Editorials

Cardiology in Wisconsin: Take 2

Thomas C. Meyer, MD, Medical Editor, WMJ

Two cardiology issues in one year. When the Editorial Board decided last fall to devote two issues of WMJ to cardiovascular disease, we had no doubt that there would be enough interest to generate some fine manuscripts, both from clinical and public health perspectives. Still, we have been pleasantly surprised by the level of interest and subsequent response we’ve gotten. Like the cardiology issue in the spring, this too is packed with peer-reviewed manuscripts. And while this issue also focuses on the epidemiology of cardiovascular disease, there is much of clinical interest in these pages as well.


Author Affiliations: Medical Editor, WMJ

Corresponding Author: Please address correspondence to Wisconsin Medical Society at 608.442.3800

Original Research

Heart Failure: New Data and Guidelines

Michael L. Keown, MD; Peter S. Rahko, MD

Heart failure is a common clinical problem, affecting at least 5 million Americans. There have been substantial advances in the understanding and treatment of heart failure in the last several years. We review current concepts for the evaluation and treatment of the various manifestations of patients with heart failure.



Author Affiliations: Authors are with the University of Wisconsin Medical School, Madison, WI.

Corresponding Author: Address reprint requests to Peter S. Rahko, MD, G7/343 CSC, Cardiovascular Medicine Section, University of Wisconsin Hospital, 600 Highland Ave, Madison, WI 53792-3248, 608.263.8838; e-mail psr@medicine.wisc.edu.

An Update on the Epidemiology, Pathogenesis and Management of Infective Endocarditis with Emphasis on Staphylococcus aureus

Tahir Tak, MD, PhD; Kurt D. Reed, MD; Ray C. Haselby, DO; Charles S. McCauley, Jr, MD; Sanjay K. Shukla, PhD

The incidence of infective endocarditis (IE) is thought to be around 4/100,000 person years in the general population, and 15/100,000 over the age of 50 years. The risk of acquiring IE is higher among patients with valvular heart disease (e.g., rheumatic valves, bicuspid aortic valves, myxomatous degeneration, etc.), congenital heart disease (e.g., coarctation, patent ductus arteriosus, ventricular septal defect, etc.), prosthetic cardiac valves, and among intravenous drug abusers. Staphylococcus aureus is one of the most common infective agents of IE, and most commonly originates from nosocomial sources, e.g., intravenous and arterial catheters, pacemaker leads, and prosthetic valves. Endocarditis caused by S aureus has a mortality rate of approximately 20% to 40%. In up to 40% of patients, IE caused by S aureus is associated with embolic complications. The risk of death increases with the development of complications. The epidemiology and microbiology of S aureus are changing rapidly, and resistance to antibiotics, especially methicillin, is becoming more widespread. In this review we will focus on the epidemiology, microbiology, and pathogenesis of S aureus IE, and also summarize the current guidelines for diagnosis, treatment, and prophylaxis of this clinical condition.



Author Affiliations: Doctors Tak and McCauley are with the Department of Cardiology and Dr. Haselby is with the Department of Infectious Disease, Marshfield Clinic, Marshfield, WI. Doctor Reed and Dr. Shukla are with the Clinical Research Center, Marshfield Medical Research a

Corresponding Author: Correspondence to Tahir Tak, MD, PhD, Department of Cardiology, Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449; 715.387.5301; e-mail takt@mfldclin.edu.

A Comparison of Cardiovascular Disease Risk Factors in Farm and Non-farm Residents: the Wisconsin Rural Women’s Health Study

Catherine McCarty, PhD, MPH; Po-Huang Chyou, PhD; Lorelle Ziegelbauer, AS; Debra Kempf, BSN; Daniel McCarty, PhD; Paul Gunderson, PhD; Douglas Reding, MD, MPH

Objectives: The purpose of this paper is to describe the baseline difference in cardiovascular disease risk factors between farm and non-farm women in the Rural Women’s Health Study. Methods: Women aged 25 to 75 years were recruited from the Central Marshfield Epidemiologic Study Area, a geographically defined area surrounding Marshfield, Wis. (population 19,000), where more than 95% of residents seek their health care from the Marshfield Clinic. The baseline examination included measurements of blood pressure, skin folds, height, weight, fasting blood lipids, and blood glucose. Health behavior information collected included smoking, dietary intake, reproductive health, physical activity, medical history, social support, occupational strain and symptoms of anxiety and depression. Results: Between 1995 and 2001, 825 non-farm residents and 675 farm residents were examined (58% of eligible women). The farm residents were similar in age to the non-farm residents (mean 47.6 years and 47.0 years, t-test=-0.91, P value=0.36). The total number of modifiable risk factors for atherosclerosis ranged theoretically from 0 to 6, and actually from 0 to 5, with a small percentage of women having either none or 5 risk factors. The percentage of women with 3 or more modifiable risk factors was 26.1% (95%CL=23.9, 28.4). The median number of total risk factors was 2 and the frequency distribution was not significantly different between farm and non-farm residents (c2 5 df=4.6, P=0.47). The prevalence of current cigarette smoking was significantly higher in the non-farm residents, while the prevalence of hypertension and obesity was significantly higher in the farm residents. Overall, obesity prevalence is significantly higher in the study cohort than US women in general (35% versus 23%). Only 5 (0.7%) of the farm residents and 10 (1.2%) of the non-farm residents reported a previous myocardial infarction. Conclusions: These data suggest that the prevalence



Author Affiliations: Authors are with Marshfield Clinic, Marshfield, Wis.

Corresponding Author: Address correspondence to Catherine McCarty, PhD, Marshfield Clinic, 1000 N Oak Ave (ML2), Marshfield, WI 54449; 715.389.3120; e-mail mccartyc@mmrf.mfldclin.edu.

Clinical Cardiac Manifestations of HIV Infection: A Review of Current Literature

William W. Chu, MD, PhD; James M. Sosman, MD; James H. Stein, MD

New cases of Human Immunodeficiency Virus (HIV) infection are becoming more prevalent in Wisconsin. As advances in HIV treatment have improved patient survival, more individuals are living with this disease. Consequently, previously uncommon manifestations, such as cardiac complications, are likely to be encountered in clinical practice more often. In general, cardiac manifestations in patients with HIV infection are clinically subtle in their initial stages. Symptoms are usually nonspecific; however, dyspnea is very common and may be overlooked or attributed to pulmonary diseases and opportunistic infections. Cardiac abnormalities in HIV infection may involve any of the structures of the heart including pericardium, myocardium, and endocardium. Furthermore, HIV infection is associated with pulmonary hypertension, cardiac neoplasms, and use of potentially cardiotoxic medications. This article reviews the clinical cardiac manifestations currently seen in patients with HIV infection. Most of the cardiac complications were identified in the era before highly-active antiretroviral therapy, however, new complications have also been observed. To further reduce morbidity and mortality caused by HIV, early recognition and prompt intervention of cardiac diseases is extremely important. Further delineation of the natural history and clinical trials of the treatment of cardiac complications in patients with HIV infection are needed given recent advances in antiretro-viral therapy.



Author Affiliations: Authors are with the University of Wisconsin Medical School Department of Medicine. Doctors Chu and Stein are with the Section of Cardiovascular Medicine; Dr. Sosman is with the Section of General Internal Medicine. This research was funded by the Univers

Corresponding Author: Address correspondence to James H. Stein, MD, Section of Cardiovascular Medicine, Department of Medicine, H6/315 CSC (MC 3248), 600 Highland Ave, Madison, WI 53792; 608.263.9648.

Incidence of Myocardial Infarction in a General Population: The Marshfield Epidemiologic Study Area

Robert T. Greenlee, PhD; Allison L. Naleway, PhD; Humberto Vidaillet, MD

Background: Much of what is known about the occurrence of myocardial infarction (MI) in populations is derived from mortality data. International heart disease registries and recent population-based studies provide only limited incidence data from selected areas of the United States. Methods: The Marshfield Epidemiologic Study Area (MESA), a defined geographic region where nearly all residents receive their health care from the Marshfield Clinic and affiliated hospitals, is a resource for estimating disease incidence in a general population. MI incidence rates and time trends from 1992 to 1998 were evaluated in MESA. Results: A total of 1691 MESA residents had their first MI during the study period (age-adjusted rate, 292.4 per 100,000 per year). Rates in MESA were similar to some, and higher than other, incidence rates reported from US populations. About 20% of first MIs were detected only on death certificates. Overall incidence did not change much over time (-0.4% per year, P=0.68), although rates declined 2.3% per year among women (P=0.07). Conclusions: This is the first report of MI incidence in a general population from Wisconsin. The fairly steady incidence trend and the large number of incident events detected through death certificates demonstrate the continued need for primary prevention.



Author Affiliations: Doctor Greenlee is an epidemiologist and Dr. Naleway is a post-doctoral fellow in epidemiology with the Marshfield Medical Research Foundation. Doctor Vidaillet is a cardiologist at the Marshfield Clinic. Research supported by funds from the Marshfield Me

Corresponding Author: Address correspondence to Robert Greenlee, PhD, Epidemiology Research Center, Marshfield Medical Research Foundation, 1000 N Oak Ave, Marshfield, WI 54449; e-mail greenler@mmrf.mfldclin.edu.

Rhabdomyolysis from the Combination of a Statin and Gemfibrozil: An Uncommon But Serious Adverse Reaction

Amy Haavisto Kind, MD; Laura J. Zakowski, MD; Patrick E. McBride, MD

We report a patient with renal insufficiency who developed rhabdomyolysis 1 month after initiating cerivastatin and gemfibrozil for hyperlipidemia. Myopathy caused by HMG-CoA reductase inhibitors (statins) alone is rare, but occurs more frequently when a statin is used with gemfibrozil, a medication that likely has a direct toxic effect on muscles. Predisposing factors to the development of myopathy from the combination include use of medications affecting statin metabolism, higher doses of statins, renal insufficiency, diuretics, and hypothyroidism. It has been proposed that alternate-day therapy with a statin and fibrate, spacing of doses in a single day, or use of lower doses of statins may prevent the development of myopathy. Currently, no predictable method to determine who is at risk for myopathy exists, nor is there a reliable screening test. Therefore, patients should be advised to watch for generalized muscle pain or weakness, and if it occurs, stop medications and report symptoms immediately.

Author Affiliations: Doctor Kind is a second year internal medicine resident at Massachusetts General Hospital. She graduated from the University of Wisconsin Medical School in May 2001. Doctor Zakowski is assistant professor of medicine at the University of Wisconsin Medical

Corresponding Author: Address reprint requests to Laura Zakowski, MD, 326 Bradley Memorial, 1300 University Ave; Madison, WI 53706; e-mail zakowski@facstaff.wisc.edu.

Endoleak: The Achilles Heel of Endovascular Abdominal Aortic Aneurysm Exclusion—A Case Report

John P. Pacanowski Jr, MD; Robert S. Dieter, MD, RVT; Scott L. Stevens, MD; Michael B. Freeman, MD; Mitchell H. Goldman, MD

Endovascular exclusion of abdominal aortic aneurysms (EAAA) is an alternative treatment to open surgical repair in patients with suitable anatomy. The development of endoluminal vascular procedures has allowed aneurysm exclusion via remote arterial access techniques. Aneurysm exclusion by these methods revealed the phenomenon of endoleak, a unique complication characterized by an extravasation of blood into the aneurysm sac after stent-graft deployment. We present a patient treated for an endoleak following EAAA repair and review the endoleak classification system and management.



Author Affiliations: Doctors Pacanowski, Stevens, Freeman and Goldman are with the University of Tennessee, Department of Vascular Surgery; Knoxville, Tenn. Doctor Dieter is with the University of Wisconsin, Section of Cardiovascular Medicine; Madison, Wis.

Corresponding Author: Please address the Wisconsin Medical Society at 608.442.3800

Workplace AED Resuscitation of a Patient with a Rare Congenital Anomalous Coronary Circulation

Jeffrey N. Glaspy, MD; Gregory T. Berman, MD; Tom P. Aufderheide, MD

We describe the case of a 44-year-old male with anomalous pulmonary artery origin of the left main coronary artery who was successfully resuscitated after sudden cardiac death with use of an automated external defibrillator (AED) in the workplace. The diagnosis was made on emergency cardiac catheterization and treated with surgical intervention. This case illustrates: 1) that congenital anomalies, although rare, must continue to be considered in the differential diagnosis of sudden cardiac death, and 2) that AEDs in the workplace can be a crucial, lifesaving intervention in the time-dependent condition of sudden cardiac death.

Author Affiliations: Doctor Glaspy is an Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Truman Medical Center, Kansas City, Mo. Doctor Berman is an EM1 Resident, Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Ariz. Doctor Auf

Corresponding Author: Address correspondence to Jeffrey N. Glaspy, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Truman Medical Center, 2301 Holmes St, Kansas City, MO 64108; 816.556.3250.

Prosthetic Heart Valve Thrombosis: An Overview

Robert S. Dieter, MD, RVT; Raymond A. Dieter, Jr, MD; Raymond A. Dieter, III MD; John P. Pacanowski, Jr, MD; Micheal J. Costanza, MD; William W. Chu, MD, PhD; Eugene A. Gulliver Jr, MD, PhD

Background: Valvular heart disease represents a significant burden to patients with cardiovascular diseases. Surgical treatment of diseased heart valves represents a significant advancement for these patients. However, there are specific complications related to prosthetic valves, including valve thrombosis.

Methods: Review article. Results: Thrombosis of a prosthetic heart valve can present with gradual cardiac decline, embolic phenomena, or frank cardiogenic shock. The diagnosis of prosthetic valve thrombosis is by history, physical examination, and by an imaging modality. Treatment of the thrombosed valve is either surgical or with thrombolysis. Both modalities have significant morbidity and mortality.

Conclusion: Treatment of valvular heart disease does not remove the patient from significant risks. Inherent to a prosthetic heart valve is the risk for valvular thrombosis. Prompt recognition and treatment of prosthetic valve thrombosis is important.

INTRODUCTION Treatment of advanced valvular heart disease frequently involves the surgical replacement of the valve. There are multiple types of prosthetic valves including homograft and bioprosthetic tissue valves and mechanical valves. Although prosthetic valves have the potential to significantly alter the natural course of valvular heart disease, there are inherent problems that may arise as a result of the prosthesis. Among potential complications of prosthetic valves are biomechanical failure, endocarditis, bleeding complications of anticoagulation, and valve thrombosis. This article will briefly overview the complication of prosthetic valve thrombosis.


Author Affiliations: Doctors Robert Dieter and Chu are with the Section of Cardiovascular Medicine, University of Wisconsin, Madison. Doctor Raymond Dieter, Jr., a Cardio-Thoracic and Vascular Surgeon, is World President-Elect, International College of Surgeons. Doctors Raymo

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Your Practice

The promise of translational research in cardiovascular disease

Philip M. Farrell, MD, PhD

The University of Wiscon-sin Medical School had the distinct honor of hosting the 24th annual meeting of the International Society for Heart Research (ISHR), North American Section in July. The theme of the three-day meeting was “Translational Approaches to Cardiovascular Disease.”



Author Affiliations: Doctor Farrell is Dean, University of Wisconsin Medical School, and Vice Chancellor for Medical Affairs at UW-Madison

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800