complete >1 mo of CR) attenuates these benefits. We analyzed whether early termination varied by referral indication in the context of recent growth in patients referred for heart failure with reduced ejection fraction (HFrEF). Methods: We reviewed records from 1111 consecutive patients enrolled in the NYU Langone Health Rusk CR program (2013-2017). Sessions attended, demographics, and comorbidities were abstracted, as well as primary referral indication: HFrEF or ischemic heart disease (IHD; including post-coronary revascularization, post-acute myocardial infarction, or chronic stable angina). We compared rates of early termination between HFrEF and IHD, and used multivariable logistic regression to determine whether differences persisted after adjusting for relevant characteristics (age, race, ethnicity, body mass index, smoking, hypertension, chronic obstructive pulmonary disease, and depression). Results: Mean patient age was 64 yr, 31% were female, and 28% were nonwhite. Most referrals (85%) were for IHD; 15% were for HFrEF. Early termination occurred in 206 patients (18%) and was more common in HFrEF (26%) than in IHD (17%) ( P < .01). After multivariable adjustment, patients with HFrEF remained at higher risk of early termination than patients with IHD (unadjusted OR = 1.73, 95% CI, 1.17-2.54; adjusted OR = 1.53, 95% CI, 1.01-2.31). Conclusions: Nearly 1 in 5 patients in our program terminated CR within 1 mo, with HFrEF patients at higher risk than IHD patients. While broad efforts at preventing early termination are warranted, particular attention may be required in patients with HFrEF.

With the ubiquity of mobile devices, the availability of mobile health (mHealth) applications for cardiovascular disease (CVD) has markedly increased in recent years. Older adults represent a population with a high CVD burden and therefore have the potential to benefit considerably from interventions that utilize mHealth. Traditional facility-based cardiac rehabilitation represents one intervention that is currently underutilized for CVD patients and, because of the unique barriers that older adults face, represents an attractive target for mHealth interventions. Despite potential barriers to mHealth adoption in older populations, there is also evidence that older patients may be willing to adopt these technologies. In this review, we highlight the potential for mHealth uptake for older adults with CVD, with a particular focus on mHealth cardiac rehabilitation (mHealth-CR) and evidence being generated in this field.

BackgroundOver the past decade, a growing number of patients with advanced heart failure (HF) have undergone ventricular assist device (VAD) implantation, including some ineligible for transplant. Cardiac rehabilitation (CR) may improve functional capacity and symptoms among VAD recipients, but feasibility of completing a full 12-week outpatient CR program among VAD recipients has not been characterized. We therefore sought to determine the prevalence and predictors of early CR cessation in VAD recipients referred to outpatient CR in an urban center.MethodsWe prospectively enrolled all eligible 18 VAD recipients who were referred to outpatient CR between 2013-2016 at NYU Langone Rusk Rehabilitation from 4 New York City VAD centers in an IRB-approved observational study. The primary feasibility outcome was completion of CR (all 36 scheduled sessions). We reviewed demographic data, comorbidities, number of CR sessions attended, and physiologic data from baseline cardiopulmonary exercise testing (CPET) in patients who completed and did not complete CR. We used two-sample t-tests and chi-squared test for continuous and categorical variables, respectively.ResultsMedian age was 59 years, 22.2% were female, 72.3% were non-White, and median BMI was 25.4. The majority of VADs were Heartmate II devices. Fewer than half of study participants (7/18) completed all 36 scheduled CR sessions. Among those who did not complete CR (N=11) 4 participants were transplanted, 5 stopped due to medical reasons, and 2 stopped due to social barriers. Baseline demographics, medications, and comorbidities were similar between those who did and did not complete CR (Table). VAD recipients with more severe functional impairment based on pre-CPET measures were significantly less likely to complete CR.ConclusionsOur study demonstrates the feasibility of CR implementation among VAD recipients in a diverse urban cohort, although a considerable proportion failed to complete all 36 scheduled sessions. Among those who did not complete CR, functional capacity was lower at baseline. More work is warranted to determine the optimal timing and CR regimen for VAD recipients. Over the past decade, a growing number of patients with advanced heart failure (HF) have undergone ventricular assist device (VAD) implantation, including some ineligible for transplant. Cardiac rehabilitation (CR) may improve functional capacity and symptoms among VAD recipients, but feasibility of completing a full 12-week outpatient CR program among VAD recipients has not been characterized. We therefore sought to determine the prevalence and predictors of early CR cessation in VAD recipients referred to outpatient CR in an urban center. We prospectively enrolled all eligible 18 VAD recipients who were referred to outpatient CR between 2013-2016 at NYU Langone Rusk Rehabilitation from 4 New York City VAD centers in an IRB-approved observational study. The primary feasibility outcome was completion of CR (all 36 scheduled sessions). We reviewed demographic data, comorbidities, number of CR sessions attended, and physiologic data from baseline cardiopulmonary exercise testing (CPET) in patients who completed and did not complete CR. We used two-sample t-tests and chi-squared test for continuous and categorical variables, respectively. Median age was 59 years, 22.2% were female, 72.3% were non-White, and median BMI was 25.4. The majority of VADs were Heartmate II devices. Fewer than half of study participants (7/18) completed all 36 scheduled CR sessions. Among those who did not complete CR (N=11) 4 participants were transplanted, 5 stopped due to medical reasons, and 2 stopped due to social barriers. Baseline demographics, medications, and comorbidities were similar between those who did and did not complete CR (Table). VAD recipients with more severe functional impairment based on pre-CPET measures were significantly less likely to complete CR. Our study demonstrates the feasibility of CR implementation among VAD recipients in a diverse urban cohort, although a considerable proportion failed to complete all 36 scheduled sessions. Among those who did not complete CR, functional capacity was lower at baseline. More work is warranted to determine the optimal timing and CR regimen for VAD recipients.

Background: Impairments in psychosocial status and cognition relate to poor clinical outcomes in patients with atrial fibrillation (AF). However, how often these conditions co-occur and associations between burden of psychosocial and cognitive impairment and quality of life (QoL) have not been systematically examined in patients with AF. Methods: A total of 218 patients with symptomatic AF were enrolled in a prospective study of AF and psychosocial factors between May 2013 and October 2014 at the University of Massachusetts Medical Center. Cognitive function, depression, and anxiety were assessed at baseline and AF-specific QoL was assessed 6 months after enrollment using validated instruments. Demographic and clinical information were obtained from a structured interview and medical record review. Results: The mean age of the study participants was 63.5 ± 10.2 years, 35% were male, and 81% had paroxysmal AF. Prevalences of impairment in 1, 2, and 3 psychosocial/cognitive domains (eg, depression, anxiety, or cognition) were 75 (34.4%), 51 (23.4%), and 16 (7.3%), respectively. Patients with co-occurring psychosocial/cognitive impairments (eg, >1 domain) were older, more likely to smoke, had less education, and were more likely to have heart failure (all P < 0.05). Compared with participants with no psychosocial/cognitive impairments, AF-specific QoL at 6 months was significantly poorer among participants with baseline impairment in 2 (B = −13.6, 95% CI: −21.7 to −5.4) or 3 (B = −15.1, 95% CI: −28.0 to −2.2) psychosocial/cognitive domains. Conclusion: Depression, anxiety, and impaired cognition were common in our cohort of patients with symptomatic AF and often co-occurred. Higher burden of psychosocial/cognitive impairment was associated with poorer AF-specific QoL.

OBJECTIVE:The Society for Vascular Surgery Wound, Ischemia, foot Infection (WIfI) system aims to stratify threatened limbs according to their anticipated natural history and estimate the likelihood of benefit from revascularization, but whether it accurately stratifies outcomes in limbs undergoing aggressive treatment for limb salvage is unknown. We investigated whether the WIfI stage correlated with the intensity of limb treatment required and patient-centered outcomes. METHODS:We stratified limbs from a prospectively maintained database of consecutive patients referred to a limb preservation center according to WIfI stage (October 2013-May 2015). Comorbidities, multimodal limb treatment, including foot operations and revascularization, and patient-centered outcomes (wound healing, limb salvage, amputation-free survival, maintenance of ambulatory and independent living status, and mortality) were compared among WIfI stages. Multivariate analysis was performed to identify predictors of wound healing and limb salvage. RESULTS:We identified 280 threatened limbs encompassing all WIfI stages in 257 consecutive patients: stage 1, 48 (17%); stage 2, 67 (24%); stage 3, 64 (23%); stage 4, 83 (30%); and stage 5 (unsalvageable), 18 (6%). Operative foot débridement, minor amputation, and use of revascularization increased with increasing WIfI stage (P ≤ .04). Revascularization was performed in 106 limbs (39%), with equal use of open and endovascular procedures. Over a median follow-up of 209 days (interquartile range, 95, 340) days, 1-year Kaplan-Meier wound healing cumulative incidence was 71%, and the proportion with complete wound healing decreased with increasing WIfI stage. Major amputation was required in 26 stage 1 to 4 limbs (10%). Increasing WIfI stage was associated with decreased 1-year Kaplan-Meier limb salvage (stage 1: 96%, stage 2: 84%, stage 3: 90%, and stage 4: 78%; P = .003) and amputation-free survival (P = .006). Stage 4 WIfI independently predicted amputation (hazard ratio, 12; 95% confidence interval, 1.6-94). Amputation rates in patients with severe Ischemia grade 3 were lower in those who underwent revascularization than in those who did not (14% vs 41%; P = .01) Ambulatory and independent living status at follow-up deteriorated significantly from baseline in stage 4 but not stage 1 to 3 patients. Mortality was not different between WIfI stages. CONCLUSIONS:In patients treated aggressively for limb salvage, WIfI stage correlated with intensity of multimodal limb treatment and with limb salvage and patient-centered outcomes at 1 year. Revascularization improved limb salvage in severe ischemia. These data support the Society for Vascular Surgery WIfI system as a powerful tool to risk-stratify patients with threatened limbs and guide treatment.

Objective: The Society for Vascular SurgeryWound, Ischemia, foot Infection (WIfI) system aims to stratify threatened limbs according to their anticipated natural history and estimate the likelihood of benefit from revascularization, but whether it accurately stratifies outcomes in limbs undergoing aggressive treatment for limb salvage is unknown. We investigated whether the WIfI stage correlated with the intensity of limb treatment required and patient-centered outcomes. Methods: We stratified limbs from a prospectively maintained database of consecutive patients referred to a limb preservation center according to WIfI stage (October 2013-May 2015). Comorbidities, multimodal limb treatment, including foot operations and revascularization, and patient-centered outcomes (wound healing, limb salvage, amputation-free survival, maintenance of ambulatory and independent living status, and mortality) were compared among WIfI stages. Multivariate analysis was performed to identify predictors of wound healing and limb salvage. Results: We identified 280 threatened limbs encompassing all WIfI stages in 257 consecutive patients: stage 1, 48 (17%); stage 2, 67 (24%); stage 3, 64 (23%); stage 4, 83 (30%); and stage 5 (unsalvageable), 18 (6%). Operative foot débridement, minor amputation, and use of revascularization increased with increasing WIfI stage (P # .04). Revascularization was performed in 106 limbs (39%), with equal use of open and endovascular procedures. Over a median follow-up of 209 days (interquartile range, 95, 340) days, 1-year Kaplan-Meier wound healing cumulative incidence was 71%, and the proportion with complete wound healing decreased with increasing WIfI stage. Major amputation was required in 26 stage 1 to 4 limbs (10%). Increasing WIfI stage was associated with decreased 1-year Kaplan-Meier limb salvage (stage 1: 96%, stage 2: 84%, stage 3: 90%, and stage 4: 78%; P 1⁄4 .003) and amputation-free survival (P 1⁄4 .006). Stage 4 WIfI independently predicted amputation (hazard ratio, 12; 95% confidence interval, 1.6-94). Amputation rates in patients with severe Ischemia grade 3 were lower in those who underwent revascularization than in those who did not (14% vs 41%; P 1⁄4 .01) Ambulatory and independent living status at follow-up deteriorated significantly from baseline in stage 4 but not stage 1 to 3 patients. Mortality was not different between WIfI stages. Conclusions: In patients treated aggressively for limb salvage, WIfI stage correlated with intensity of multimodal limb treatment and with limb salvage and patient-centered outcomes at 1 year. Revascularization improved limb salvage in severe ischemia. These data support the Society for Vascular Surgery WIfI system as a powerful tool to risk-stratify patients with threatened limbs and guide treatment. (J Vasc Surg 2017;-:1-11.) Lower extremity neuroischemic wounds are increasing in prevalence, but the natural history of these patients remains poorly understood. Existing classification systems have been narrowly focused on limb ischemia, the extent of diabetic foot ulceration, or the presence the Division of Vascular and Endovascular Surgery, University of ia School of Medicine, Charlottesville; the Division of Vascular ndovascular Surgery, UMass Memorial Medical Center, and Center utcomes Research, University of Massachusetts Medical School, ester; and the University of Massachusetts Medical School, ester. conflict of interest: none. ted at the Forty-third Annual Meeting of the New England Society for lar Surgery, Stowe, Vt, September 23-25, 2016. nal material for this article may be found online at www.jvascsurg.org. of infection. The Society for Vascular Surgery (SVS) Lower Extremity Guidelines Committee therefore recently proposed an integrated Lower Extremity Classification System for the Threatened Limb based on three major determinants of limb threat: wound severity, Correspondence: William P. Robinson, MD, Division of Vascular and Endovascular Surgery, University of Virginia School of Medicine, PO Box 800679, 1215 Lee St, UH, Charlottesville, VA 22908 (e-mail: wprobins3@gmail.com). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright 2017 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2017.01.063

BACKGROUND:In recent years there has been a surge in the number of global health programs operated by academic institutions. However, most of the existing programs describe partnerships that are primarily faculty-driven and supported by extramural funding.PROGRAM DESCRIPTION:Research and Advocacy for Health in India (RAHI, or "pathfinder" in Hindi) and Support and Action Towards Health-Equity in India (SATHI, or "partnership" in Hindi) are 2 interconnected, collaborative efforts between the University of Massachusetts Medical School (UMMS) and Charutar Arogya Mandal (CAM), a medical college and a tertiary care center in rural western India. The RAHI-SATHI program is the culmination of a series of student/trainee-led research and capacity strengthening initiatives that received institutional support in the form of faculty mentorship and seed funding. RAHI-SATHI's trainee-led twinning approach overcomes traditional barriers faced by global health programs. Trainees help mitigate geographical barriers by acting as a bridge between members from different institutions, garner cultural insight through their ability to immerse themselves in a community, and overcome expertise limitations through pre-planned structured mentorship from faculty of both institutions. Trainees play a central role in cultivating trust among the team members and, in the process, they acquire personal leadership skills that may benefit them in their future careers.CONCLUSION:This paradigm of trainee-led twinning partnership promotes sustainability in an uncertain funding climate and provides a roadmap for conducting foundational work that is essential for the development of a broad, university-wide global health program.