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  • 1
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 146, No. 9 ( 2022-08-30), p. 657-672
    Abstract: Apolipoprotein B (apoB) provides an integrated measure of atherogenic risk. Whether apoB levels and apoB lowering hold incremental predictive information on residual risk after acute coronary syndrome beyond that provided by low-density lipoprotein cholesterol is uncertain. Methods: The ODYSSEY OUTCOMES trial (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) compared the proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab with placebo in 18 924 patients with recent acute coronary syndrome and elevated atherogenic lipoproteins despite optimized statin therapy. Primary outcome was major adverse cardiovascular events (MACE; coronary heart disease death, nonfatal myocardial infarction, fatal/nonfatal ischemic stroke, hospitalization for unstable angina). Associations between baseline apoB or apoB at 4 months and MACE were assessed in adjusted Cox proportional hazards and propensity score–matched models. Results: Median follow-up was 2.8 years. In proportional hazards analysis in the placebo group, MACE incidence increased across increasing baseline apoB strata (3.2 [95% CI, 2.9–3.6], 4.0 [95% CI, 3.6–4.5] , and 5.5 [95% CI, 5.0–6.1] events per 100 patient-years in strata 〈 75, 75– 〈 90, ≥90 mg/dL, respectively; P trend 〈 0.0001) and after adjustment for low-density lipoprotein cholesterol ( P trend =0.035). Higher baseline apoB stratum was associated with greater relative ( P trend 〈 0.0001) and absolute reduction in MACE with alirocumab versus placebo. In the alirocumab group, the incidence of MACE after month 4 decreased monotonically across decreasing achieved apoB strata (4.26 [95% CI, 3.78–4.79], 3.09 [95% CI, 2.69–3.54] , and 2.41 [95% CI, 2.11–2.76] events per 100 patient-years in strata ≥50, 〉 35– 〈 50, and ≤35 mg/dL, respectively). Compared with propensity score–matched patients from the placebo group, treatment hazard ratios for alirocumab also decreased monotonically across achieved apoB strata. Achieved apoB was predictive of MACE after adjustment for achieved low-density lipoprotein cholesterol or non–high-density lipoprotein cholesterol but not vice versa. Conclusions: In patients with recent acute coronary syndrome and elevated atherogenic lipoproteins, MACE increased across baseline apoB strata. Alirocumab reduced MACE across all strata of baseline apoB, with larger absolute reductions in patients with higher baseline levels. Lower achieved apoB was associated with lower risk of MACE, even after accounting for achieved low-density lipoprotein cholesterol or non–high-density lipoprotein cholesterol, indicating that apoB provides incremental information. Achievement of apoB levels as low as ≤35 mg/dL may reduce lipoprotein-attributable residual risk after acute coronary syndrome. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01663402.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
    detail.hit.zdb_id: 1466401-X
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  • 2
    In: Medicine & Science in Sports & Exercise, Ovid Technologies (Wolters Kluwer Health), Vol. 48 ( 2016-05), p. 10-
    Type of Medium: Online Resource
    ISSN: 0195-9131
    RVK:
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
    detail.hit.zdb_id: 2031167-9
    SSG: 31
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  • 3
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 139, No. Suppl_1 ( 2019-03-05)
    Abstract: Introduction: Reliable and valid measures are essential in research; however, it remains unclear if self-reported sleep measures are concordant with objective measures. Purpose: To examine the associations between subjective and objective sleep duration and awakenings among adults enrolled in a behavioral weight loss study. Methods: Self-report data included responses to the questions “How many hours of sleep did you get?” and “Number of awakenings?” collected each morning by ecological momentary assessment. Objective measures included actigraphic data on sleep duration and awakenings collected for 7 days at 6 and 12 mos. Concordance between measures was examined using linear mixed models predicting self-report measures of sleep from objectively measured sleep. Results: The sample (N = 137) was 89.8% female and 81.8% white with a mean age of 51.5 ± 9.9 yrs. Based on self-report, sleep duration was 417.2 ± 77.7 min./night with 1.7 ± 1.5 awakenings. Based on actigraphy, sleep duration was 413.1 ± 79.5 min./night with 33.0 ± 14.1 awakenings. The fitted model for sleep duration yielded an estimated intercept of 197.3 min. (95% CI, 178.0, 216.6) and slope of 0.54 (95% CI, 0.49, 0.58). In the scatter plot of self-report against objective sleep (Fig 1a), the plotted points were well-scattered about the 45-degree line suggesting that self-report min. of sleep predicted objective min. of sleep. The fitted model for awakenings yielded an estimated intercept of 0.95 awakenings (95% CI, 0.66, 1.2) and slope of 0.02 (95% CI, 0.015, 0.028). In the scatter plot of self-report against objective awakenings (Fig 1b), all of the plotted points fell below the 45-degree line indicating that self-report drastically underestimated actigraphic awakenings. Conclusion: Self-reported sleep duration was a good indicator of objective sleep duration, while self-reported awakenings significantly underestimated actigraphic awakenings. Sleep is multi-dimensional and both subjective and objective measures are needed to capture its various features.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 4
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 135, No. suppl_1 ( 2017-03-07)
    Abstract: Introduction: It is assumed that inadequate sleep is associated with sedentary behavior and that being active during the day improves sleep. Given the emergence of sedentary behavior as an independent risk factor for cardiovascular disease (CVD), a better understanding of this bi-directional relationship in adults who are obese is needed for developing CVD-risk reducing interventions. Hypotheses: Total sleep time (TST) is negatively associated with next day sedentary time (SED) and SED is negatively associated with that night’s TST in adults who are obese. Methods: We used objective baseline data from the EMPOWER Study, a 12-mo study of lapses during weight loss. We instructed subjects to wear accelerometers on the waist (ActiGraph GT3X) for 7 days and wrist (Actiwatch 2) for 14 days to assess daily activity and sleep, respectively. Subjects with ≥2 weekdays and 2 weekend days of overlapping data were included. SED was defined as 〈 150 counts/min. Linear mixed modeling was used to examine the associations between TST and SED; each directional relationship was examined separately. Covariates included sex, race, body mass index (BMI), age, and day of the week. Results: The majority of subjects (N=109) were white (82.6%), employed (92.6%), and female (89.0%) with mean (±SD) age of 50.6±10.6 years and BMI of 33.8±4.6 kg/m 2 . Mean daily TST and SED were 409.5±83.0 min and 638.8±132.2 min, respectively. Previous night’s TST independently predicted the next day’s SED (p 〈 .001) with each 3 min increase in TST being associated with a 1 min decrease in SED. SED did not predict that night’s TST. Weekends were associated with less SED (p 〈 .001) and greater TST (p 〈 .001; see Table). Conclusions: Sedentary behavior and decreased TST were prevalent in this sample of mostly middle-aged working women. Less TST was associated with greater SED and weekdays were associated with greater SED and less TST, highlighting how weekdays influences these behaviors. These findings point to a need for interventions to increase TST in an effort to reduce SED and CVD risk.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 5
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 131, No. suppl_1 ( 2015-03-10)
    Abstract: Background: Sleep is emerging as an important factor that impacts dietary habits, physical activity, and metabolism. However, minimal attention is typically given to sleep in traditional lifestyle interventions. The purpose of these analyses was to examine baseline associations between sleep and physical activity and perceived barriers to healthy eating, which are two common lifestyle intervention targets, in a sample of apparently healthy adults enrolled in a behavioral weight loss intervention study. Methods: 150 overweight adults (51.1±10.2 y; 91% female; 79% Caucasian) participated in a 12-month lifestyle intervention that featured adaptive ecological momentary assessment. Sleep, physical activity, barriers to healthy eating and body habitus/composition were assessed prior to the intervention. Objective sleep was estimated with 7 days of wrist-worn actigraphy (Philips Actiwatch 2); sleep onset latency (SOL; the amount of time it takes to fall asleep after going to bed), sleep efficiency (SE; the percentage of time in bed that is spent asleep), and total sleep time (TST; total time spent asleep) served as the primary actigraphic sleep variables. Subjective sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI). Physical activity was assessed with 7 days of waist-worn accelerometry (ActiGraph GT3x). Perceived barriers to healthy eating were assessed with the Barriers to Healthy Eating questionnaire. Body mass index (BMI) served as the measure of body habitus, and body fat was assessed with bioelectrical impedance. Results: Mean BMI and body fat for the sample were 34.0±4.6 kg/m2 and 43.7±5.5%, respectively. Mean TST was 6.6±0.8 h/night; approximately 23% of the sample averaged less than 6 hours of sleep. Mean SOL and SE for the sample were 15.3±16.2 min and 85.7±6.1%, respectively. Based on the PSQI, 52.0% of the sample had poor sleep quality. Following adjustment for age, sex, and race, longer SOL was associated with fewer steps/day (β=-.19, p=.02) and less time spent in moderate to vigorous physical activity (MVPA; β=-.16, p=.03), and lower SE was related to less MVPA (β=.15, p=.04). Shorter TST was associated with greater barriers to healthy eating (β=-.16, p=.05). Longer SOL was associated with higher BMI (β=.16, p=.05) and body fat % (β=.15, p=.03), and lower SE was related to higher body fat % (β=-.13, p=.06). Conclusions: Short sleep duration and sleep disturbance were highly prevalent in this sample of overweight adults. Significant associations were observed between sleep and measures of body habitus/composition and eating and physical activity habits. Efforts to improve sleep during a behavioral intervention for weight loss may reduce barriers to healthy eating and improve physical activity habits as well as weight loss outcomes.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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  • 6
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 133, No. suppl_1 ( 2016-03)
    Abstract: Introduction: Lifestyle interventions, with physical activity (PA) as a key component, are important to reducing cardiometabolic disease risk. In our work in both efficacy and effectiveness clinical trials, we have shown that season has a significant impact on subjectively determined moderate-vigorous (MV) PA levels, both at baseline and during the intervention. However, the effect of season in these lifestyle interventions has not yet been examined utilizing objective measurements of PA so that time spent in all PA intensities and sedentary behavior(SB) can be quantified. Hypothesis: Our hypothesis is that PA would increase and SB would decrease due to the intervention but that season would have an additional effect on both. Methods: We enrolled 150 overweight/obese adults (51.1±10.2 y; 79% Caucasian; 91% female) in a 12-month lifestyle intervention for weight loss that provided regular feedback to participants on diet and PA goal achievement. Six cohorts were recruited from 2012-2014. The PA goal was to achieve and maintain 150 minutes/week of MVPA. ActiGraph GT3x accelerometers, worn on the waist, were used to assess average daily step counts and time spent in PA and SB. Accelerometer recordings with 10 hours/day of wear time on ≥4 days were considered a valid assessment of typical PA and SB. Changes in activity variables at 6 months and 12 months were examined using linear mixed models. We also examined the season (winter, spring, summer, or autumn) when the intervention was implemented and if this affected changes in PA and SB. Results: Baseline accelerometer data were valid for 149 participants. Mean (SD) baseline values were 6132 (1873) steps counts/day, 11 (11) MVPA min/day, 245 (64) light intensity (L)PA min/day, 635 (85) SB min/day. Season was significantly related to step counts, LPA, MVPA, and SB with significantly lower PA and higher SB in the winter (p 〈 0.05). Changes in LPA and SB were not significant over the entire follow-up (p 〉 0.05). When adjusted (for monitor wear time/day and season) mean (SD) increases in step counts from baseline were 1128 (208) and 742(209) steps/day at 6 and 12 months, respectively (both p 〈 0.0001). For MVPA adjusted mean (SD) increases from baseline were 7(1) and 6(1) min/day at 6 and 12 months, respectively (both p 〈 0.0001). Conclusions: Relevant improvements in steps counts and MVPA were recorded at 6 and 12 months. This was true even after controlling for the effect of differences in the season of implementation. When considering the effect of lifestyle interventions on activity, future studies should consider the effect of seasonal changes on PA levels.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
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  • 7
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 133, No. suppl_1 ( 2016-03)
    Abstract: Introduction: Despite increased recognition of the influence of sleep on weight loss, lifestyle interventions have paid little attention to sleep and its change with intervention. Moreover, available evidence on the relevance of sleep in weight loss interventions has been limited to self-reported sleep data. The purpose of these analyses was to examine the influence of a 12-mo behavioral weight loss intervention on objective and subjective sleep parameters and to evaluate whether changes in sleep were related to weight loss. Hypothesis: We hypothesized that objective and subjective sleep measures would improve following the intervention and that improved sleep would be associated with greater weight loss. Methods: A sample of 127 adults (89% female, 84% Caucasian, 51.8±9.7 y, 34.0±4.5 kg/m2) participated in a 12-mo standard behavioral weight loss intervention that included 24 group sessions. Sleep was assessed objectively at baseline and 12 mo with 5-7 days of actigraphy (Philips Actiwatch 2). Measures included total sleep time (total time spent asleep), sleep efficiency (percentage of time asleep while in bed), and the Fragmentation Index (restlessness during sleep). Subjective sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), yielding a global PSQI score (overall sleep quality) and individual PSQI factors (perceived sleep quality, sleep efficiency, daytime disturbance) were evaluated. Weight outcomes included the percentage of baseline weight lost at 12 mo and whether clinically significant weight loss (≥10%) was achieved. Analyses (repeated measures ANOVA, multiple linear regression, and binary logistic regression) were adjusted for age, sex, and race. Results: The mean 12-mo weight loss was 9.1±8.1%, with 43% achieving at least 10% weight loss. No actigraphic sleep measures significantly changed from baseline to 12 mo. Overall sleep quality significantly improved over the 12 mo (6.4±3.6 to 5.9±3.1 [P=.02]), as did the PSQI factors of perceived sleep quality (P=.05) and sleep efficiency (P=.03). Baseline to 12-mo improvements in the Fragmentation Index and PSQI perceived sleep quality were associated with greater weight loss (β=.22 [P=.03] and β=.29 [P 〈 .01]). Blunted improvements in the Fragmentation Index and the PSQI perceived sleep quality factor were associated with reduced odds of achieving at least 10% weight loss (OR=0.89 [P=.02] and OR=0.20 [P 〈 .01]). No other sleep measures were associated with weight loss outcomes. Conclusions: Following a behavioral intervention that resulted in clinically significant weight loss, only subjective sleep quality was improved. However, weight loss was optimized among adults whose sleep fragmentation decreased and sleep quality improved. Whether augmenting behavioral weight loss interventions with sleep-focused content would lead to greater weight loss remains to be determined.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
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  • 8
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 135, No. suppl_1 ( 2017-03-07)
    Abstract: Introduction: Several trials have documented that behavioral weight loss interventions reduce obstructive sleep apnea (OSA) severity. However, despite the known bidirectional association between body weight and OSA severity, few studies have addressed whether the presence of OSA impedes weight loss outcomes in a lifestyle intervention. Hypothesis: We hypothesized that a behavioral weight loss intervention would significantly reduce OSA severity, but that the presence of OSA would lead to poorer weight loss outcomes. Methods: Overweight and obese adults (N = 101; 50.6 ± 10.3 y, body mass index: 34.1 ± 4.6; 91.1% female, 80.2% white) who participated in a 12-mo behavioral weight loss intervention study and had OSA assessed were included in these secondary analyses. Participants wore a limited-channel home sleep testing device (ResMed ApneaLink Plus) for one night at baseline, 6 and 12 mo. Measures of OSA severity included the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and snoring index (i.e., number of snoring events divided by flow recording time). Weight change at 6 and 12 mo was expressed as percentage change from baseline. Linear mixed models were used to evaluate the effect of the intervention on OSA measures, and ANCOVA models examined the effect of weight change on OSA and the effect of OSA on subsequent weight loss. All analyses were adjusted for age, sex, and race. Results: Baseline AHI, ODI, and snoring index were 6.6 ± 7.1, 8.7 ± 8.3, and 109.9 ± 122.0, respectively; 50.5% of the sample had a baseline AHI ≥ 5. AHI and ODI, but not the snoring index, were significantly reduced by the end of the intervention (12-mo changes: -1.3 [P 〈 .05], -2.3 [P 〈 .01], -2.8 [P = .82] , respectively). Weight loss at 6 and 12 mo were 9.0 ± 6.0% and 9.1 ± 8.3%, respectively. Participants with ≥ 5% weight loss at 6 mo had significant reductions in AHI (P = .02), ODI (P 〈 .05), and the snoring index (P 〈 .001) at 6 mo; adults with ≥ 5% weight loss at 12 mo had a significant reduction in the snoring index at 12 mo (P 〈 .01), but not AHI (P = .29) or ODI (P = .39), relative to baseline. Participants with a baseline AHI ≥ 5 lost significantly less weight at 6 mo compared to those without OSA at baseline (-8.4% vs. -11.4%; P 〈 .01), and those with an AHI ≥ 5 at 6 mo lost significantly less weight at 12 mo compared to those without OSA at 6 mo (-7.1% vs. -10.9%; P = .04). Conclusion: Behavioral weight loss interventions in overweight and obese adults lead to significant improvement in OSA severity. However, the presence of at least mild OSA is associated with less favorable weight loss in this population. Future work should explore the mechanisms underlying the blunted weight loss in overweight and obese adults with OSA.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 9
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 137, No. suppl_1 ( 2018-03-20)
    Abstract: Introduction: Intention to engage in physical activity (PA) is an important concept in behavior change theories. However, age, body mass index (BMI), and sleep may influence one’s intention to engage in PA and intention might not predict actual activity. Purpose: This secondary analysis examined predictors of intention to engage in PA and if the factors associated with intention predicted objectively measured moderate-to-vigorous physical activity (MVPA) in adults who were overweight or obese and enrolled in a weight loss study. Methods: We used 6- and 12-mo data from the EMPOWER Study, an observational study examining triggers of lapse following intentional weight loss. Objective measures included up to 7 days of overlapping accelerometer and actigraphy data to assess daily MVPA and sleep. Self-report data included responses to the question “Do you intend to be physically active today?” hereafter called intention, collected at the beginning of each day via ecological momentary assessment. Analyses were performed examining: 1) the effects of subject-level covariates (e.g., age, sex, race, BMI) on intention, 2) the effects of objectively measured sleep characteristics (e.g., total sleep time [TST], number of awakenings, sleep fragmentation) on intention, and 3) the relationships between sleep, intention, and MVPA. Logistic regression using generalized estimating equations and linear mixed-effect models were used. Results: The analyses included 680 person-days at 6 mo and 678 person-days at 12 mo. Participants (N=136) were mostly female (89.8%) and white (81.8%) with a mean (± SD) age of 51.5 ± 9.9 years and BMI of 33.5 ± 4.6. At 6 mo, participants intended to engage in PA on 81.2% of days, had a mean TST of 408.9 ± 81.8 min/night, and a mean of 32.4 ± 14.7 awakenings/night. At 12 mo, PA intention decreased to 80.6% of days, TST increased to 416.5 ± 82.5 min/night, and awakenings increased to 34.0 ± 14.4 per night (p = .089 for TST; p = .043 for awakenings). Mean daily MVPA decreased from 19.0 ± 23.9 min at 6 mo to 17.3 ± 23.4 min at 12 mo (p = .185). Intention increased with increasing age (odds ratio [OR] = 1.04; 95% confidence interval [95% CI] = 1.02 -1.07). At 6 mo, sleep fragmentation, after adjusting for age, negatively affected intention (OR = 0.96; 95% CI = 0.94 - 0.98); however, it did not significantly affect intention at 12 mo. When comparing days with no PA intention to days in which participants intended to engage in PA, mean MVPA nearly tripled from 7.4 min (95% CI = 3.6 - 11.2) to 21.2 min (95% CI = 18.4 - 24.0). Furthermore, when controlling for age, time of assessment, and intention, participants engaged in an estimated 0.135 (95% CI = 0.241 - 0.029) fewer min of MVPA for each awakening. Conclusions: Based on these findings, future weight loss programs should include interventions that improve sleep quality by reducing fragmentation and strengthen the link between intention and engagement in PA.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
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  • 10
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 142, No. Suppl_3 ( 2020-11-17)
    Abstract: Introduction: A novel pediatric disease, MIS-C, has emerged during the COVID -19 pandemic. The majority of cases were reported from European and Northeastern US centers. We present our experience of MIS-C with cardiac findings from a large tertiary pediatric cardiac center. Methods: We conducted a retrospective study of all MIS-C patients evaluated and treated from 03/29/2020 to 6/18/2020 at our center. Demographics, clinical, echo and ECG data were extracted from the echo database and EHR. Abnormal cardiac findings during the acute phase were defined as coronary artery abnormality (CAA), decreased ejection fraction (EF) and rhythm abnormality. CAAs were defined as dilation (z-score of 〉 2 to ≤ 2.49) or aneurysm (2.5 to 〈 5) as well as reviewed for qualitative changes. Results: 32 children, 17 (53%) males have been treated for MIS-C. The median (IQR) age was 9 (7 - 13) years. Underlying medical conditions were noted in 9 (28%) patients including 2 with cardiac conditions (one with previous history of atypical Kawasaki Disease (KD) and one with previous history of pericardial effusion s/p pericardial window). Ten (31%) patients had abnormal cardiac findings; 4 had isolated CAA, 3 had combined CAA and low EF and 2 had isolated low EF. One patient had aneurysms in all 3 CA’s, 2 patients had abnormalities in 2 CA’s (LMCA and RCA aneurysms in 1 and LMCA aneurysm and LAD dilation in 1 patient), and 4 patients had single CAA (RCA dilation in 1, LAD aneurysm in 1, and LAD dilation in 2 patients). No patient with CAA had morphologic evidence of saccular or fusiform changes. CAA persisted on subsequent echo in 3 patients and normalized in 3 patients. EF normalized on subsequent echo in 3 patients. One of the patients with isolated low EF was also found to have intermittent high grade atrioventricular (AV) block. The 10 th patient had normal echo but 1st degree AV block, sinus bradycardia, and long QTc. No arrhythmia was noted. No mortality occurred and overall length of stay was 13.6±9 days. Conclusion: Our MIS-C patients had a high rate of cardiac findings in the acute phase which exceeded rates historically observed in the setting of KD. Further long term study is needed to assess if the cardiac abnormalities persist, improve with immune modulation or are associated with major cardiac events.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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