Digital health literacy is an extension of health literacy and uses the same operational definition, but in the context of technology. Technology solutions have the potential to both promote health literacy or be a barrier. To be effective, health technology solutions should go beyond building literacy and numeracy skills to functional and critical skills, such as navigating the healthcare system, communication with healthcare providers, and shared decision making. New and emerging technologies are highlighted: AI/machine learning, voice first, remote patient monitoring, wearables, and apps and web sites. Health technology represents enormous promise in the building of digital health literacy skills and improved health outcomes in patients with cardiovascular and other chronic conditions. This is a promise, however, that is yet to be fulfilled. Topics: Hypertension, Rehabilitation, Metabolic Syndrome, Health Policy, Risk Factor. (C) 2019 Elsevier B.V. All rights reserved.
Background: Mobile health applications may improve patient education and self-care for a complex condition such as atrial fibrillation (AF). Little is known about the accessibility of mobile health applications ("apps") and their readability. We evaluated the readability and quality of available apps for AF. Methods: We searched the Apple and Google Play app stores with the terms "atrial fibrillation" and "afib." We downloaded English-language apps (up to n = 100 for each term) and categorized them by name, App store, cost, content, uploading agency (heath care associated [HCA] versus non-HCA), target audience (health care professional [HCP] versus non-HCP), scientific validity (i.e., citation of peer-reviewed or validated medical information), and user ratings. We analyzed the text of apps intended for a non-HCP target audience for readability with 10 established measures. Results: Of the 206 downloaded apps, 50.5% were excluded as unrelated to AF, inaccessible, or non-English language. The majority of apps contained information about AF (63.2% Apple, 52.2% Google Play) and AF detection (52.6% Apple, 56.5% Google Play). A minority of non-HCP apps contained scientifically validated content (Apple, 15.8%; Google Play, 13.0%; P = NS). App mean readability was grade 12.1 +/- 2.6. Conclusions: Most AF apps lacked scientific validation and were written at excessively high reading-grade levels. Our results suggest caution with mobile health apps, particularly for users with limited health literacy. There is potential opportunity for a multi-disciplinary effort by regulatory agencies, healthcare organizations, and app stores to improve relevance, scientific validity, and readability of AF apps for patients with this complex and morbid disease. (C) 2019 Elsevier B.V. All rights reserved.
Aims: This study aimed to compare the diagnostic accuracy of stress myocardial perfusion imaging between cardiac magnetic resonance (CMR) and nuclear medical imaging, including single-photon emission computed tomography (SPECT) and positron emission tomography (PET), for the diagnosis of hemodynamically significant coronary artery disease (CAD) with fractional flow reserve (FFR) as the reference standard. Methods and results: We searched PubMed and Embase for all published studies that evaluated the diagnostic accuracy of stress myocardial perfusion imaging modalities, including CMR, SPECT, and PET, to diagnose hemodynamically significant CAD with FFR as the reference standard. A total of 28 articles met the inclusion criteria and were included in the meta-analysis: 14 CMR, 13 SPECT, and 5 PET articles. The results demonstrated a pooled sensitivity of 0.88 (95% confidence interval [CI]: 0.80-0.93), 0.69 (95% CI: 0.56-0.79), and 0.83 (95% CI: 0.70-0.91), and a pooled specificity of 0.89 (95% CI: 0.85-0.93), 0.85 (95% CI, 0.80-0.89), and 0.89 (95% CI, 0.86-0.91) for CMR, SPECT, and PET, respectively. The area under the curve (AUC) of CMR, PET, and SPECT was 0.94 (95% CI, 0.92-0.96), 0.92 (95% CI, 0.89-0.94), and 0.87 (95% CI, 0.83-0.89), respectively. Conclusions: CMR and PET both have high accuracy and SPECT has moderate accuracy to detect hemodynamically significant CAD with FFR as the reference standard. Furthermore, the diagnostic accuracy of CMR at 3.0 T is superior to 1.5 T. (C) 2019 Elsevier B.V. All rights reserved.
Increased native myocardial T1 times in chronic kidney disease (CKD) may be due to diffuse interstitial myocardial fibrosis (DIF) or due to interstitial edema/inflammation. Concerns relating to nephrogenic systemic fibrosis with gadolinium-based contrast agents (GBCA) limit their use in end-stage kidney disease (ESKD) to measure extracellular volume (ECV) and characterise myocardial fibrosis. This study aimed to examine stability of myocardial T1 and T2 times before, and within 2 months after kidney transplantation; a time frame when volume status normalises but myocardial remodelling is unlikely to have occurred, and to compare these with ECV using GBCA after transplantation. Twenty-four patients with ESKD underwent serial cardiovascular magnetic resonance imaging, including T1 and T2 mapping. GBCA was administered on follow-up provided eGFR was >30 ml/min/1.73 m(2). Eighteen age- and sex-matched controls were studied at one timepoint. ECV (ECV 28 +/- 2% vs. 24 +/- 2%, p = 0.001) and T2 times were higher in ESKD compared to controls. After transplantation, septal T1 times increased (MOLLI 985 ms +/- 25 vs. 1002 ms +/- 30, p = 0.014; ShMOLLI 974 ms +/- 39 vs. 992 ms +/- 33, p = 0.113), LV volumes reduced (LVEDvol indexed 79 +/- 24 vs. 63 +/- 20 ml/m(2), p = 0.005) but LV mass was unchanged (LV mass index 89 g/m(2) +/- 38 to 83 g/m(2) +/- 23, p = 0.141). T2 times did not change after transplantation. Both ECV and myocardial T1 times are elevated in ESKD, supporting the theory that elevated T1 times are due to DIF, although a contribution from myocardial edema cannot be fully excluded. The lack of any fall in T1 or T2 times after transplantation suggests that myocardial T1 times are a stable measure of DIF in CKD. (C) 2019 The Authors. Published by Elsevier B.V.
Plaque progression prediction is of fundamental significance to cardiovascular research and disease diagnosis, prevention, and treatment. Magnetic resonance image (MRI) data of carotid atherosclerotic plaques were acquired from 20 patients with consent obtained. 3D thin-layer models were constructed to calculate plaque stress and strain. Data for ten morphological and biomechanical risk factors were extracted for analysis. Wall thickness increase (WTI), plaque burden increase (PBI) and plaque area increase (PAI) were chosen as three measures for plaque progression. Generalized linear mixed models (GLMM) with 5-fold cross-validation strategy were used to calculate prediction accuracy and identify optimal predictor. The optimal predictor for PBI was the combination of lumen area (LA), plaque area (PA), lipid percent (LP), wall thickness (WT), maximum plaque wall stress (MPWS) and maximum plaque wall strain (MPWSn) with prediction accuracy = 1.4146 (area under the receiver operating characteristic curve (AUC) value is 0.7158), while PA, plaque burden (PB), WT, LP, minimum cap thickness, MPWS and MPWSn was the best for WTI (accuracy = 1.3140, AUC = 0.6552), and a combination of PA, PB, WT, MPWS, MPWSn and average plaque wall strain (APWSn) was the best for PAI with prediction accuracy = 1.3025 (AUC = 0.6657). The combinational predictors improved prediction accuracy by 9.95%, 4.01% and 1.96% over the best single predictors for PAI, PBI and WTI (AUC values improved by 9.78%, 9.45%, and 2.14%), respectively. This suggests that combining both morphological and biomechanical risk factors could lead to better patient screening strategies. (C) 2019 Elsevier B.V. All rights reserved.
Background: Drug treatment for secondary prevention of cardiovascular disease is recommended by guidelines, but it is not always followed in real life. This study wanted to assess the size of this gap and its impact on mortality in subjects after a cardiovascular event (MACE). Methods: Patients with any of MACE in the period from January 1st 2011 to December 31st 2013, and more than one year of follow-up were selected from population of the Valencian Community. Drugs for secondary prevention were antiplatelets, renin-angiotensin system blockers and statins. Assessment of treatment was performed one year after the initial event. Mortality risk was assessed using Cox by the number of drug classes (G0 no medication, G1 one, G2 two and G3 three drugs) adjusted by confounders. Results: A total of 92,436 patients (62% men, mean age 72 years) of whom 60.5% presented with stroke, 30.6% with myocardial infarction and 8.9% with revascularization were included. Among them, 4.1% were G0, 20.2% G1, 32.9% G2 and 42.7% G3. A progressive decrease in mortality was observed in G1 (HR 0.83, CI 95% 0.73-0.95), G2 (HR 0.70, CI 95% 0.60-0.82) and G3 (HR 0.61, CI95% 0.51-0.74) vs. G0. In diabetic subgroup, significant reduction of risk was observed in the G2 (0.79, CI 95% 0.63-0.98) and G3 (0.72, CI9 5% 0.56-0.95), but not in G1 (0.97, CI 95% 0.80-1.17). Conclusion: A gap between guidelines and reality in the use of cardiovascular protecting drugs one year after the initial event still exists and it is largely related with all-cause late mortality. (C) 2019 Elsevier B.V. All rights reserved.
Background: In patients undergoing dialysis therapy, mitral annular calcification (MAC) is a powerful predictor of cardiovascular events and all-cause mortality. However, there is little data on predictors for MAC progression in patients undergoing dialysis therapy. Methods and results: We retrospectively analyzed 98 hemodialysis-dependent patients in Japanese Red Cross Kumamoto Hospital who underwent routine transthoracic echocardiography (TTE) in 2017. Three patients with history of surgical valve replacement or severe valvular heart diseases were excluded. In the 95 enrolled patients, MAC was detected by TTE in 28 patients (29%). A multivariate logistic regression analysis revealed that duration of hemodialysis therapy was independently associated with presence of MAC (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.02-1.16; p < 0.01). Among the 95 patients, 72 patients also underwent routine TTE 5 years previously in 2012. In these patients, progression of MAC from 2012 to 2017 was observed in 11 patients (15%). A multivariate logistic regression analysis revealed that number of coronary risk factors (OR: 2.67; 95% CI: 1.24-5.76; p = 0.01), baseline MAC diameter (OR: 1.23; 95% CI: 1.05-1.45; p = 0.01), and left atrial diameter (OR: 0.81; 95% CI: 0.68-0.95; p = 0.01) were significantly associated with progression of MAC. Conclusions: Accumulation of coronary risk factors was associated with progression of MAC in patients undergoing dialysis. Management of coronary risk factors may be important for inhibition of MAC progression. (C) 2019 Elsevier B.V. All rights reserved.
Background: A sustained low grade inflammatory state is a recognized feature of various diseases, including cardiovascular disease. This state of chronic inflammation involves activation of Toll-like receptor (TLR) signaling. However, little is known regarding the genetic profile of TLR components in cardiac tissue from patients with cardiac disease. Methods: In this study we investigated the genetic profile of 84 TLR markers in a unique set of cardiac tissue from patients that had undergone either coronary artery bypass grafting (CABG) or aortic valve replacement (AVR). In addition, we compared the gene data from the cardiac tissue with the same gene profile in blood as well as circulating cytokines to elucidate possible targets in blood that could be used to estimate the inflammatory state of the heart in cardiac disease. Results: We found a marked upregulation of TLR-induced inflammation in cardiac tissue from both patient groups compared to healthy controls. The inflammation appeared to be primarily mediated through TLR1, 3, 7, 8 and 10, resulting in a marked induction of mediators of the innate immune response. Furthermore, the gene expression data in combination with unbiased multivariate analysis suggested a difference in inflammatory response in ischemic cardiac tissue compared to non-ischemic cardiac tissue. Serum levels of IL-13 were significantly elevated in both CABG and AVR patients compared to controls, whereas other cytokines did not appear to coincide with cardiac TLR-induced inflammation. Conclusions: We propose that cardiac disease in humans may be mediated by local cardiac TLR signaling under both ischemic and non-ischemic conditions. (C) 2019 Elsevier B.V. All rights reserved.
Objective: To evaluate the role of YKL-40 as a biomarker of disease activity in patients with Takayasu arteritis (TA). Methods: The study included 40 patients diagnosed with TA between January 2017 and January 2018. 40 age and sex matched healthy controls were included. Serum levels of YKL-40, as well as IL-6, IL-8, IL-17, sCD163, VEGF, MMP-2, MMP-9, OPN, PTX-3 and IFN-gamma, were detected at the base line and end of the 6-month follow-up. Modified Kerr criteria, in which MRA was performed instead of traditional angiography, was used a standard measure of disease activity. The association of the measured biomarkers with disease activity was analysed. Results: The serum levels of YKL-40, IL-6, IL-8, IFN-gamma, MMP-2, MMP-9, PTX-3 and OPN were significantly higher in active disease than in inactive disease. Significant differences in the serum levels of YKL-40, IL-6 and PTX-3 were also observed according to the disease activity degree. Logistic analysis demonstrated that high YKL-40 levels and high IL-6 levels were independent risk factors for active disease. When YKL-40 was combined with IL-6, the specificity and sensitivity for detecting active disease were increased (87.6% and 70.4% respectively); similar findings were obtained when YKL-40 was combined with CRP (72.3% and 84.6% respectively). A predictive model of active disease using ESR, CRP, IL-6, PTX-3 and MMP-9 showed significantly improved diagnostic efficiency when YKL-40 was added to the model (sensitivity: 85.1%; specificity: 94.3%; NRI value: 12.4%; IDI value: 4.6%, p < 0.05). Conclusions: Serum YKL-40 concentrations may be a useful biomarker of disease activity in TA. (C) 2019 Elsevier B.V. All rights reserved.