- 1514 Jefferson Highway
New Orleans, LA 70121 - 504-842-5874
Richard V Milani
Ochsner Medical Center, Cardiology, Faculty Member
- The University of Queensland, Australia, Cardiovascular Disease, Faculty Memberadd
Despite the well-known adverse effects of obesity on almost all aspects of coronary heart disease, many studies of coronary heart disease cohorts have demonstrated an inverse relationship between obesity, as defined by body mass index... more
Despite the well-known adverse effects of obesity on almost all aspects of coronary heart disease, many studies of coronary heart disease cohorts have demonstrated an inverse relationship between obesity, as defined by body mass index (BMI), and subsequent prognosis; the 'obesity paradox'. The etiology of this and the potential role of inflammation in this process remain unknown. We studied 519 patients with coronary heart disease before and after cardiac rehabilitation, dividing them into groups based on CRP (CRP ⩾3 mg/l and CRP <3 mg/l after cardiac rehab). BMI was calculated and body fat was measured using the skinfold method. Lean mass index (LMI) was calculated as (1-%body fat) x BMI. The population was divided according to age- and gender- adjusted categories based on LMI and body fat and analyzed by total mortality over more than 3-year follow-up by National Death Index in both CRP groups. During >3-year follow-up, all-cause mortality was higher in the high infl...
Research Interests:
A decade of research from the Ochsner Heart and Vascular Institute's cardiopulmonary rehabilitation and exercise training programs demonstrates the benefits of this therapy on coronary risk factors, exercise capacity, cardiopulmonary... more
A decade of research from the Ochsner Heart and Vascular Institute's cardiopulmonary rehabilitation and exercise training programs demonstrates the benefits of this therapy on coronary risk factors, exercise capacity, cardiopulmonary parameters, behavioral characteristics, and quality of life in various subgroups of patients, including the elderly, women, obese patients, and groups with dyslipidemia and psychological distress, as well as in patients with congestive heart failure or severe lung disease. Substantial data from our program support the idea that cardiopulmonary rehabilitation and exercise training programs are underemphasized and underutilized for the secondary prevention of coronary artery disease.
Research Interests:
To determine the the prevalence of isolated low high-density lipoprotein cholesterol and its response to hygienic therapy in coronary patients after major cardiac events. Data before and after phase II cardiac rehabilitation and exercise... more
To determine the the prevalence of isolated low high-density lipoprotein cholesterol and its response to hygienic therapy in coronary patients after major cardiac events. Data before and after phase II cardiac rehabilitation and exercise training were assessed in 275 consecutive patients from two institutions. All patients had known coronary artery disease and underwent a 12-week program of aggressive hygienic therapy. The prevalence of isolated low high-density lipoprotein cholesterol in this cohort was determined and its response to vigorous nonpharmacologic therapy was assessed and compared with that of other coronary patients undergoing similar therapy. At baseline, 113 (41%) had low high-density lipoprotein cholesterol, including 70 (25%) with isolated low high-density lipoprotein cholesterol. In contrast, 147 (53%) had "high-risk" low-density lipoprotein-cholesterol > or = 130 mg/dL. In the subgroup with isolated low high-density lipoprotein cholesterol, improveme...
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Although functions of dehydroepiandrosterone (DHEA) and its sulfate ester are unknown, investigators have found an inverse relation between DHEA-sulfate levels and coronary artery disease, suggesting its importance as an inverse coronary... more
Although functions of dehydroepiandrosterone (DHEA) and its sulfate ester are unknown, investigators have found an inverse relation between DHEA-sulfate levels and coronary artery disease, suggesting its importance as an inverse coronary risk factor. In previous studies, where behavioral therapy was used to try to reduce stress and social isolation, DHEA levels increased--although other confounding factors, including enhanced physical activity, also were affected. To determine the influence of physical activity alone on plasma DHEA-sulfate levels in patients with coronary artery disease, the authors studied the effects of exercise training by measuring plasma DHEA-sulfate levels and other parameters in 96 patients at baseline and after 12 weeks of cardiac rehabilitation and exercise training. They confirmed that DHEA-sulfate levels decreased with age (r = 0.41; P < 0.0001) and that DHEA-sulfate levels correlated with body mass index (r = 0.32; P < 0.001), but not with other ba...
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The predictive value of a screening test depends on its accuracy and the pretest likelihood of disease (i.e, prevalence of the disease in the population). In ischemic heart disease, there are no absolute indications for exercise... more
The predictive value of a screening test depends on its accuracy and the pretest likelihood of disease (i.e, prevalence of the disease in the population). In ischemic heart disease, there are no absolute indications for exercise electrocardiographic testing in asymptomatic patients. However, it is the major noninvasive test for coronary artery disease (CAD). We prefer to use exercise testing whenever possible, because it provides physiologic data that may indicate prognosis and aid in decision making regarding medical treatment. In several situations, exercise assessment combined with radionuclide angiography or echocardiography is indicated for evaluation of patients with CAD. In certain groups of patients, pharmacologic stress testing is preferred. The two methods used most often are dipyridamole administration followed by thallium perfusion imaging and dobutamine administration followed by echocardiography. They have similar sensitivity, specificity, and diagnostic accuracy for C...
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Considerable research from the Ochsner Heart and Vascular Institute has focused on the effects of exercise training in patients with coronary heart disease. In this review, the authors discuss the risks and benefits of exercise training... more
Considerable research from the Ochsner Heart and Vascular Institute has focused on the effects of exercise training in patients with coronary heart disease. In this review, the authors discuss the risks and benefits of exercise training in general patients, as well as those with known vascular disease, and provide suggestions for exercise prescriptions for these patients, including modes of exercise and intensity, duration, and frequency of exercise sessions.
Research Interests:
We review data from our institution demonstrating the benefits of cardiac rehabilitation and exercise training on coronary risk factors, exercise capacity, behavioral characteristics, and quality of life in various subgroups of patients.... more
We review data from our institution demonstrating the benefits of cardiac rehabilitation and exercise training on coronary risk factors, exercise capacity, behavioral characteristics, and quality of life in various subgroups of patients. In addition, we discuss our research in several other areas of preventive cardiology, including lipid disorders, hypertension, left ventricular hypertrophy, fish oils, and antioxidants. We believe that we are now in a very exciting era in which a multifactorial approach to the primary and secondary prevention of coronary artery disease is needed in order to further reduce morbidity and mortality rates.
Can atherosclerotic heart disease be halted or even reversed by aggressive pharmacologic therapy? Studies in recent years have shown that small amounts of plaque regression may be accompanied by considerable reduction in the rate of... more
Can atherosclerotic heart disease be halted or even reversed by aggressive pharmacologic therapy? Studies in recent years have shown that small amounts of plaque regression may be accompanied by considerable reduction in the rate of clinical cardiac events. In this article, the authors examine the results of important studies on lipid-lowering agents, low-dose aspirin, estrogen replacement, and calcium antagonists.
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Accepted for publication 3 May 1996 Abstract Objectives-To evaluate whether changes in the ventilationicarbon dioxide production ratio during early exercise could reliably serve as a surrogate marker for maximal oxygen consumption in... more
Accepted for publication 3 May 1996 Abstract Objectives-To evaluate whether changes in the ventilationicarbon dioxide production ratio during early exercise could reliably serve as a surrogate marker for maximal oxygen consumption in heart failure patients. Maximal oxygen consumption is an important determinant of the severity of congestive heart failure with values > 14 mllkglmin confering a good 2-year survival. However, many patients undergoing cardiopulmonary exercise testing cannot exercise maximally because of other functional limitations. Methods-Ventilationlcarbon dioxide production ratio was assessed at rest, anaerobic threshold, and peak exercise in 75 patients with chronic heart failure and in 12 healthy controls. Patients were divided into two groups on the basis of heart failure severity as judged by maximal oxygen consumption. Results-Patients with mild-moderate heart failure had a 20% reduction in the ventilation/carbon dioxide production ratio at anaerobic thresho...
Considerable research from the Ochsner Heart and Vascular Institute has focused on the effects of exercise training in patients with coronary heart disease. In this review, the authors discuss the risks and benefits of exercise training... more
Considerable research from the Ochsner Heart and Vascular Institute has focused on the effects of exercise training in patients with coronary heart disease. In this review, the authors discuss the risks and benefits of exercise training in general patients, as well as those with known vascular disease, and provide suggestions for exercise prescriptions for these patients, including modes of exercise and intensity, duration, and frequency of exercise sessions.
Research Interests:
A decade of research from the Ochsner Heart and Vascular Institute's cardiopulmonary rehabilitation and exercise training programs demonstrates the benefits of this therapy on coronary risk factors, exercise capacity, cardiopulmonary... more
A decade of research from the Ochsner Heart and Vascular Institute's cardiopulmonary rehabilitation and exercise training programs demonstrates the benefits of this therapy on coronary risk factors, exercise capacity, cardiopulmonary parameters, behavioral characteristics, and quality of life in various subgroups of patients, including the elderly, women, obese patients, and groups with dyslipidemia and psychological distress, as well as in patients with congestive heart failure or severe lung disease. Substantial data from our program support the idea that cardiopulmonary rehabilitation and exercise training programs are underemphasized and underutilized for the secondary prevention of coronary artery disease.
Research Interests:
Evidence is increasing that oxidation of low-density lipoprotein cholesterol may be instrumental in atherogenesis. As a result, a number of studies have been undertaken to evaluate the effects of antioxidant vitamins, beta carotene,... more
Evidence is increasing that oxidation of low-density lipoprotein cholesterol may be instrumental in atherogenesis. As a result, a number of studies have been undertaken to evaluate the effects of antioxidant vitamins, beta carotene, selenium, and monounsaturated fat on coronary artery disease. Results in many instances have been promising, particularly in the case of vitamin E supplements. Studies of pro-oxidants, such as iron and copper, are inconclusive at this time, and a trial to assess the value of probucol in hypercholesterolemic patients is currently under way.
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e15192 Background: ADT is a mainstay treatment in pts with PC and is supposedly associated to an unfavorable metabolic and cardiovascular profile. Recently, a meta-analysis of randomized controlled trials (RCT) found no association... more
e15192 Background: ADT is a mainstay treatment in pts with PC and is supposedly associated to an unfavorable metabolic and cardiovascular profile. Recently, a meta-analysis of randomized controlled trials (RCT) found no association between ADT and increased risk of CVE (JAMA 2011). However, no conclusive data were available about ADT association with metabolic changes and adverse CVE or DM because of pts selection in RCT. Therefore, we performed a meta-analysis of adjusted observational results in order to look for DM and CVE onset in an ADT unselected population. Methods: Medline, Cochrane Library and Biomed Central were searched for articles addressing adverse events related to ADT in patients with PC. Selection criteria were: not RCT, pts assigned to ADT or not, adjusted risk of CVE and DM according to ADT. Exclusion criteria were: duplicate publication, comparison of two different strategies of ADT (different drugs or duration). Cardiovascular death was the primary endpoint; non...
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A third of healthcare spending in the United States is considered waste, and costs are growing at an unsustainable rate. Reducing unnecessary cardiac telemetry, a costly intervention with a high potential for overuse, may be an... more
A third of healthcare spending in the United States is considered waste, and costs are growing at an unsustainable rate. Reducing unnecessary cardiac telemetry, a costly intervention with a high potential for overuse, may be an opportunity to reduce waste. We performed a review of 250 consecutive patients admitted to telemetry capable beds on the general medical-surgical, noncritical care units. Based on the American Heart Association Practice Standards for Electrocardiographic Monitoring in Hospital Settings, appropriateness of telemetric monitoring during each inpatient day was assessed, with identification of significant new arrhythmias, code calls, and clinical decisions resulting from telemetry. Cost of a telemetry day was calculated using a time-driven activity-based cost model. Patients (63 ± 19 years, 54% male) spent a total of 1,640 days hospitalized, 1,399 (85%) of which were on telemetry. Average length of stay was 6.6 days, and average telemetry time was 5.6 days. Only 3...
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Assessments of cardiac rehabilitation (CR) in coronary heart disease (CHD) cohorts usually examine mortality in aggregate. This study examines the prognosis and characteristics of patients who enrolled and completed CR, stratified by... more
Assessments of cardiac rehabilitation (CR) in coronary heart disease (CHD) cohorts usually examine mortality in aggregate. This study examines the prognosis and characteristics of patients who enrolled and completed CR, stratified by their level of improvement in cardiorespiratory fitness (CRF) by examining the characteristics, outcomes and predictors of non-response in CRF (NonRes) compared with low-responders (LowRes) and high-responders (HighRes) after CR. A total of 1171 CHD patients were referred for a phase II CR programme after therapy for an acute coronary syndrome, coronary artery bypass graft procedure or a percutaneous coronary intervention between 1 January 2000 and 30 June 2013 underwent cardiopulmonary exercise testing before and after CR. This cohort was divided according to absolute improvements in CRF (i.e. change in peak oxygen consumption expressed in mL⋅kg-1⋅min-1). Mortality was analysed after 0.5-13.4 years of follow-up (mean 6.4 years). A total of 266 (23%) su...
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Obesity increases a number of cardiovascular disease (CVD) risk factors, but patients with many types of CVD may have a better prognosis if classified as overweight or obese, a phenomenon known as the "obesity paradox". This... more
Obesity increases a number of cardiovascular disease (CVD) risk factors, but patients with many types of CVD may have a better prognosis if classified as overweight or obese, a phenomenon known as the "obesity paradox". This paradoxical benefit of a medically unfavorable phenotype is particularly strong in the overweight and class I obesity, and less pronounced in the more severe or morbidly obese populations (class II-III and greater). Rather than an obesity paradox, it is possible that this phenomenon may represent a "lean paradox", in which individuals classified as normal weight or underweight may have a poorer prognosis with respect to CVD, as a result of a progressive catabolic state and lean mass loss. Cardiorespiratory fitness (CRF) is a fundamental part of this discussion. A greater CRF is associated with lower CVD risk, regardless of body mass index (BMI). Also, the assessment of body composition compartments (i.e., fat mass, fat-free mass, lean mass) a...
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The management of cardiovascular diseases (CVD) in patients with obesity presents numerous challenges. Obesity has a negative effect on almost all of the major CVD risk factors, and adversely influences cardiovascular structure and... more
The management of cardiovascular diseases (CVD) in patients with obesity presents numerous challenges. Obesity has a negative effect on almost all of the major CVD risk factors, and adversely influences cardiovascular structure and function. Patients who are overweight or obese have a higher incidence of almost all CVDs compared with patients who are of normal weight. However, those who are overweight or obese seem to have a better short-term and medium-term prognosis after major CVD events and interventional procedures or cardiac surgeries than leaner patients, a phenomenon termed the &#39;obesity paradox&#39;. In considering the mechanisms underlying this paradox, we review evidence of the deleterious consequences of obesity in patients with coronary heart disease, and the limited data on the benefits of weight loss in patients with CVD. Additional studies are needed on the efficacy of purposeful weight loss on cardiovascular outcomes to determine the ideal body composition for patients with CVD.
Cardiovascular rehabilitation (CR) is the process of developing and maintaining an optimal level of physical, social, and psychological well-being in order to promote recovery from cardiovascular (CV) illness. It is a multi-disciplinary... more
Cardiovascular rehabilitation (CR) is the process of developing and maintaining an optimal level of physical, social, and psychological well-being in order to promote recovery from cardiovascular (CV) illness. It is a multi-disciplinary approach encompassing supervised exercise training, patient counseling, education and nutritional guidance that may also enhance quality of life. Beneficial CV effects may include improving coronary heart disease risk factors; particularly exercise capacity, reversing cardiac remodeling, and favorably modifying metabolism and systemic oxygen transport. We review the historical basis for contemporary CR, the indications and critical components of CR, as well as the potential salutary physiological and clinical effects of exercise-based CR.
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Hypertension (HTN) is the most common chronic disease in the United States, and the standard model of office-based care delivery continues to yield suboptimal outcomes, with approximately 50% of affected patients not achieving blood... more
Hypertension (HTN) is the most common chronic disease in the United States, and the standard model of office-based care delivery continues to yield suboptimal outcomes, with approximately 50% of affected patients not achieving blood pressure (BP) control. Poor population-level BP control has been primarily attributed to therapeutic inertia and low patient engagement resulting in significant and preventable morbidity and mortality. This review will highlight the rationale for a reengineered model of care delivery for populations with HTN. New technologies now enable patients to generate accurate home-based BP readings that are transmitted directly into the electronic medical record. Using more frequent BP measurements in conjunction with assessment of social health determinants, computerized algorithms can be generated that provide tailored interventions and communications that can transform HTN control. New capabilities enable healthcare providers the means to measure larger volumes of BP data directly from home and provide near real-time interventions that can dramatically improve HTN control.
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Hypertension (HTN) is a global health problem and a leading risk factor for cardiovascular disease (CVD) morbidity and mortality. The hemodynamic overload from HTN causes left ventricular (LV) remodeling, which usually manifests as... more
Hypertension (HTN) is a global health problem and a leading risk factor for cardiovascular disease (CVD) morbidity and mortality. The hemodynamic overload from HTN causes left ventricular (LV) remodeling, which usually manifests as distinct alterations in LV geometry, such as concentric remodeling or concentric and eccentric LV hypertrophy (LVH). In addition to being a common target organ response to HTN, LV geometric abnormalities are well-known independent risk factors for CVD. Because of their prognostic implications and quantifiable nature, changes in LV geometric parameters have commonly been included as an outcome in anti-HTN drug trials. The purpose of this paper is to review the relationship between HTN and LV geometric changes with a focus on (1) diagnostic approach, (2) epidemiology, (3) pathophysiology, (4) prognostic effect and (5) LV response to anti-HTN therapy and its impact on CVD risk reduction.