Pragmatic Study of Clinician Use of a Personalized Patient Decision Aid Integrated into the Electronic Health Record: An 8-Year Experience.

Patient decision aids (PDAs) facilitate shared decision-making (SDM) and are delivered in a variety of formats, including printed material or instructional videos, and, more recently, web-based tools. Barriers such as time constraints and disruption to clinical workflow are reported to impede usage in routine practice. This pragmatic study examines use of PDAs integrated (iPDAs) into the electronic health record (EHR) over an 8-year period.

Reduced haemodynamic coupling and exercise are associated with vascular stiffening in pulmonary arterial hypertension.

Objective: Inadequate right ventricular (RV) and pulmonary arterial (PA) functional responses to exercise are important yet poorly understood features of pulmonary arterial hypertension (PAH). This study combined invasive catheterisation with echocardiography to assess RV afterload, RV function and ventricular-vascular coupling in subjects with PAH.

Methods: Twenty-six subjects with PAH were prospectively recruited to undergo right heart catheterisation and Doppler echocardiography at rest and during incremental exercise, and cardiac MRI at rest.

Intracranial Arterial 4D-Flow is Associated with Metrics of Brain Health and Alzheimer's Disease.

Introduction: While cerebrovascular disease has long been known to co-occur with Alzheimer's disease (AD), recent studies suggest an etiologic contribution to AD pathogenesis. We used 4D-Flow magnetic resonance imaging (MRI) to evaluate blood flow and pulsatility indices in the Circle of Willis. We hypothesized decreased mean blood flow and increased pulsatility, metrics indicative of poor vascular health, would be associated with cerebral atrophy and an AD cerebrospinal fluid (CSF) profile.

Successful computed tomography angiogram through tibial intraosseous access: a case report.

Background: Intraosseous access has been used increasingly with proven efficacy in emergent situations for adults when intravenous access could not be obtained.

Objective: Our aim was to demonstrate if tibial intraosseous (IO) is an effective route for iodinated contrast administration and pulmonary vasculature visualization.

Case Report: We report on an obtunded patient requiring a computed tomography angiogram to help with diagnosis and tibial IO was the only viable access appropriate to withstand the pressure of a computed tomography iodinated contrast load.

Trends in low-density lipoprotein cholesterol goal achievement in high risk United States adults: longitudinal findings from the 1999-2008 National Health and Nutrition Examination Surveys.

Background: Previous studies have demonstrated gaps in achievement of low-density lipoprotein-cholesterol (LDL-C) goals among U.S. individuals at high cardiovascular disease risk; however, recent studies in selected populations indicate improvements.

Women up, men down: the clinical impact of replacing the Framingham Risk Score with the Reynolds Risk Score in the United States population.

Background: The Reynolds Risk Score (RRS) is one alternative to the Framingham Risk Score (FRS) for cardiovascular risk assessment. The Adult Treatment Panel III (ATP III) integrated the FRS a decade ago, but with the anticipated release of ATP IV, it remains uncertain how and which risk models will be integrated into the recommendations. We sought to define the effects in the United States population of a transition from the FRS to the RRS for cardiovascular risk assessment.

The population effects of the global cardiovascular risk model in United States adults: findings from the National Health and Nutrition Surveys, 2005-2006.

Background: The Framingham Global Cardiovascular Disease (FRS-CVD) risk assessment is a proposed alternative for the assessment of hard coronary heart disease (FRS-CHD) event risk. Beyond heart attack and death, FRS-CVD risk adds the end points of cerebrovascular disease, angina, heart failure, and peripheral vascular disease.

Objective: We sought to estimate the population impact of using FRS-CVD instead of FRS-CHD risk prediction on U.

Cardiac computed tomography and quadricuspid aortic valve: a case report.

A quadricuspid aortic valve is rare and often incidentally found by echocardiography, surgically, or on post mortem examination. Aortic regurgitation is common and if severe enough can lead to symptoms of dyspnea. We report a case of a quadricuspid aortic valve, which was found by cardiac multidetector computed tomography during a pre-operative assessment for severe aortic regurgitation.

National improvements in low-density lipoprotein cholesterol management of individuals at high coronary risk: National Health and Nutrition Examination Survey, 1999 to 2002.

Background: This study sought to evaluate national levels of elevated low-density lipoprotein cholesterol (LDL-C) before and after publication of the Adult Treatment Panel III (ATP III). The ATP III guidelines intensified LDL-C targets and defined additional high-risk conditions. These recommendations are expected to have a noticeable impact on US cholesterol levels.

Implications of cardiac risk and low-density lipoprotein cholesterol distributions in the United States for the diagnosis and treatment of dyslipidemia: data from National Health and Nutrition Examination Survey 1999 to 2002.

Background: Updated guidelines from the National Cholesterol Education Program Adult Treatment Panel III stratify patients into 5 groups of coronary heart disease (CHD) risk that determine intensity of lipid-lowering therapy. The present study assesses the distribution of low-density lipoprotein cholesterol (LDL-C) in the United States across the 5 groups of CHD risk as defined in the updated guidelines.

Methods And Results: Subjects included 7399 individuals 20 to 79 years of age in the 1999 to 2002 National Health and Nutrition Examination Survey representing 171 million individuals in the United States.

Is the ankle-brachial index a useful screening test for subclinical atherosclerosis in asymptomatic, middle-aged adults?

Background: Measurement of the ankle-brachial index (ABI) is recommended as a screening test for cardiovascular risk prediction in individuals > or = 50 years old; however, there is little data regarding the utility of the ABI as a screening test in individuals for whom physicians actually order non-invasive testing for cardiovascular risk prediction.

Methods: This study included 493 consecutive asymptomatic patients without known atherosclerotic vascular disease who were referred by their physician for measurement of the ABI and ultrasound measurement of carotid intima-media thickness (CIMT). ABI values were classified as "reduced" (<0.

Use of carotid intima-media thickness and vascular age to modify cardiovascular risk prediction.

Background: This study identified predictors of patients for whom carotid artery intima-media thickness (CIMT) measurement and determination of vascular age could change cardiovascular disease (CVD) risk assessment.

Methods: We studied consecutive patients who were asymptomatic and nondiabetic, referred for ultrasound measurement of CIMT. Individuals with CIMT 75th percentile or greater for age, sex, and race were defined as having advanced subclinical atherosclerosis.

Transient left ventricular apical ballooning: a review of the literature.

Transient left ventricular apical ballooning is a newly defined syndrome characterized by sudden onset of chest symptoms, electrocardiographic changes characteristic of myocardial ischemia, transient left ventricular dysfunction-particularly in the apical region, low-grade troponin elevation, and no significant coronary stenosis by angiogram. This syndrome is also referred to as Takotsubo cardiomyopathy, "Ampulla" cardiomyopathy, Human Stress cardiomyopathy, and Broken Heart Syndrome. Emergency physicians, family physicians, general internists, and cardiologists may all encounter this syndrome at the point of contact.

Ultrasound-detected carotid plaque as a screening tool for advanced subclinical atherosclerosis.

Background: There is great need for a simple, noninvasive tool that can be used in an office setting to screen for subclinical atherosclerosis. In patients referred for cardiovascular (CV) risk assessment, we evaluated the ability of ultrasound screening for carotid plaque to identify patients with advanced subclinical atherosclerosis.

Methods: Consecutive asymptomatic patients without vascular disease referred by their physician for measurement of the ankle-brachial pressure index and carotid intima-media thickness (CIMT) were included.

The association of homocysteine and coronary artery disease.

Hyperhomocysteinemia has been associated with increased risk of atherosclerosis and myocardial infarction by a number of prospective case-control studies. A variety of genetic mutations, nutritional deficiencies, disease states, and drugs can elevate homocysteine concentrations. Treatment with folic acid with or without B-complex vitamins effectively lowers homocysteine levels.

Cardiovascular disease prevention.

In this chapter, we have reviewed many of the steps necessary for effective CHD risk reduction. The first step in the office setting is to assess the individual CHD risk. This combines the evaluation of current CHD or a "secondary risk equivalent" with the counting of risk factors and in many cases, the absolute risk calculation.