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Background: Team-based care (TBC), a team of ≥2 healthcare professionals working collaboratively toward a shared clinical goal, is a recommended strategy to manage blood pressure (BP). However, the most effective and cost-effective TBC strategy is unknown. Methods: A meta-analysis of clinical trials in US adults (aged ≥20 years) with uncontrolled hypertension (≥140/90 mm Hg) was performed to estimate the systolic BP reduction for TBC strategies versus usual care at 12 months. TBC strategies were stratified by the inclusion of a nonphysician team member who could titrate antihypertensive medications. The validated BP Control Model-Cardiovascular Disease Policy Model was used to project the expected BP reductions out to 10 years and simulate cardiovascular disease events, direct healthcare costs, quality-adjusted life years, and cost-effectiveness of TBC with physician and nonphysician titration. Results: Among 19 studies comprising 5993 participants, the 12-month systolic BP change versus usual care was −5.0 (95% CI, −7.9 to −2.2) mm Hg for TBC with physician titration and −10.5 (−16.2 to −4.8) mm Hg for TBC with nonphysician titration. Relative to usual care at 10 years, TBC with nonphysician titration was estimated to cost $95 (95% uncertainty interval, −$563 to $664) more per patient and gain 0.022 (0.003–0.042) quality-adjusted life years, costing $4400/quality-adjusted life year gained. TBC with physician titration was estimated to cost more and gain fewer quality-adjusted life years than TBC with nonphysician titration. Conclusions: TBC with nonphysician titration yields superior hypertension outcomes compared with other strategies and is a cost-effective way to reduce hypertension-related morbidity and mortality in the United States.

ImportanceAdding a sodium-glucose cotransporter-2 inhibitor (SGLT2-I) to standard-of-care treatment in patients with heart failure with preserved ejection fraction (HFpEF) reduces the risk of a composite outcome of worsening heart failure or cardiovascular mortality, but the cost-effectiveness in US patients with HFpEF is uncertain.ObjectiveTo evaluate the lifetime cost-effectiveness of standard therapy plus an SGLT2-I compared with standard therapy in individuals with HFpEF.Design, Setting, and ParticipantsIn this economic evaluation conducted from September 8, 2021, to December 12, 2022, a state-transition Markov model simulated monthly health outcomes and direct medical costs. Input parameters including hospitalization rates, mortality rates, costs, and utilities were extracted from HFpEF trials, published literature, and publicly available data sets. The base-case annual cost of SGLT2-I was $4506. A simulated cohort with similar characteristics as participants of the Empagliflozin in Heart Failure With a Preserved Ejection Fraction (EMPEROR-Preserved) and Dapagliflozin in Heart Failure With Mildly Reduced or Preserved Ejection Fraction (DELIVER) trials was used.ExposuresStandard of care plus SGLT2-I vs standard of care.Main Outcomes and MeasuresThe model simulated hospitalizations, urgent care visits, and cardiovascular and noncardiovascular death. Future medical costs and benefits were discounted by 3% per year. Main outcomes were quality-adjusted life-years (QALYs), direct medical costs (2022 US dollars), and incremental cost-effectiveness ratio (ICER) of SGLT2-I therapy from a US health care sector perspective. The ICER of SGLT2-I therapy was evaluated according to the American College of Cardiology/American Heart Association value framework (high value: ResultsThe simulated cohort had a mean (SD) age of 71.7 (9.5) years and 6828 of 12 251 participants (55.7%) were male. Standard of care plus SGLT2-I increased quality-adjusted survival by 0.19 QALYs at an increased cost of $26 300 compared with standard of care. The resulting ICER was $141 200 per QALY gained, with 59.1% of 1000 probabilistic iterations indicating intermediate value and 40.9% indicating low value. The ICER was most sensitive to SGLT2-I costs and effect of SGLT2-I therapy on cardiovascular death (eg, increasing to $373 400 per QALY gained if SGLT2-I therapy was assumed to have no effect on mortality).Conclusions and RelevanceResults of this economic evaluation suggest that at 2022 drug prices, adding an SGLT2-I to standard of care was of intermediate or low economic value compared with standard of care in US adults with HFpEF. Efforts to expand access to SGLT2-I for individuals with HFpEF should be coupled with efforts to lower the cost of SGLT2-I therapy.

The 2017 American College of Cardiology/American Heart Association blood pressure (BP) Hypertension Clinical Practice Guidelines recommends ambulatory BP monitoring to detect masked hypertension. Data on the short-term reproducibility of masked hypertension are scarce. The IDH study (Improving the Detection of Hypertension) enrolled 408 adults not taking antihypertensive medication from 2011 to 2013. Office BP and 24-hour ambulatory BP monitoring were performed on 2 occasions, a median of 29 days apart. After excluding participants with office hypertension (mean systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg), the analytical sample included 254 participants. Using the κ statistic, we evaluated the reproducibility of masked awake hypertension (awake systolic/diastolic BP ≥130/80 mm Hg) defined by the 2017 BP guideline thresholds, as well as masked 24-hour (24-hour systolic/diastolic BP ≥125/75 mm Hg), masked asleep (asleep systolic/diastolic BP ≥110/65 mm Hg), and any masked hypertension (high awake, 24-hour, and asleep BP). The mean (SD) age of participants was 38.0 (12.3) years and 65.7% were female. Based on the first and second ambulatory BP recordings, 24.0% and 26.4% of participants, respectively, had masked awake hypertension. The κ statistic (95% CI) was 0.50 (0.38–0.62) for masked awake, 0.57 (0.46–0.69) for masked 24-hour, 0.57 (0.47–0.68) for masked asleep, and 0.58 (0.47–0.68) for any masked hypertension. Clinicians should consider the moderate short-term reproducibility of masked hypertension when interpreting the results from a single ambulatory BP recording.

OBJECTIVE Recent studies have suggested that prediabetes is associated with an increased risk for cardiovascular disease (CVD) only among individuals with concomitant hypertension. RESEARCH DESIGN AND METHODS We analyzed the association between prediabetes and CVD by hypertension status among 3,313 black adults in the Jackson Heart Study (JHS) without diabetes or a history of CVD at baseline (2000–2004). Prediabetes was defined as fasting plasma glucose between 100 and 125 mg/dL or hemoglobin A1c between 5.7 and 6.4% (39 and 46 mmol/mol). Hypertension was defined as systolic/diastolic blood pressure ≥140/90 mmHg and/or self-reported antihypertensive medication use. Participants were followed for incident CVD events and all-cause mortality through 31 December 2014. RESULTS Overall, 35% of JHS participants did not have prediabetes or hypertension, 18% had prediabetes alone, 22% had hypertension alone, and 25% had both prediabetes and hypertension. Compared with participants without either condition, the multivariable-adjusted hazard ratios for CVD events among participants with prediabetes alone, hypertension alone, and both prediabetes and hypertension were 0.86 (95% CI 0.51, 1.45), 2.09 (1.39, 3.14), and 1.93 (1.28, 2.90), respectively. Among participants with and without hypertension, there was no association between prediabetes and an increased risk for CVD (0.78 [0.46, 1.34] and 0.94 [0.70, 1.26], respectively). No association was present between prediabetes and all-cause mortality among participants with or without hypertension. CONCLUSIONS Regardless of hypertension status, prediabetes was not associated with an increased risk for CVD or all-cause mortality in this cohort of black adults.

Background:In LABBPS (Los Angeles Barbershop Blood Pressure Study), pharmacist-led hypertension care in Los Angeles County Black-owned barbershops significantly improved blood pressure control in non-Hispanic Black men with uncontrolled hypertension at baseline. In this analysis, 10-year health outcomes and health care costs of 1 year of the LABBPS intervention versus control are projected.Methods:A discrete event simulation of hypertension care processes projected blood pressure, medication-related adverse events, fatal and nonfatal cardiovascular disease events, and noncardiovascular disease death in LABBPS participants. Program costs, total direct health care costs (2019 US dollars), and quality-adjusted life-years (QALYs) were estimated for the LABBPS intervention and control arms from a health care sector perspective over a 10-year horizon. Future costs and QALYs were discounted 3% annually. High and intermediate cost-effectiveness thresholds were defined as Results:At 10 years, the intervention was projected to cost an average of $2356 (95% uncertainty interval, –$264 to $4611) more per participant than the control arm and gain 0.06 (95% uncertainty interval, 0.01–0.10) QALYs. The LABBPS intervention was highly cost-effective, with a mean cost of $42 717 per QALY gained (58% probability of being highly and 96% of being at least intermediately cost-effective). Exclusive use of generic drugs improved the cost-effectiveness to $17 162 per QALY gained. The LABBPS intervention would be only intermediately cost-effective if pharmacists were less likely to intensify antihypertensive medications when systolic blood pressure was ≥150 mm Hg or if pharmacist weekly time driving to barbershops increased.Conclusions:Hypertension care delivered by clinical pharmacists in Black barbershops is a highly cost-effective way to improve blood pressure control in Black men.

Background Independent associations between cardiovascular risk factor exposures during midlife and later life development of heart failure (HF) with preserved ejection fraction (HFpEF) versus reduced EF (HFrEF) have not been previously studied. Methods We pooled data from 4 US cohort studies (Atherosclerosis Risk in Communities, Cardiovascular Health, Health , Aging and Body Composition, and Multi-Ethnic Study of Atherosclerosis) and imputed annual risk factor trajectories for body mass index, systolic and diastolic blood pressure, low-density lipoprotein and high-density lipoprotein cholesterol, and glucose starting from age 40 years. Time-weighted average exposures to each risk factor during midlife and later life were calculated and analyzed for associations with the development of HFpEF or HFrEF. Results A total of 23,861 participants were included (mean age at first in-person visit, 61.8 ±1 0.2 years; 56.6% female). During a median follow-up of 12 years, there were 3666 incident HF events, of which 51% had EF measured, including 934 with HFpEF and 739 with HFrEF. A high midlife systolic blood pressure and low midlife high-density lipoprotein cholesterol were associated with HFrEF, and a high midlife body mass index, systolic blood pressure, pulse pressure, and glucose were associated with HFpEF. After adjusting for later life exposures, only midlife pulse pressure remained independently associated with HFpEF. Conclusions Midlife exposure to cardiovascular risk factors are differentially associated with HFrEF and HFpEF later in life. Having a higher pulse pressure during midlife is associated with a greater risk for HFpEF but not HFrEF, independent of later life exposures.

Introduction: The Predicting Out-of-Office Blood Pressure in the Clinic (PROOF-BP) algorithm accurately estimates out-of-office BP to guide ambulatory BP monitoring (ABPM) among adults in the UK and Canada with suspected high BP. We tested the validity of PROOF-BP in a diverse US population and developed a US-specific algorithm. Methods: We pooled data from four US studies (CARDIA, JHS, Masked Hypertension Study, and Improving Detection of Hypertension Study) that assessed both office BP and 24-hour ABPM. We included participants with >=2 office and >=10 daytime ambulatory BP readings. PROOF-BP estimates the difference between office systolic BP (SBP) and diastolic BP (DBP) and daytime ambulatory SBP and DBP using clinic BP measurements and patient characteristics. We examined the performance of PROOF-BP in US data and then used multivariable linear regression to develop a new algorithm optimized for the US population. We tested the ability of PROOF-BP to discriminate high awake ambulatory SBP and DBP (SBP/DBP >=130/80 mm Hg) using the area under the receiver-operator curve (AUROC). Models were developed in a 70% randomly selected derivation set and tested in a 30% validation set. The optimal predicted ambulatory BP thresholds were defined as those that resulted in the smallest proportion of individuals recommended for ABPM with an overall classification error Results: We analyzed 3,080 individuals with a mean (SD) age of 52.0 (11.9) years, 38% were male, and 54% were black. Mean (SD) office SBP/DBP was 121.8 (16.6)/75.3 (9.8) mm Hg, mean (SD) awake ambulatory SBP/DBP was 127.3 (13.5)/78.6 (8.8) mm Hg, and 51% had awake ABPM >=130/80 mm Hg. The discrimination for high awake ABPM was similar between the existing (AUROC SBP = 0.77, DBP = 0.73) and US-specific models (AUROC SBP = 0.77, DBP = 0.72). Optimal predicted ambulatory BP thresholds with the US-specific algorithm were 125-134/75-84 mm Hg, resulting in 55% of the pooled cohort recommended for ABPM; compared to 66% recommended by the 2017 ACC/AHA guidelines. Conclusions: Both the original and US-specific PROOF-BP algorithms predicted high out-of-office BP among US adults. PROOF-BP may be used to guide clinical decisions and resource allocation among individuals considered for ABPM.

Background The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends ambulatory BP monitoring to exclude white coat hypertension (WCH) among adults with office systolic BP (SBP)/diastolic BP (DBP) of 130–159/80–99 mm Hg, and masked hypertension (MHT) among adults with office SBP/DBP of 120–129/75–79 mm Hg after a 3-month trial of lifestyle modification. We estimated the proportion of individuals with ideal lifestyle factors among those who meet these office BP criteria. Methods We analyzed data from participants not taking antihypertensive medication in the Coronary Artery Risk Development in Young Adults (CARDIA) and Jackson Heart Study (JHS) who met the office BP criteria for screening for WCH (CARDIA n = 490, JHS n = 873) and MHT (CARDIA n = 486, JHS n = 614). We estimated the prevalence of lifestyle factors including ideal body mass index (BMI), physical activity, diet, and alcohol use among participants who met office BP criteria for WCH or MHT screening. Results Among participants who met office BP criteria for WCH screening, 15.5% in CARDIA and 3.6% in JHS had 3 or more ideal lifestyle factors. Among participants who met office BP criteria for MHT screening, 22.6% in CARDIA and 4.7% in JHS had 3 or more ideal lifestyle factors. Ideal BMI, diet, and physical activity were present in less than half of participants in each sample. Conclusions Few participants who met office BP criteria for the screening of WCH or MHT had ideal lifestyle factors.

Almost 1 in 5 US adults with hypertension has apparent treatment resistant hypertension (aTRH). Identifying modifiable risk factors for incident aTRH may guide interventions to reduce the need for additional antihypertensive medication. We evaluated the association between cardiovascular health and incident aTRH among participants with hypertension and controlled blood pressure (BP) at baseline in the Jackson Heart Study (N=800) and the Reasons for Geographic and Racial Differences in Stroke study (N=2316). Body mass index, smoking, physical activity, diet, BP, cholesterol and glucose, categorized as ideal, intermediate, or poor according to the American Heart Association’s Life’s Simple 7 were assessed at baseline and used to define cardiovascular health. Incident aTRH was defined by uncontrolled BP, systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg, while taking ≥3 classes of antihypertensive medication or controlled BP, systolic BP

Guidelines recommend using out-of-office blood pressure (BP) measurements to confirm the diagnoses of hypertension and in the titration of antihypertensive medication. The prevalence of out-of-office BP phenotypes for an office systolic/diastolic BP goal

Purpose: Patients who present with concurrent heart failure (HF) and acute coronary syndrome (ACS) have an increased risk of mortality, but changes in clinical practice have improved clinical outcomes. We sought to examine recent trends in concurrent HF and ACS hospitalizations in the United States (US) through review of published literature. Methods: We searched the Medline and PubMed databases for studies published after January 1, 2000 reporting the hospitalizations for HF with concurrent acute coronary syndromes. We included studies performed in the US or with at least 25% US participants, that reported the proportion with concurrent HF and ACS, and used a clinical definition of HF (e.g. Killip Class II or III, NYHA Class, or Framingham Criteria). Studies were reviewed by and data was extracted using a standardized form. We extracted study and patient characteristics, definition of HF, and rates of concurrent HF and ACS hospitalizations. We categorized included studies by ACS type: (1) non-specific myocardial infarction (MI) or ACS, (2) non-ST elevation (NSTE) MI or NSTE-ACS, or (3) ST elevation (STE) MI. We descriptively examined recent trends in hospitalizations for concurrent HF and ACS over time; rates reported for multiple time periods or ACS types were considered separately. Results: We identified 23 observational studies, systematic reviews, and randomized clinical trials. Of these, we excluded 13 due to non-US populations, use of non-clinical definitions of HF (i.e., diagnosis codes), or not reporting rates of concurrent HF and ACS. Of the 10 included studies, 7 reported concurrent HF with non-specific MI or ACS from 1975 through 2005 across multiple registries and literature reviews. Rates ranged from 12.5% to 48.0% with no clear time-related trends. We identified 3 studies reporting concurrent HF with NSTEMI or NSTE-ACS from pooled analysis or the Global Registry of Acute Coronary Events (GRACE) registry from 1994 to 2008. Reported rates ranged from 8.2%-15.7% for studies starting in the 1990s with one study reporting and 6.1% in 2005. We identified 4 studies reporting concurrent HF with STEMI, including a pooled analysis, the GRACE registry, and a clinical trial. Rates of concurrent HF with STEMI appeared to decrease over time from 32.5% in 1990 to 1998, 15.6%-19.5% from 1999 to 2001, and 2.6%-11.0% in 2005. Conclusion: Our literature review found that there may be a decrease in concurrent HF and STEMI hospitalizations in recent decades, but no apparent trends with other types of ACS. This may be related to emphasis on early revascularization strategies, improved primary prevention, and/or earlier time to presentation due to increasing public awareness.. However, there was a dearth of data reporting concurrent HF and ACS hospitalization within the last decade. Further research is needed to understand the impact of multiple changes in clinical practice on secular trends.

Introduction: The 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline uses lower clinic and out-of-clinic BP thresholds to define hypertension compared to previous US guidelines. Using these thresholds, we determined the associations between white coat hypertension (WCH) and masked hypertension with cardiovascular disease (CVD) events and mortality. Methods: We included 993 African Americans participating in the Jackson Heart Study who had clinic BP measured during their baseline study visit between 2000 and 2004 and underwent ambulatory blood pressure monitoring (ABPM). We defined normotension, WCH/white coat effect (WCE), masked/masked uncontrolled hypertension, and sustained hypertension using clinic BP and mean awake BP on ABPM (Table). CVD events (i.e., coronary heart disease and stroke; n=107), and all-cause mortality (n=185) were adjudicated from baseline through December 2014 and December 2016, respectively. Results: The mean age of participants was 59 years and 68% were female. Among those not taking antihypertensive medication, 38% had normotension, 27% had WCH, 33% had masked hypertension, and 31% had sustained hypertension. WCH, masked hypertension, and sustained hypertension were each associated with an increased risk for CVD and mortality compared to normotension (Table). Among those taking antihypertensive medication, 26% had controlled normotension, 25% had a WCE, 45% had masked uncontrolled hypertension, and 39% had treated sustained hypertension. Masked uncontrolled hypertension was associated with a higher risk for CVD and a lower risk for mortality compared to controlled normotension. WCE was not associated with CVD events or all-cause mortality. Conclusions: According to the ACC/AHA BP guideline, WCH and masked hypertension are common among African American adults. ABPM could have an important role in guiding antihypertensive medication initiation and intensification to reduce CVD and mortality risk among African Americans.

Experts have expressed concerns that patients with chronic conditions are being excessively excluded from cancer randomized clinical trials (RCTs), limiting generalizability. Accordingly, we queried clinicaltrials.gov to determine the extent to which patients with chronic conditions were excluded from phase III cancer trials, using National Cancer Institute-sponsored breast cancer RCTs as a test case. Two physicians independently coded for the presence of 19 prevalent chronic conditions within eligibility criteria. They also coded for exclusions based on performance status and vague criteria that could have broadly excluded patients with chronic conditions. The search identified 58 RCTs, initiated from 1993 to 2012. Overall, 88% of trials had at least one exclusion for a chronic condition, performance status, or vague criterion. The three most commonly excluded conditions were chronic kidney disease, heart failure, and ischemic heart disease. Our study demonstrated that patients with prevalent chronic conditions were commonly excluded from National Cancer Institute-sponsored RCTs.

Introduction Increased salt taste sensitivity may be associated with improved heart failure (HF) outcomes following HF hospitalization. Hypothesis An increase in salt taste sensitivity from admission to 12-weeks follow-up will be associated with fewer days rehospitalized and higher Kansas City Cardiomyopathy Questionnaire clinical summary scores (KCCQ-CSS) compared to subjects with no increase in salt taste sensitivity. Methods We examined salt taste sensitivity in the GOURMET-HF trial, a pilot study investigating the effects of home-delivered meals in post-discharge patients with HF. Salt taste sensitivity was assessed by measuring changes in salt taste recognition threshold on enrollment, discharge, 1, 4, and 12-weeks follow-up using Salsave test strips standardized with 0.6-1.6 mg/cm2 NaCl solution. Subjects were divided into two groups: increase or no increase salt taste sensitivity. Baseline characteristics between groups and outcomes were compared using two-sample t-tests, chi-squared tests, and log-transformed t-tests for parameters that were not normally distributed. Results Baseline characteristics did not differ for subjects with an increase in salt taste sensitivity over 12-weeks (n=25) compared to those without an increase in salt taste sensitivity (n=24); they were elderly (71 vs. 69 years) and predominately male (76 vs. 75%). There was a high representation of black (36 vs. 29%) and Hispanic (28 vs. 42%) subjects. Baseline KCCQ-CSS (45.84 [21.74] vs. 44.31 [17.70]) were similar. The enrollment salt taste recognition threshold was higher (1.19 [0.39]) vs. 0.76 [0.28] mg/cm2, p=0.001) and the 12-week threshold was lower (0.71 [0.16] vs. 0.86 [0.32] mg/cm2, p=0.042) in the group with increased salt taste sensitivity. The total number 12-week hospital days was 60 vs. 121 days, with an average number of hospital days of 5.45 [3.88] vs. 11.00 [6.74] (p=0.028) among those hospitalized in the groups with an increase vs. no increase in salt taste sensitivity, respectively (Figure 1). KCCQ-CSS at 12-weeks trended higher in the group with an increase in salt taste sensitivity: (64.24 [23.06] vs. 56.25 [24.80], p=0.195). Conclusions Changes in salt taste sensitivity occurred in some but not all subjects in a 12-week period following hospitalization for HF. Subjects with increased salt taste sensitivity over this time period were rehospitalized for fewer days. Improved salt taste sensitivity may represent a novel prognostic factor in post-discharge patients with HF.

Background Heart failure (HF) disproportionately affects older adults. Dietary sodium indiscretion is frequently implicated in HF decompensation. The affinity for and ability to taste salt in this process is unexplored. We sought to evaluate differences in salt taste by age and HF diagnosis and to map changes after hospitalization for acute decompensated heart failure (ADHF). Methods Seventy-two subjects underwent initial salt-taste testing during hospitalization for ADHF. Follow-up taste testing occurred at discharge and 1, 4, and 12 weeks after hospitalization. Three different groups were included as control subjects and underwent 1-time salt-taste testing: 10 patients with stable HF, 10 healthy older adults, and 10 healthy younger adults. Salt-taste testing was completed with the use of commercially available and validated Salsave test strips with increasing concentrations of NaCl (0.6–1.6 mg/cm 2 ) to identify salt taste recognition threshold. Respectively, 2-sample t tests, multiple regression, and linear mixed-effects modeling were used for intergroup comparisons, to adjust for confounders, and to assess the effect of time after discharge from ADHF hospitalization. Results The baseline salt taste recognition threshold was lowest in the young healthy control group (0.62 [SD 0.05] mg/cm 2 NaCl) compared with the healthy older control subjects (0.92 [SD 0.29] mg/cm 2 NaCl), stable HF outpatients, (1.06 [SD 0.22] mg/cm 2 NaCl), and ADHF subjects on admission (1.06 [SD 0.48] mg/cm 2 NaCl). There was a strong trend toward higher recognition threshold in HF patients ( P = .051) that was independent from age and other potential confounders. Serial salt-taste testing in the ADHF group demonstrated a decrease in recognition threshold that persisted over the 12 weeks after discharge (1.04 [SD 0.44] to 0.76 [SD 0.22] mg/cm 2 NaCl; P = .003). Discussion When compared with young healthy control subjects, HF patients have impaired recognition of salt taste. The salt taste recognition threshold decreases after hospitalization for ADHF. This change demonstrates the first evidence of the phenomenon known as the “hedonic shift” in HF, in which the threshold to recognize salt taste decreases after prescribed sodium restriction.

Stokke et al. [(1)][1] showed that despite reduced longitudinal and circumferential strain, ejection fraction is maintained by geometric factors, which prompted the editorialists to note, “although strain is emerging as the more optimal marker for LV systolic function, there seems to be no way to

We read with great interest the study by Fontana et al1 in a large cohort of subjects with cardiac amyloidosis demonstrating the association of late gadolinium enhancement (LGE) on magnetic resonance imaging with increasing amyloid infiltration of the myocardium, as measured by extracellular volume, and the incremental prognostic value associated with transmural LGE on survival. LGE is pathologically associated with amyloid infiltration of the myocardium and concomitant fibrosis. Thus, LGE is indicative of pathological hypertrophy and has now been shown to have prognostic significance in amyloid. Accordingly, we hypothesize that a novel …

In the current transformative health care landscape, it is imperative that clinician educators inspire future clinicians to practice primary care in a dynamic environment. A focus on patient-centered, goal-oriented care for patients with chronic conditions is critical.In 2009, Harvard Medical School founded the Crimson Care Collaborative, a student-faculty collaborative practice (SFCP) network. With the aim of expanding clinical and educational opportunities for medical students and improving patient control of chronic disease (i.e., hypertension, obesity, and diabetes) in an innovative learning environment, in 2012, the authors developed a novel SFCP at their hospital-based academic primary care practice. In this SFCP, students learn to explore patient priorities, provide focused counseling and education, and assist patients with self-management goals during clinical visits.From 2012 to 2014, 250 student volunteers participated in the SFCP as clinicians, innovators, educators, and leaders, with between 80 and 95 medical students engaging each semester. Between January 2012 and March 2014, there were 476 urgent care or chronic disease management visits. Patients with chronic diseases were seen at least twice on average, and by 2014, chronic disease management visits accounted for approximately 74% of visits.Work is under way to create assessment tools to evaluate the practice's educa tional impact and student understanding of the current health care system, develop interdisciplinary care teams, expand efforts in registry management and broaden the patient recruitment scope, further emphasize patient engage ment and retention, and evaluate chronic disease management and patient satisfaction effectiveness.

Purpose—To investigate biomarker differences in routine preoperative blood tests performed on primary open-angle glaucoma (POAG) case and control patients presenting for anterior segment eye surgery. Methods—POAG cases and age-related cataract surgery patients (controls) who underwent anterior segment surgery at Massachusetts Eye and Ear from January 2009 through March 2012 were identified by retrospective record review. Patients with diabetes mellitus, secondary glaucoma, and cataract due to trauma or steroid exposure were excluded. Data on demographic features, preoperative ophthalmological and medical diagnosis, blood pressure, anthropometric measures, basic metabolic panel, and complete blood count were extracted from the medical records. Univariate differences in lab values between POAG cases and controls were assessed using unpaired t tests. Multivariate logistic regression analysis was completed to determine the independent associations of biomarkers with POAG. Results—A total of 150 cases and 150 age-related controls were included. In multivariate analysis, higher AG was inversely associated with POAG (odds ratio [OR] = 0.90; 95% confidence interval [CI], 0.80– 1.00), and higher Cl− level was positively associated with POAG (OR = 1.15; 95% CI, 1.02–1.29). The lower AG in POAG patients could be explained by higher IgG levels as the available data in post hoc analysis showed a nonsignificant trend toward higher IgG in cases compared to controls (17 vs 23; 1142 ± 284 mg/dl vs 1028 ± 291 mg/dl; P = 0.22). Furthermore, in multivariable analysis, a higher red blood cell count was also associated with POAG (OR = 1.91; 95% CI, 1.11–3.28). Conclusions—Patients with POAG presenting for anterior segment surgery had a lower AG compared to age-related cataract surgery patients. The etiology of this reduced gap is unclear but the possible contribution of IgG warrants further exploration. The etiology of higher red blood cell counts in POAG cases is unknown and deserves further exploration. The development and discovery of clinically useful biomarkers is an important area of research for primary open-angle glaucoma (POAG). A biomarker for glaucoma could identify at-risk patients for early treatment and allow for treatment response monitoring. The discovery of biomarkers associated with POAG could also provide insights into disease pathophysiology. A variety of molecules and proteins have been identified in serum, aqueous humor, and tears that are associated with POAG and represent potential disease biomarkers. They include

Glaucoma is a neurodegenerative disorder in which degenerating retinal ganglion cells (RGC) produce significant visual disability. Clinically, glaucoma refers to an array of conditions associated with variably elevated intraocular pressure (IOP) that contributes to RGC loss via mechanical stress, vascular abnormalities, and other mechanisms, such as immune phenomena. The clinical diagnosis of glaucoma requires assessment of the ocular anterior segment with slit lamp biomicroscopy, which allows the clinician to recognize signs of conditions that can produce elevated IOP. After measurement of IOP, a specialized prismatic lens called a gonioscope is used to determine whether the angle is physically open or closed. The structural manifestation of RGC loss is optic nerve head atrophy and excavation of the neuroretinal rim tissue. Treatment is guided by addressing secondary causes for elevated IOP (such as inflammation, infection, and ischemia) whenever possible. Subsequently, a variety of medical, laser, and surgical options are used to achieve a target IOP.