Author Interviews, Exercise - Fitness, Heart Disease, JACC / 13.02.2016
Beet Root Juice Improved Exercise Endurance in Heart Failure With Preserved Ejection Fraction
MedicalResearch.com Interview with:
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Dr. Daniel Kim-Shapiro[/caption]
Daniel Kim-Shapiro, PhD
Professor and Associate Chair of Physics
Harbert Family Distinguished Chair
Director, Translational Science Center
Wake Forest University
Medical Research: What is the background for this study? What are the main findings?
Dr. Kim-Shapiro: Heart failure with preserved ejection fraction (HDPEF) is the most common form of heart failure. It is characterized by poor perfusion to active muscles which results in poor exercise capacity and a poor quality of life. Currently, the only effective treatment for this condition is aerobic exercise.
Several studies have shown that dietary nitrate, usually in the form of beet root juice, increases nitric oxide bioavaiability in a way that targets areas of low oxygen so that perfusion increases where it is needed. This action relies on conversion of nitrate to nitrite by oral bacteria with subsequent conversion of nitrite to nitric oxide. Nitrite from the blood is taken up by salivary glands so that dosing with dietary nitrate can be long-lasting.
The main finding of this study was that daily intake of high nitrate containing beet root juice improved exercise endurance in patients with HFPEF.
Dr. Daniel Kim-Shapiro[/caption]
Daniel Kim-Shapiro, PhD
Professor and Associate Chair of Physics
Harbert Family Distinguished Chair
Director, Translational Science Center
Wake Forest University
Medical Research: What is the background for this study? What are the main findings?
Dr. Kim-Shapiro: Heart failure with preserved ejection fraction (HDPEF) is the most common form of heart failure. It is characterized by poor perfusion to active muscles which results in poor exercise capacity and a poor quality of life. Currently, the only effective treatment for this condition is aerobic exercise.
Several studies have shown that dietary nitrate, usually in the form of beet root juice, increases nitric oxide bioavaiability in a way that targets areas of low oxygen so that perfusion increases where it is needed. This action relies on conversion of nitrate to nitrite by oral bacteria with subsequent conversion of nitrite to nitric oxide. Nitrite from the blood is taken up by salivary glands so that dosing with dietary nitrate can be long-lasting.
The main finding of this study was that daily intake of high nitrate containing beet root juice improved exercise endurance in patients with HFPEF.
Prof. Ian Wong[/caption]
MedicalResearch.com Interview with:
Professor Ian C K Wong
Fellow of Royal Pharmaceutical Society
Fellow of Royal College of Paediatrics and Child Health (Honorary)
Fellow of the Higher Education Academy
Chair in Pharmacy Practice
Head of Research Department of Practice and Policy
UCL School of Pharmacy
London
Medical Research: What is the background for this study? What are the main findings?
Dr. Wong: Previous studies had showed an increased cardiovascular risk associated with clarithromycin (a widely used antibiotic) but the duration of effect remained unclear. Therefore, we conducted this study to investigate the duration of cardiovascular adverse effect provided that the risk exists after patients receiving clarithromycin in Hong Kong. We used three study designs to examine the association (temporal relationship) between clarithromycin and cardiovascular adverse outcomes such as myocardial infarction, arrhythmia, stroke, cardiac mortality at different time points.
Dr. Frank Rybicki[/caption]
MedicalResearch.com Interview with:
Frank J. Rybicki, MD, PhD
Professor, Chair and Chief, Department of Radiology
The University of Ottawa, Faculty of Medicine and
The Ottawa Hospital
Editor-in-Chief, 3D Printing in Medicine
Medical Research: What is the background for this document?
Dr. Rybicki: This document represents a conglomeration of the approach to appropriateness of three large medical professional groups. The American College of Radiology Appropriateness Criteria® are evidence based guidelines to assist referring physicians to order the most appropriate imaging test for a wide range of clinical scenarios. The Appropriateness Criteria are divided by organ section, and while they include emergent imaging studies, there is not a single publication to provide imaging guidance for patients who present to the emergency room with chest pain. The American College of Cardiology Appropriate Use Criteria provides evidence based data for a very large gamut of cardiovascular conditions. These guidelines include emergent cardiovascular imaging; however the Appropriate Use Criteria are divided by modality and like the ACR have not specially addressed this important, high risk patient population. The American College of Emergency Physicians, a key stakeholder group that represents referring physicians, has developed a large number of guidelines but also has not organized this group of imaging recommendations. Thus, the background of this document was a joint effort among all three societies to update, harmonize, and publish contemporary guidelines that can be readily incorporated into clinical practice but also provide standards for a large fraction of patients who come to the emergency room with chest pain who require imaging to evaluate for a life threatening diagnosis.
Medical Research: What types of chest pain conditions are covered by these guidelines?
Dr. Rybicki: Based on the background as noted above, the Writing Group for this important document included cardiologists, emergency physicians, and radiologists. Since the group was charged with describing common clinical scenarios seen in contemporary practice, there are four entry points for chest pain conditions. They are as follows:
Dr. Yitschak Biton[/caption]
MedicalResearch.com Interview with:
Yitschak (Yitsik) Biton, MD
Postdoctoral Research Fellow
University of Rochester Medical Center
Saunders Research Building
Heart Research Follow-Up Program
Rochester, NY
Medical Research: What is the background for this study? What are the main findings?
Dr. Biton: Patients with heart failure and reduced ejection fraction have increased risk for sudden cardiac death due to ventricular arrhythmias. The causes of these arrhythmias are thought to be adverse left ventricular remodeling and scarring. Cardiac resynchronization therapy has been previously shown to reverse the adverse process of remodeling and induce reduction in cardiac chamber volumes. Relative wall thickness is a measure of the remodeling process, and it could be classified into normal, eccentric and concentric. In our study we showed that the degree relative wall thickness in patients with dilated cardiomyopathy and eccentric hypertrophy is inversely associated with the risk of ventricular arrhythmias. Furthermore we showed the CRT treated patients who had increase in relative wall thickness (became less eccentric) had lower risk for ventricular arrhythmias.
Prof. De Caterina[/caption]
Prof. Raffaele De Caterina M.D., Ph.D
University Cardiology Division G. d'Annunzio University
Medical Research: What is the background for this study? What are the main findings?
Dr. De Caterina: There is uncertainty on how to predict bleeding upon treatment with anticoagulants, because bleeding risk scores and thromboembolic risk score fare very similarly in predicting bleeding, making the net clinical benefit difficult to assess in the single patient. Here we find that a history of bleeding – even minor bleeding – has an important prognostic value on the risk of future bleeding – virtually all sorts of future bleeding, with the notable exception of intracranial hemorrhage. Some novel oral anticoagulants (NOACs), such as apixaban, studied here, reduce the risk of major bleeding, and appear to benefit independent of the bleeding history.
Dr. Ajay Dharod[/caption]
Dr. Islam Elgendy[/caption]
MedicalResearch.com Interview with:
Dr.James DiNicolantonio[/caption]
MedicalResearch.com Interview with:
James J. DiNicolantonio, PharmD
Associate Editor BMJ Open Heart
Cardiovascular Research Scientist
Saint Luke's Mid America Heart Institute
Medical Research: What is the background for this study? What are the main findings?
Dr. DiNicolantonio: We comprehensively reviewed the literature looking at the cardiovascular effects of saturated fat and compared them with refined sugars (sucrose and high-fructose corn syrup). Our main finding is that saturated fat per se is not necessarily unhealthy. Importantly, people eat foods, not saturated fat, and depending on what foods are consumed determines if saturated fat associates with health risk. For example, the consumption of processed meat is associated with an increased risk of cardiovascular disease, whereas dairy is not. Importantly, the replacement of saturated fat with refined sugars seems to increase the risk of myocardial infarction. Hence, reducing added sugars should be the main focus rather than reducing saturated fat, as the latter could translate to reductions in healthy whole foods that just so happen to also be high in saturated fat (but also provide other healthy fats).
MedicalResearch.com Interview with:
Tanush Gupta, MD
Chief Resident & Instructor of Medicine and
Prakash Harikrishnan, MD
Fellow in Cardiology
New York Medical College at
Westchester Medical Center
Valhalla, NY
Medical Research: What is the background for this study?
Response: Complete heart block (CHB) is a relatively frequent complication in patients hospitalized with ST-elevation myocardial infarction (STEMI). Patients who develop complete heart block in the setting of STEMI have a 3- to 5-fold increase in in-hospital mortality compared to those without CHB. However, most of the existing reports on CHB complicating STEMI are from the pre-thrombolytic and thrombolytic era in the 1980s and 1990s, before the widespread use of percutaneous coronary intervention (PCI) and advent of modern adjunctive medical therapies.
Hence, the purpose of this investigation was to examine the association of complete heart block with in-hospital outcomes in patients hospitalized with STEMI and to examine the temporal trends in the incidence and outcomes of CHB complicating STEMI using the National Inpatient Sample (NIS) databases from 2003 to 2012.
Dr. Victor Serebruany[/caption]
MedicalResearch.com Interview with:
Dr. Sunil Sharma[/caption]
MedicalResearch.com Interview with:
Sunil Sharma MD, FAASM
Associate Professor of Medicine
Director, Pulmonary Sleep Medicine
Associate Director, Jefferson Sleep Disorders Center
Thomas Jefferson University and Hospitals
Philadelphia, PA 19107
Medical Research: What is the background for this study?
Dr. Sharma: Congestive heart failure (CHF) is the most common cause of hospital admission and readmissions in United States. More health care dollars are spent on CHF than any other diagnosis. A large chunk of this cost is due to hospital admission. An estimated 50% of the CHF patients are readmitted within 6 months of discharge. The recent Protection Affordable Care Act (ACA) imposes penalties on hospitals for readmissions within first 30-days. It is therefore imperative to find ways to impact the natural history of the disease.
Sleep disordered breathing is a common disorder associated with 
Dr. Green[/caption]
MedicalResearch.com Interview with:
Ariel R. Green, M.D., M.P.H
Assistant Professor of Medicine
Johns Hopkins University School of Medicine
Medical Research: What is the background for this study? What are the main findings?
Response: Implantable cardioverter-defibrillators (ICDs) are widely used to prevent sudden cardiac death in patients with systolic heart failure. Older adults with heart failure often have multiple coexisting conditions and are frail, increasing their risk of death from non-cardiac causes. Our understanding of outcomes in older patients with ICDs is limited.
Medical Research: What should clinicians and patients take away from your report?
Response: Our major finding was that more than 10% of patients currently receiving ICDs for primary prevention of sudden cardiac death (meaning that they have never had a potentially lethal arrhythmia but are at risk for one, usually due to systolic heart failure) are frail or have dementia. Patients with these geriatric conditions had substantially higher mortality within the first year after ICD implantation than those without these conditions. 
Dr. Dalane Kitzman[/caption]
MedicalResearch.com Interview with:
Dalane W. Kitzman, M.D.
Professor, Cardiology
Sticht Center on Aging
Gerontology and Geriatric Medicine
Translational Science Institute
Wake-Forest Baptist Health
Winston-Salem, NC
Medical Research: What is the background of the research?
Dr. Kitzman: Heart Failure With Preserved Ejection Fraction (HFPEF) is a relatively recently recognized disorder. It used to be thought that it was rare. However, we now realize that HFPEF is the dominant form of heart failure in America. It is also the fastest growing cardiovascular disorder. Interestingly, this disorder occurs almost exclusively among older persons, particularly women. The need is great because outcomes in persons with HFPEF (death, rehospitalization, health care costs) are worsening. This stands in contrast to most other cardiovascular disorders which are on the decline and / or are experiencing greatly improved outcomes. Remarkably, all of the large studies that have used medications in HFPEF that seemed they should be ‘sure bets’ showed no benefit for their primary outcomes. Thus, this is also the only major cardiovascular disorder where there is no proven medication treatment. That means physicians take ‘educated guesses’ in choosing treatment for this large group of patients.
The main symptom in patients with chronic HFPEF is shortness of breath and and fatigue with exertion. We showed in 2002 in JAMA that when we objectively measured this symptom with expired gas analysis (Peak VO2), this was as severely decreased in HFPEF as in patients with HFREF (severely reduced EF), the classic, well accepted form of heart failure. That and other studies helped lead to acceptance of HFPEF as a true Heart Failure disorder.
We first showed 5 years ago that 4 months of exercise training improves peak VO2 and quality of life in patients with HFPEF. In fact, exercise remains the only proven means to improve these patients’ chronic symptoms.
The goal of our study was to determine if weight loss diet also improved peak VO2 and quality of life in HFPEF patients, alone and in combination with exercise training. This was based on the under-recognized fact that over 80% of Heart Failure With Preserved Ejection Fraction patients are overweight or obese. It was already known that weight loss diet in other groups of older persons improves peak VO2 and quality of life. And small studies of 
Dr. Daniel Mulrooney[/caption]
MedicalResearch.com Interview with:
Daniel A. Mulrooney, MD, MS
Cancer Survivorship
Jude Children's Research Hospital
TN 38105-3678
Medical Research: What is the background for this study? What are the main findings?
Dr. Mulrooney: This is a cross-sectional analysis performed in the St. Jude Lifetime Cohort Study (SJLIFE), an ongoing study designed to facilitate longitudinal evaluation of health outcomes among adults previously treated for childhood cancer. Following patients over the life spectrum can be challenging making it difficult to understand the long-term health effects of childhood cancer therapy. Previous studies have relied on self-report, registry, or death certificate data. Our study is novel because we clinically evaluated cancer survivors on the St. Jude campus and identified substantial, asymptomatic cardiac disease (cardiomyopathy, coronary artery disease, valvular disease, and conduction/rhythm disorders).