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Biomedical subjects

Michael W Rich

Publications and source records attributed to Michael W Rich.

At least 19 recordsLinked to original sources
PubMed2007

Epidemiology, pathophysiology, and prognosis of heart failure in the elderly.

Heart failure (HF) represents the quintessential disorder of cardio-vascular aging, reflecting the convergence of age-related changes in the cardiovascular system and other organ systems and the increasing prevalence of cardiovascular diseases at older age. The prevalence and incidence of HF increase progressively with advancing age, and HF imposes an enormous burden on society in mortality,morbidity, and associated health care costs. Despite major advances in treatment of HF over the last 25 years, the prognosis re-mains poor, with median survival rates of less than 5 years in older adults. As the population ages, it is anticipated that the number of older people with HF will increase dramatically over the next several decades.

Aged↗
PubMed2006

Long-term survival in elderly patients hospitalized for heart failure: 14-year follow-up from a prospective randomized trial.

BACKGROUND: The growing heart failure epidemic imposes a substantial burden on the US health care system. The ability to accurately assess prognosis would allow clinicians to triage patients to appropriate therapy and to plan the intensity of care following hospital discharge. METHODS: A cohort of 282 elderly (mean +/- SD age, 79.2 +/- 6.1 years) patients with heart failure were followed for up to 14 years after enrollment in a prospective randomized multidisciplinary disease management trial conducted from 1990 through 1994. Kaplan-Meier survival curves were constructed to assess the probability of survival during the follow-up period. A Cox proportional hazards model was developed to identify independent predictors of long-term survival. C statistics were calculated to assess the utility of the model for predicting mortality at 6 months, 1 year, and 5 years. RESULTS: During the 14-year follow-up period, 269 patients (95%) died and the median survival was 894 days. Cox analysis identified 7 variables that were independent predictors of shorter survival time: older age (hazard ratio [HR], 1.14 per 5 years; 95% confidence interval [CI], 1.03-1.26), serum sodium level less than 135 mEq/L (HR, 1.67; 95% CI, 1.19-2.32), coronary artery disease (HR 1.51; 95% CI, 1.16-1.95), dementia (HR, 2.02; 95% CI, 1.13-3.61), peripheral vascular disease (HR, 1.74; 95% CI, 1.20-2.52), systolic blood pressure (HR, 0.95 per 10 mm Hg; 95% CI, 0.92-0.98), and serum urea nitrogen level (HR, 1.20 per 10 mg/dL [3.57 mmol/L]; 95% CI, 1.12-1.29). C statistics for the model were 0.84, 0.79, and 0.75 at 6 months, 1 year, and 5 years, respectively. A risk score for mortality was developed using the 7 independent predictor variables. One-year mortality rates among patients with 0 to 1 (n = 89), 2 to 3 (n = 153), and 4 or more (n = 37) risk factors were 9.0%, 22.2%, and 73.0%, respectively (P<.001). CONCLUSIONS: Among elderly patients hospitalized with heart failure, median survival is about 2.5 years. However, there is considerable heterogeneity in survival, with 25% of patients dying within 1 year and 25% surviving for more than 5 years. A simple 7-item risk score, based on data readily available at the time of admission, provides a reliable estimate of prognosis.

Age Factors↗
PubMed2006

Effects of digoxin on morbidity and mortality in diastolic heart failure: the ancillary digitalis investigation group trial.

BACKGROUND: About half of the 5 million heart failure patients in the United States have diastolic heart failure (clinical heart failure with normal or near-normal ejection fraction). Except for candesartan, no drugs have been tested in randomized clinical trials in these patients. Although digoxin was tested in an appreciable number of diastolic heart failure patients in the Digitalis Investigation Group ancillary trial, detailed findings from this important study have not previously been published. METHODS AND RESULTS: Ambulatory chronic heart failure patients (n = 988) with normal sinus rhythm and ejection fraction > 45% (median, 53%) from the United States and Canada (1991 to 1993) were randomly assigned to digoxin (n = 492) or placebo (n = 496). During follow-up with a mean length of 37 months, 102 patients (21%) in the digoxin group and 119 patients (24%) in the placebo group (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.63 to 1.07; P = 0.136) experienced the primary combined outcome of heart failure hospitalization or heart failure mortality. Digoxin had no effect on all-cause or cause-specific mortality or on all-cause or cardiovascular hospitalization. Use of digoxin was associated with a trend toward a reduction in hospitalizations resulting from worsening heart failure (HR, 0.79; 95% CI, 0.59 to 1.04; P = 0.094) but also a trend toward an increase in hospitalizations for unstable angina (HR, 1.37; 95% CI, 0.99 to 1.91; P = 0.061). CONCLUSIONS: In ambulatory patients with chronic mild to moderate diastolic heart failure and normal sinus rhythm receiving angiotensin-converting enzyme inhibitor and diuretics, digoxin had no effect on natural history end points such as mortality and all-cause or cardiovascular hospitalizations.

Aged↗
PubMed2006

Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF).

BACKGROUND: Although warfarin and other anticoagulants can prevent ischemic events, they can cause hemorrhage. Quantifying the rate of hemorrhage is crucial for determining the risks and net benefits of prescribing antithrombotic therapy. Our objective was to find a bleeding classification scheme that could quantify the risk of hemorrhage in elderly patients with atrial fibrillation. METHODS: We combined bleeding risk factors from existing classification schemes into a new scheme, HEMORR2HAGES, and validated all bleeding classification schemes. We scored HEMORR2HAGES by adding 2 points for a prior bleed and 1 point for each of the other risk factors: hepatic or renal disease, ethanol abuse, malignancy, older (age > 75 years), reduced platelet count or function, hypertension (uncontrolled), anemia, genetic factors, excessive fall risk, and stroke. We used data from quality improvement organizations representing 7 states to assemble a registry of 3791 Medicare beneficiaries with atrial fibrillation. RESULTS: There were 162 hospital admissions with an International Classification of Diseases, Ninth Revision, Clinical Modification code for hemorrhage. With each additional point, the rate of bleeding per 100 patient-years of warfarin increased: 1.9 for 0, 2.5 for 1, 5.3 for 2, 8.4 for 3, 10.4 for 4, and 12.3 for > or =5 points. In patients prescribed warfarin, HEMORR2HAGES had greater predictive accuracy (c statistic 0.67) than other bleed prediction schemes (P < .001). CONCLUSIONS: Adaptations of existing classification schemes, especially a new bleeding risk scheme, HEMORR2HAGES, can quantify the risk of hemorrhage and aid in the management of antithrombotic therapy.

Aged↗
PubMed2006

Prediction of medical morbidity and mortality after acute myocardial infarction in patients at increased psychosocial risk in the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study.

BACKGROUND: Patients with myocardial infarction (MI) are at further increased risk for untoward events when patients also exhibit low social support and/or depression. The ENRICHD study was the largest controlled trial in post-MI patients attempting to treat these psychological comorbidities and provides an opportunity to examine the medical and psychological characteristics that may affect risk in this population. METHODS: We analyzed the baseline characteristics and their relationship to the primary end point of long-term mortality and recurrent infarction and to the secondary end points of overall mortality and cardiovascular mortality in 2481 post-MI patients. Cox proportional hazards models were used to predict the risk of these outcomes over a mean of 2.5 years of follow-up. RESULTS: Death or nonfatal MI occurred in 24.1%, all-cause mortality in 13.7%, and cardiovascular mortality in 8.4% of the sample (62% of the total). Age, heart failure, pulmonary disease, Killip class, ejection fraction, an elevated creatinine, the use of non-angiotensin-coverting enzyme asodilators, prior MI, diabetes, depression, and bypass surgery after acute MI were all significant multivariable predictors. CONCLUSIONS: The medical predictors of adverse events in post-MI patients with low social support and/or depression were similar to those of patients with MI in other clinical trials.

Area Under Curve↗
PubMed2006

Effects of angiotensin-converting enzyme inhibitors in systolic heart failure patients with chronic kidney disease: a propensity score analysis.

BACKGROUND: Chronic kidney disease (CKD) is common in systolic heart failure (SHF) and is associated with poor outcomes. It is also associated with underuse of angiotensin-converting enzyme (ACE) inhibitors, yet the effect of these drugs in these (SHF-CKD) patients has not been well studied. The objective of this analysis was to determine if ACE inhibitor use was associated with reduction in mortality and hospitalization in SHF-CKD patients. METHODS AND RESULTS: Of the 6800 SHF patients (ejection fraction < or = 45%) in the Digitalis Investigation Group trial, 1707 had CKD (serum creatinine 1.3-2.5 mg/dL for women and 1.5-2.5 mg/dL for men). Propensity scores for ACE inhibitor use were calculated for each of the 1707 patients and were used to match 104 of the 127 no-ACE inhibitor patients with 104 ACE inhibitor patients. We estimated the effect of ACE inhibitor use on outcomes at 2 years using multivariable-adjusted Cox regression analyses. Overall, 35% of patients died and 67% were hospitalized. Compared with 30% of ACE inhibitor patients, 39% of no-ACE inhibitor patients died (adjusted HR = 0.58; 95% CI = 0.35-0.96; P = .034). Compared with 64% of ACE inhibitor patients, 69% of no-ACE inhibitor patients had hospitalizations from all causes (adjusted HR = 0.69; 95% CI = 0.48-0.98; P = .040). CONCLUSION: We observed an association between use of ACE inhibitor and reductions in mortality and hospitalization in ambulatory chronic SHF patients with mild to moderate CKD. However, the results of this observational study should be interpreted with caution, and need to be replicated in larger and more recent databases, and confirmed prospectively in well-designed follow-up studies and/or randomized clinical trials.

Aged↗
PubMed2006

Heart failure in older adults.

Heart failure affects approximately 5 million Americans, half of whom are at least 75 years of age, and is the leading cause of hospital admission among older adults. Additionally, the prevalence of heart failure is increasing, largely owing to the aging of the population. Heart failure in older adults differs in many respects from heart failure that occurs during middle age, including an increased proportion of women, increasing prevalence of heart failure with preserved left ventricular systolic function, and a marked increase in the number of coexisting medical conditions. In light of these factors, this article reviews the epidemiology, pathophysiology, clinical features, and treatment of heart failure in older adults.

Aged↗
PubMed2006

Isolation of health services research from practice and policy: the example of chronic heart failure management.

This study examined how health services research connects with practice and policy, first by investigating whether successful research projects continued in their test settings and engendered replication and then by examining whether a coherent body of research helped shape public policy. Chronic heart failure (CHF) was studied because randomized, controlled trials of posthospital CHF disease management have repeatedly demonstrated patient benefits and reduced costs, yet this practice has not become standard in the United States. Literature review produced 30 randomized, controlled trials of multidisciplinary outpatient CHF management, generally yielding improved patient outcomes. An e-mail survey of first authors (97% response rate) showed that practices proven to be effective in U.S. studies generally did not continue or expand (13 of 15 studies), mostly attributed to financial constraints (11 of 13), whereas similar projects in other countries often became permanent (7 of 13). U.S. respondents generally rated current quality of clinical care as good, whereas those elsewhere mostly rated it as excellent. Recent Medicare reforms implemented a model of CHF management substantially different from those studied in health services research. The Congressional hearings leading to these Medicare reforms, and the statute itself, mostly evidence the model used by commercial disease-management firms. Policy-makers, health service researchers, and funding agencies could develop more-effective methods for translating proven models of healthcare delivery into routine practice. Reforms that might improve the effectiveness of the linkages between research, policy, and practice are suggested.

Guideline Adherence↗
PubMed2006

The cardiomyopathy of iron deficiency.

Iron-deficiency anemia can have deleterious effects on the heart. Herein, we describe the effects of iron deficiency on the heart as corroborated with electrocardiography, radiology, echocardiography, and cardiac catheterization. We review the pathophysiology, clinical features, and management of iron-deficiency-induced cardiomyopathy.

Adult↗
PubMed2005

Digoxin and reduction in mortality and hospitalization in heart failure: a comprehensive post hoc analysis of the DIG trial.

AIMS: To determine the effects of digoxin on all-cause mortality and heart failure (HF) hospitalizations, regardless of ejection fraction, accounting for serum digoxin concentration (SDC). METHODS AND RESULTS: This comprehensive post-hoc analysis of the randomized controlled Digitalis Investigation Group trial (n=7788) focuses on 5548 patients: 1687 with SDC, drawn randomly at 1 month, and 3861 placebo patients, alive at 1 month. Overall, 33% died and 31% had HF hospitalizations during a 40-month median follow-up. Compared with placebo, SDC 0.5-0.9 ng/mL was associated with lower mortality [29 vs. 33% placebo; adjusted hazard ratio (AHR), 0.77; 95% confidence interval (CI), 0.67-0.89], all-cause hospitalizations (64 vs. 67% placebo; AHR, 0.85; 95% CI, 0.78-0.92) and HF hospitalizations (23 vs. 33% placebo; AHR, 0.62; 95% CI, 0.54-0.72). SDC> or =1.0 ng/mL was associated with lower HF hospitalizations (29 vs. 33% placebo; AHR, 0.68; 95% CI, 0.59-0.79), without any effect on mortality. SDC 0.5-0.9 reduced mortality in a wide spectrum of HF patients and had no interaction with ejection fraction >45% (P=0.834) or sex (P=0.917). CONCLUSIONS: Digoxin at SDC 0.5-0.9 ng/mL reduces mortality and hospitalizations in all HF patients, including those with preserved systolic function. At higher SDC, digoxin reduces HF hospitalization but has no effect on mortality or all-cause hospitalizations.

Adrenergic beta-Antagonists↗
PubMed2005

Office management of heart failure in the elderly.

Heart failure is one of the most common conditions affecting older patients seen by clinicians in routine office practice. This article reviews the clinical features, diagnosis, and management of heart failure in elderly patients evaluated in the ambulatory care setting, and provides concise, practical information relevant to all major aspects of care. Specific topics include the role of diagnostic testing, such as echocardiography and B-type natriuretic peptide; principles of nonpharmacological management, including patient education, diet, exercise, and daily weights; drug therapy for systolic heart failure as well as heart failure with preserved left ventricular systolic function; end-of-life issues; and when to refer the patient to a specialist. Although heart failure in the elderly differs in many important respects from heart failure occurring in middle-aged patients, the general approach to diagnosis and management is similar in younger and older patients.

Aged↗
PubMed2005

Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall.

PURPOSE: Patients at high risk for falls are presumed to be at increased risk for intracranial hemorrhage, and high risk for falls is cited as a contraindication to antithrombotic therapy. Data substantiating this concern are lacking. METHODS: Quality improvement organizations identified 1245 Medicare beneficiaries who were documented in the medical record to be at high risk of falls and 18261 other patients with atrial fibrillation. The patients were elderly (mean 80 years), and 48% were prescribed warfarin at hospital discharge. The primary endpoint was subsequent hospitalization for an intracranial hemorrhage, based on ICD-9 codes. RESULTS: Rates (95% confidence interval [CI]) of intracranial hemorrhage per 100 patient-years were 2.8 (1.9-4.1) in patients at high risk for falls and 1.1 (1.0-1.3) in other patients. Rates (95% CI) of traumatic intracranial hemorrhage were 2.0 (1.3-3.1) in patients at high risk for falls and 0.34 (0.27-0.45) in other patients. Hazard ratios (95% CI) of other independent risk factors for intracranial hemorrhage were 1.4 (1.0-3.1) for neuropsychiatric disease, 2.1 (1.6-2.7) for prior stroke, and 1.9 (1.4-2.4) for prior major bleeding. Warfarin prescription was associated with intracranial hemorrhage mortality but not with intracranial hemorrhage occurrence. Ischemic stroke rates per 100 patient-years were 13.7 in patients at high risk for falls and 6.9 in other patients. Warfarin prescription in patients prone to fall who had atrial fibrillation and multiple additional stroke risk factors appeared to protect against a composite endpoint of stroke, intracranial hemorrhage, myocardial infarction, and death. CONCLUSION: Patients at high risk for falls with atrial fibrillation are at substantially increased risk of intracranial hemorrhage, especially traumatic intracranial hemorrhage. However, because of their high stroke rate, they appear to benefit from anticoagulant therapy if they have multiple stroke risk factors.

Accidental Falls↗
PubMed2005

Shortness of breath, syncope, and cardiac arrest caused by systemic mastocytosis.

During a 3-month period, a 33-year-old man presented to the emergency department on 4 occasions with dyspnea, palpitations, and syncope. His initial presentation was accompanied by acute myocardial injury and ventricular fibrillation. An extensive evaluation spanned the 3 months and included echocardiography, cardiac catheterization, electrophysiology study, tilt-table evaluation, pulmonary angiography, electroencephalography, and serum and urine analysis. Diagnosis eluded clinicians until a rash was recognized to be urticaria pigmentosa, and biopsy of the rash then implicated mastocytosis. Since the initiation of pharmacotherapy nearly 5 years ago, the patient has remained asymptomatic. This case demonstrates that systemic mastocytosis can present as recurrent syncope and even as cardiac arrest. Diagnosis of this rare but potentially fatal disease is made particularly challenging by its protean manifestations.

Adult↗
PubMed2005

Infliximab-induced headache and infliximab-induced meningitis: two ends of the same spectrum?

This report describes a case of aseptic meningitis induced by the tumor necrosis factor-alpha inhibitor infliximab. The patient, a 51-year-old female, was being treated for Crohn's disease. After an infliximab infusion, she had headache, fever, arthralgia, myalgia, and meningismus. Cerebrospinal fluid analysis was remarkable for a neutrophilic pleocytosis and elevated protein. Other potential causes of meningitis were excluded. Her symptoms completely resolved within 24 hours of presentation. Because infliximab commonly causes headache and is very immunogenic, we infer that infliximab-induced meningitis is immune-mediated and underrecognized. Potential risk factors and means for minimizing its occurrence are offered.

Antibodies, Monoclonal↗