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1.
Impact of cardiorespiratory fitness on outcomes in cardiac rehabilitation.
Tutor, A, Lavie, CJ, Kachur, S, Dinshaw, H, Milani, RV
Progress in cardiovascular diseases. 2022;:2-7
Abstract
Cardiovascular rehabilitation (CR) significantly improves outcomes in patients with cardiovascular diseases (CVD), especially coronary heart disease and heart failure (HF). Although CR is often considered as an exercise training (ET) program for patients following CVD events, CR is more than just ET as it involves education, dietary and psychological counseling, as well as a multi-factorial risk factor modification. However, a major component of ET involves efforts to measure and improve levels of cardiorespiratory fitness (CRF). In this state-of-the-art review, we analyze the data, including from our John Ochsner Heart and Vascular Institute, evaluating CRF and its impact on psychological improvements and major outcomes with CR, especially long-term survival.
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2.
Effect of Omega-3 Dosage on Cardiovascular Outcomes: An Updated Meta-Analysis and Meta-Regression of Interventional Trials.
Bernasconi, AA, Wiest, MM, Lavie, CJ, Milani, RV, Laukkanen, JA
Mayo Clinic proceedings. 2021;96(2):304-313
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Plain language summary
There is mixed evidence to support the use of omega-3 fatty acids for the prevention and treatment of cardiovascular disease. Animal studies have shown promising results, but randomised control trials are inconsistent, possibly due to differing doses used, or differences in the subject’s omega-3 levels at the start of the trial. This meta-analysis of 40 studies with over 135,000 subjects aimed to determine whether omega-3 supplementation reduces heart disease risk and whether dosage has a role. The results showed that omega-3 supplementation reduced the risk of heart attacks, death from heart attacks and deaths due to heart disease, and the higher the dose, the greater the protection. The majority of studies were on individuals who had already had a heart attack or who had suffered from a related condition. It was concluded that supplementation with omega-3 is effective in preventing heart disease and heart attacks and the protective effect increases with dosage. This study could be used by healthcare professionals to prevent further heart disease and heart attacks in individuals who have already suffered from one of these conditions.
Abstract
OBJECTIVES To quantify the effect of eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids on cardiovascular disease (CVD) prevention and the effect of dosage. METHODS This study is designed as a random effects meta-analysis and meta-regression of randomized control trials with EPA/DHA supplementation. This is an update and expanded analysis of a previously published meta-analysis which covers all randomized control trials with EPA/DHA interventions and cardiovascular outcomes published before August 2019. The outcomes included are myocardial infarction (MI), coronary heart disease (CHD) events, CVD events (a composite of MI, angina, stroke, heart failure, peripheral arterial disease, sudden death, and non-scheduled cardiovascular surgical interventions), CHD mortality and fatal MI. The strength of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework. RESULTS A total of 40 studies with a combined 135,267 participants were included. Supplementation was associated with reduced risk of MI (relative risk [RR], 0.87; 95% CI, 0.80 to 0.96), high certainty number needed to treat (NNT) of 272; CHD events (RR, 0.90; 95% CI, 0.84 to 0.97), high certainty NNT of 192; fatal MI (RR, 0.65; 95% CI, 0.46 to 0.91]), moderate certainty NNT = 128; and CHD mortality (RR, 0.91; 95% CI, 0.85 to 0.98), low certainty NNT = 431, but not CVD events (RR, 0.95; 95% CI, 0.90 to 1.00). The effect is dose dependent for CVD events and MI. CONCLUSION Cardiovascular disease remains the leading cause of death worldwide. Supplementation with EPA and DHA is an effective lifestyle strategy for CVD prevention, and the protective effect probably increases with dosage.
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An Update on Omega-3 Polyunsaturated Fatty Acids and Cardiovascular Health.
Elagizi, A, Lavie, CJ, O'Keefe, E, Marshall, K, O'Keefe, JH, Milani, RV
Nutrients. 2021;(1)
Abstract
Interest in the potential cardiovascular (CV) benefits of omega-3 polyunsaturated fatty acids (Ω-3) began in the 1940s and was amplified by a subsequent landmark trial showing reduced CV disease (CVD) risk following acute myocardial infarction. Since that time, however, much controversy has circulated due to discordant results among several studies and even meta-analyses. Then, in 2018, three more large, randomized trials were released-these too with discordant findings regarding the overall benefits of Ω-3 therapy. Interestingly, the trial that used a higher dose (4 g/day highly purified eicosapentaenoic acid (EPA)) found a remarkable, statistically significant reduction in CVD events. It was proposed that insufficient Ω-3 dosing (<1 g/day EPA and docosahexaenoic acid (DHA)), as well as patients aggressively treated with multiple other effective medical therapies, may explain the conflicting results of Ω-3 therapy in controlled trials. We have thus reviewed the current evidence regarding Ω-3 and CV health, put forth potential reasoning for discrepant results in the literature, highlighted critical concepts such as measuring blood levels of Ω-3 with a dedicated Ω-3 index and addressed current recommendations as suggested by health care professional societies and recent significant scientific data.
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4.
Omega-3 Polyunsaturated Fatty Acids and Cardiovascular Health: A Comprehensive Review.
Elagizi, A, Lavie, CJ, Marshall, K, DiNicolantonio, JJ, O'Keefe, JH, Milani, RV
Progress in cardiovascular diseases. 2018;(1):76-85
Abstract
The potential cardiovascular (CV) disease (CVD) benefits of Omega-3 Polyunsaturated Fatty Acids (OM3) have been intensely studied and debated for decades. Initial trials were performed in patients with low use of maximal medical therapy for CVD, and reported significant mortality benefits with the use of 1 g/day OM3 intervention following myocardial infarction (MI). More recent studies, including cohorts of patients receiving modern guideline directed medical therapy for CVD, have often not shown similar benefits with OM3 use. We conducted a literature review using PubMed, professional society guidelines, specific journal databases including New England Journal of Medicine and Journal of the American College of Cardiology from January 1, 2007 to December 31, 2017. References from selected articles were also reviewed, as well as key articles outside of the selected time-frame for their important findings or historical perspectives. Currently, there are no Class I recommendations from the American Heart Association (AHA) for the use of OM3, however, considering the safety of this therapy and beneficial findings of some modern studies (including patients with current maximal medical therapy for CVD), the AHA has recently expanded their list of Class II recommendations, in which treatment with OM3 for CVD benefit is reasonable. This review discusses the current state of the evidence, summarizes current professional recommendations, and provides recommendations for future research.
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An Overview and Update on Obesity and the Obesity Paradox in Cardiovascular Diseases.
Elagizi, A, Kachur, S, Lavie, CJ, Carbone, S, Pandey, A, Ortega, FB, Milani, RV
Progress in cardiovascular diseases. 2018;(2):142-150
Abstract
Obesity increases a number of cardiovascular disease (CVD) risk factors, but patients with many types of CVD may have a better prognosis if classified as overweight or obese, a phenomenon known as the "obesity paradox". This paradoxical benefit of a medically unfavorable phenotype is particularly strong in the overweight and class I obesity, and less pronounced in the more severe or morbidly obese populations (class II-III and greater). Rather than an obesity paradox, it is possible that this phenomenon may represent a "lean paradox", in which individuals classified as normal weight or underweight may have a poorer prognosis with respect to CVD, as a result of a progressive catabolic state and lean mass loss. Cardiorespiratory fitness (CRF) is a fundamental part of this discussion. A greater CRF is associated with lower CVD risk, regardless of body mass index (BMI). Also, the assessment of body composition compartments (i.e., fat mass, fat-free mass, lean mass) and the presence of metabolic derangements may be better indicators of CVD risk than BMI alone. The focus of this review is to summarize the current evidence of the obesity paradox. Moreover, we discuss the utility and limitations of BMI for cardiometabolic risk stratification, in addition to concepts such as "metabolically healthy obesity" (MHO) and the "fat but fit" phenomenon, which describe patients who are diagnosed with obesity using BMI, but without major metabolic derangements and with greater CRF, respectively. Finally, we propose that obese patients presenting with an excess body fat, yet without metabolic abnormalities, should still be viewed as an "at risk" population, and as such should receive advice to change their lifestyle to improve their CRF and to prevent the development of impaired fasting glucose, diabetes mellitus and other CVD risk factors as a form of primary prevention.
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6.
Management of cardiovascular diseases in patients with obesity.
Lavie, CJ, Arena, R, Alpert, MA, Milani, RV, Ventura, HO
Nature reviews. Cardiology. 2018;(1):45-56
Abstract
The management of cardiovascular diseases (CVD) in patients with obesity presents numerous challenges. Obesity has a negative effect on almost all of the major CVD risk factors, and adversely influences cardiovascular structure and function. Patients who are overweight or obese have a higher incidence of almost all CVDs compared with patients who are of normal weight. However, those who are overweight or obese seem to have a better short-term and medium-term prognosis after major CVD events and interventional procedures or cardiac surgeries than leaner patients, a phenomenon termed the 'obesity paradox'. In considering the mechanisms underlying this paradox, we review evidence of the deleterious consequences of obesity in patients with coronary heart disease, and the limited data on the benefits of weight loss in patients with CVD. Additional studies are needed on the efficacy of purposeful weight loss on cardiovascular outcomes to determine the ideal body composition for patients with CVD.
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7.
Improving Hypertension Control and Patient Engagement Using Digital Tools.
Milani, RV, Lavie, CJ, Bober, RM, Milani, AR, Ventura, HO
The American journal of medicine. 2017;(1):14-20
Abstract
Hypertension is present in 30% of the adult US population and is a major contributor to cardiovascular disease. The established office-based approach yields only 50% blood pressure control rates and low levels of patient engagement. Available home technology now provides accurate, reliable data that can be transmitted directly to the electronic medical record. We evaluated blood pressure control in 156 patients with uncontrolled hypertension enrolled into a home-based digital-medicine blood pressure program and compared them with 400 patients (matched to age, sex, body mass index, and blood pressure) in a usual-care group after 90 days. Digital-medicine patients completed questionnaires online, were asked to submit at least one blood pressure reading/week, and received medication management and lifestyle recommendations via a clinical pharmacist and a health coach. Blood pressure units were commercially available that transmitted data directly to the electronic medical record. Digital-medicine patients averaged 4.2 blood pressure readings per week. At 90 days, 71% of digital-medicine vs 31% of usual-care patients had achieved target blood pressure control. Mean decrease in systolic/diastolic blood pressure was 14/5 mm Hg in digital medicine, vs 4/2 mm Hg in usual care (P < .001). Excess sodium consumption decreased from 32% to 8% in the digital-medicine group (P = .004). Mean patient activation increased from 41.9 to 44.1 (P = .008), and the percentage of patients with low patient activation decreased from 15% to 6% (P = .03) in the digital-medicine group. A digital hypertension program is feasible and associated with significant improvement in blood pressure control rates and lifestyle change. Utilization of a virtual health intervention using connected devices improves patient activation and is well accepted by patients.
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8.
Impact of cardiac rehabilitation and exercise training programs in coronary heart disease.
Kachur, S, Chongthammakun, V, Lavie, CJ, De Schutter, A, Arena, R, Milani, RV, Franklin, BA
Progress in cardiovascular diseases. 2017;(1):103-114
Abstract
Cardiovascular rehabilitation (CR) is the process of developing and maintaining an optimal level of physical, social, and psychological well-being in order to promote recovery from cardiovascular (CV) illness. It is a multi-disciplinary approach encompassing supervised exercise training, patient counseling, education and nutritional guidance that may also enhance quality of life. Beneficial CV effects may include improving coronary heart disease risk factors; particularly exercise capacity, reversing cardiac remodeling, and favorably modifying metabolism and systemic oxygen transport. We review the historical basis for contemporary CR, the indications and critical components of CR, as well as the potential salutary physiological and clinical effects of exercise-based CR.
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9.
Obesity and cardiovascular diseases.
Kachur, S, Lavie, CJ, de Schutter, A, Milani, RV, Ventura, HO
Minerva medica. 2017;(3):212-228
Abstract
Obesity is increasingly more common in postindustrial societies, and the burden of childhood obesity is increasing. The major effects of obesity on cardiovascular (CV) health are mediated through the risk of metabolic syndrome (insulin-resistance, dyslipidemia, and hypertension), such that an absence of these risk factors in obese individuals may not be associated with increased mortality risk. In individuals already diagnosed with chronic CV disease (CVD), the overweight and class I obese have significant associations with improved survival. However, this effect is attenuated by increases in cardiorespiratory fitness. The negative effects of obesity on CV health manifest as accelerated progression of atherosclerosis, higher rates of ventricular remodeling and a higher risk of associated diseases, including stroke, myocardial infarction, and heart failure. The most effective therapies at reversing CVD risk factors associated with obesity have been dietary changes with exercise, especially through structured exercise programs, such as cardiac rehabilitation.
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Obesity and Prevalence of Cardiovascular Diseases and Prognosis-The Obesity Paradox Updated.
Lavie, CJ, De Schutter, A, Parto, P, Jahangir, E, Kokkinos, P, Ortega, FB, Arena, R, Milani, RV
Progress in cardiovascular diseases. 2016;(5):537-47
Abstract
The prevalence and severity of obesity have increased in the United States and most of the Westernized World over recent decades, reaching worldwide epidemics. Since obesity worsens most of the cardiovascular disease (CVD) risk factors, not surprisingly, most CVDs, including hypertension, coronary heart disease, heart failure, and atrial fibrillation, are all increased in the setting of obesity. However, many studies and meta-analyses have demonstrated an obesity paradox with regards to prognosis in CVD patients, with often the overweight and mildly obese having a better prognosis than do their leaner counterparts with the same CVD. The implication for fitness to markedly alter the relationship between adiposity and prognosis and the potential impact of weight loss, in light of the obesity paradox, are all reviewed.