Caution with CSF Protein Levels: When Abnormal May Actually Be NormalThe lumbar puncture is an invaluable diagnostic test in many clinical settings. It plays a critically important role in the evaluation of central nervous system infections, autoimmune encephalitic syndromes, subarachnoid hemorrhage, normal-pressure hydrocephalus, intracranial pressure disorders, and demyelinating peripheral nervous system disorders such as Guillain-Barré syndrome.1 Clinicians rely on standardized reference ranges for cerebrospinal fluid (CSF) component values from the diagnostic laboratory to determine whether a result is normal or abnormal.
Cardiorespiratory Fitness and Hypnotic Drug Use for Sleep Problems: Unraveling the Array of Potential ConfoundersSleep is a basic human need for physiologic restitution and an important indicator of health and well-being. The National Institutes of Health recommends that, on average, adults sleep 7 to 8 hours per day. Poor sleep quality and inadequate sleep duration impose short- and long-term consequences that heighten disorders associated with health risks1 and adversely affect functional status, alertness, and mental and physical well-being. Daytime manifestations include early awakenings, excessive yawning, constant tiredness, poor concentration, and impaired functioning.
The LIMA: A Drug-Eluting Graft and Coronary Flow Shock AbsorberThe primary challenge of coronary artery bypass graft (CABG) surgery is the durability of graft patency. Patients with failed grafts experience an overall higher clinical event rate, with graft failure to the left anterior descending territory being the most detrimental.1 Aside from anastomotic technical issues, multiple mechanisms contribute to graft failure. They include patient-related risk profile, graft–coronary artery flow mismatch, target vessel anatomic features, hemodynamic factors, hypercoagulability, and biologic mechanisms involved in plaque formation and atherosclerosis progression.
Decreasing Door-to-Diagnosis Time in Cardiac Amyloidosis: A Simple “One-Stop Shop” ApproachCardiac amyloidosis (CA) remains a challenging disease to detect and to diagnose. Recent advancements in treatment necessitate more rapid diagnosis so that treatment can be initiated as early as possible. In this issue of Mayo Clinic Proceedings, Bézard et al1 report on the real-life evaluation of an algorithm for the diagnosis of CA. The authors propose a “one-stop shop” approach to the diagnosis of CA by performing 4 tests simultaneously at the first day of a visit: serum and urine screening for monoclonal protein (MCP), nuclear cardiac scintigraphy, salivary gland biopsy, and DNA TTR testing.
Brave New World: Improving Obesity and Preventing Cardiovascular DiseaseFor several decades, obesity and type 2 diabetes (T2D) have been rising in tandem so that today, they are worsening global pandemics with debilitating, expensive, and often lethal complications. The prevalence of T2D in the United States has risen more than 10-fold from 2.5 million in 1959 to more than 25 million in 2022.1 During the same time frame, obesity has risen 4-fold, so that now it affects 40% of US adults and is the leading cause of preventable disease and premature mortality. About 90% of people with T2D are overweight or obese, and traditional drugs for T2D, including insulin, sulfonylureas, and thiazolidinediones, cause further weight gain.
Almost a Centenarian—Bold, Forward, and Networking“Unlike in the past, there are now two kinds of people in the world: those who own and run the networks, and those who merely use them.”1Niall Ferguson
Portopulmonary Hypertension—Rethinking Our Current ApproachPatients with cirrhosis have progressive liver disease with secondary neurohormonal activation resulting in volume overload. This neurohormonal activation is due to “arterial underfilling” from a pathologically decreased systemic vascular resistance (SVR), and this is associated with a reflex increase in cardiac output (CO) to maintain blood pressure.1 When this decrease in blood pressure is sensed by arterial baroreceptors, there is secondary renin-angiotensin-aldosterone activation, which results in renal sodium retention and volume overload despite normal heart function.
Health Care for Adults With Cerebral Palsy and Spina Bifida—Must It Be so Difficult?For children with cerebral palsy and spina bifida (CP/SB), their complex medical needs are often coordinated through a medical home or multidisciplinary clinic setting. In these settings, a care team works to coordinate appointments, follow up on missed appointments, and facilitate communication with and between medical providers and patients. This care coordination is often done through many methods and contact points. Despite this, children with CP/SB may still have unexpected or potentially preventable hospitalizations (PPHs) for urinary tract infection (UTI), pneumonia, pressure wounds, and other illnesses.
Trends in Heart Failure Outcomes From a Large, Geographically Diverse Cohort During the COVID-19 PandemicThe evolving coronavirus disease 2019 (COVID-19) pandemic has presented extraordinary challenges to the health of populations globally. As our understanding of the virus continues to grow at a rapid pace, it has become increasingly clear that the clinical manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection range widely and are in large part dictated by age, underlying comorbidities, and vaccination status. Robust epidemiologic data during the past years have underscored that individuals with chronic health conditions including cardiovascular disease, diabetes mellitus, immunosuppression, tobacco use, and obesity carry a significantly greater risk of falling critically ill with SARS-CoV-2.
Explaining Unexplained Hypoglycemia Due To Insulin AnalogsHypoglycemia is a potentially life-threatening condition that requires urgent medical attention. Most hypoglycemia in patients with diabetes is related to medication use, and recent studies have indicated the contributions of insulin analogs in cases of hypoglycemia.1,2 Even in patients without diabetes, it is important to exclude insulin administration as a cause of hypoglycemia, yet detection of insulin analogs is not straightforward. The small structural changes that result in favorable pharmacokinetics of insulin analogs also affect the detection of analog insulin by immunoassays, culminating in varying results from different commercially available assays.
The Imposter Syndrome in PhysiciansImposter syndrome (IS), also known as imposter phenomenon or imposterism, is defined as feelings of uncertainty, inadequacy, and being undeserving of one’s achievements despite evidence to the contrary. Imposter syndrome has 5 subtypes1:
Racial Disparities and Excess Cardiovascular Mortality Before and During the COVID-19 Pandemic: Time for a SolutionHealth disparities are a complex and multifactorial construct involving lack of access to health care, differential treatment modalities, and different outcomes for the same disease based on racial or socioeconomic class. Disparity in health care has garnered an increasing amount of attention from health care providers and health policy experts.1 Several studies have elucidated the effect of health care disparity between different socioeconomic and ethnic groups on cardiovascular (CV) outcomes as well as relating to the ongoing SARS-CoV-2 infection (COVID-19) pandemic.
Ambulatory Remote Patient Monitoring Beyond COVID-19: Engagement and Sustainment ConsiderationsCare delivery innovations in response to the COVID-19 pandemic, particularly digital health solutions, have been wide ranging and impactful. The spectrum of such innovations includes, for example, technology-based screening tools, electronic health record–based protocols, rapid provider onboarding and education, clinical decision support and diagnostics, large-scale data collection with real-time dashboards for tracking and surveillance to monitor outcomes and hospital capacity, and rapid adoption and expansion of telehealth services and remote monitoring to improve safe access to health care and to optimize resource utilization.
Making a Case for the Anti-inflammatory Effects of ACE Inhibitors and Angiotensin II Receptor Blockers: Evidence From Randomized Controlled TrialsIn this issue of Mayo Clinic Proceedings, Awad and colleagues1 present a meta-analysis of randomized controlled trials evaluating the effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) as anti-inflammatory agents. Their findings support the beneficial role of ACEIs and ARBs in reducing blood levels of inflammatory markers but reveal potential differences in their anti-inflammatory effects. However, regardless of the class of medications used, the implications of the results merit the need to better understand the inflammation-alleviating effects of renin-angiotensin-aldosterone system (RAAS) inhibition.
Heart Disease and Kidney Failure in the Black CommunityIn the United States, Black Americans suffer from a disproportionately high prevalence of cardiometabolic disorders including cardiovascular disease (CVD) and chronic kidney disease/end-stage kidney disease (CKD/ESKD) compared with their White peers.1,2 The reasons for these disparities are multifactorial. These disparities are primarily driven by societal factors, racial- and ethnic-based inequities in the allocation of health-affirming resources and opportunities, which is commonly termed structural racism.
Even When the Heart Stops, the Sex Differences RemainCardiovascular disease remains the leading cause of death in women,1 but mechanisms of sex-related differences that affect many facets of cardiovascular disease remain underrecognized and poorly understood. Men historically have been disproportionately represented in clinical studies, and consequently, guidelines have been built on data that are predominantly applicable to men.1 There has recently been an increasing commitment to better understand sex-related differences that affect the epidemiology, presentation, diagnosis, treatment, and outcomes of cardiovascular disease.
Diuretic Resistance—A Key to Identifying Clinically Significant Worsening Renal Function in Heart Failure?Worsening renal function (WRF) in patients hospitalized with acute heart failure (AHF) presents a frequent clinical dilemma that is compounded by the inconsistent results of studies seeking to determine whether WRF in AHF is associated with worse clinical outcomes, such as death or readmission. More recent studies suggest that when serum creatinine concentration rises from a hemodynamic process such as appropriate blood pressure lowering or decongestion, WRF is no longer associated with adverse outcomes.
Transforming Diversity, Equity, and Inclusion in Medical Education—Mayo Clinic Alix School of MedicineMayo Clinic is committed to eliminating racism and reducing health care disparities. Without systemic change, these inequities compound and detract from the very patients and communities we serve. Racism limits the ability of learners, staff, and faculty to do their job and to be their full authentic self in clinical and learning environments. An effective path toward equity requires elimination of systemic barriers for both patients and staff. To do so, we must embrace opportunities to learn what is actually needed to improve their experience.
TRIO Risk Score: Simple, Yet ComplexTricuspid regurgitation (TR) occurs in 65% to 85% of the population in the United States.1,2 Although mild TR in the setting of a structurally normal tricuspid valve apparatus can be considered a normal variant, progression to moderate-severe TR increases with age and is estimated to affect nearly 1.6 million adults in the United States.3 Echocardiographic data from the Framingham Heart Study reported an overall prevalence of moderate or higher TR of 0.8%, with a majority due to functional TR and only 10% due to an organic cause.
The Optimal Dietary Calcium Intake for Preventing Incident and Recurrent Symptomatic Kidney Stone DiseaseUntil the early 1990s, it was presumed that dietary calcium intake should be limited for preventing the onset and recurrence of calcium kidney stone formation, assuming that frequent consumption of milk and dairy products could unfavorably influence urinary calcium excretion. However, a prospective investigation conducted on 45,619 men without baseline history of kidney stones, published in 1993, showed an inverse relationship between baseline dietary calcium intake, assessed by a semiquantitative food frequency questionnaire, and the risk of incident symptomatic kidney stone disease after a 4-year follow-up period.
Solving the Puzzle of Coronary Artery Disease in the ElderlyIn the process of aligning treatment options to fit each individual patient, the clinician must carefully evaluate how each decision affects the overarching goals of care. In the management of coronary artery disease, however, these tradeoffs are often confounded by a bias toward less invasive strategies in the elderly. Given that women outnumber men by 54% beyond the age of 80 years,1 this predisposition can also contribute to an insidious form of gender discrimination. Older patients are often excluded from major clinical trials,2 contributing to a lack of awareness surrounding the efficacy of aggressive treatments in this demographic.
The Right StuffCurrently in clinical cardiovascular medicine, prospective randomized controlled trials are considered the “gold standard.” The larger, the better. Such studies are considered to have high internal validity. In recent years, such studies are often subsequently compared with “real-world” data from individual institutions and registries to augment their external validity. This approach has been the foundation for the enormous progress in understanding the pathobiology and treatment of cardiovascular disease during the past half-century.
Coronary Artery Calcium and Cardiorespiratory Fitness: The Simple Keys to Truly Personalized Atherosclerotic Cardiovascular Disease Risk Prediction?Atherosclerotic cardiovascular disease (ASCVD) risk prediction is the cornerstone of decision-making strategies for the prevention of ASCVD.1,2 Whereas guideline recommendations for ASCVD risk prediction are still largely based on the measurement of traditional ASCVD risk factors, there are well-established limitations to this approach, and other predictors of ASCVD risk are needed to better personalize ASCVD risk prediction. Accordingly, the most recent American College of Cardiology/American Heart Association guidelines place added emphasis on refining risk beyond traditional ASCVD risk factors.
Importance of More Potent Antiplatelet Therapy in Myocardial Infarction With Cardiac Arrest or Cardiogenic ShockCurrent treatment of acute myocardial infarction complicated by cardiogenic shock (CS) or resuscitated cardiac arrest (CA) (whether in hospital or out of hospital) almost always includes percutaneous coronary intervention (PCI) as studies have shown improved in-hospital and long-term outcomes with PCI compared with medical therapy alone.1-3 Use of dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor is considered standard of care with PCI regardless of the circumstance, unless the patient is at a very high risk of bleeding, although the post-PCI duration of therapy is often debated.
When Will American Patients Start Benefitting From Biosimilars?The United States has one of the most expensive health care systems in the world. Annual health care cost in 2019 was almost $11,100 per person, representing some 17% of the US national income. The Organisation for Economic Co-operation and Development average cost per patient was around $5500, less than half of that in the United States. Higher health care spending can be beneficial if it results in better health outcomes. However, that is not consistently the case in the United States. Despite significantly higher health care spending, America’s health outcomes are generally not better than those in other developed countries.