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A Person-Centered Approach to Supplemental Oxygen Therapy in the Outpatient Setting: A Review

Author/s: 
Angela O Suen, Susan S Jacobs, Mary R Kitlowski, Richard D Branson, Anand S Iyer

Importance: Approximately 1.5 million adults in the US use supplemental oxygen annually in the outpatient setting. However, many do not receive delivery systems that adequately meet their needs, and few receive education about devices or how to maintain independence. This Review summarizes guidelines and evidence on outpatient supplemental oxygen across several cardiopulmonary conditions, highlights evidence gaps where benefits are unclear, and discusses outcomes that inform a person-centered framework for supplemental oxygen therapy.

Observations: Most studies of supplemental oxygen have been conducted in chronic obstructive pulmonary disease, with limited high-quality data in other cardiopulmonary conditions. Data strongly support supplemental oxygen therapy in people with severe resting desaturation (oxygen saturation [SpO2] of 88% or less), with demonstrated improvement in mortality. Whether supplemental oxygen improves symptoms or function in patients with isolated severe exertional desaturation remains inconclusive, prompting an individualized approach and exertional oxygen testing if a patient is mobile and reporting exertional symptoms. Apart from cor pulmonale, evidence does not support supplemental oxygen therapy in patients with moderate resting or exertional desaturation (SpO2 of 89% to 93%). Supplemental oxygen's broad impact on patient-centered outcomes; the supplemental oxygen landscape of devices, testing, prescription, and delivery; and how to weigh the potential harms vs benefits with patients are summarized. These data inform a person-centered supplemental oxygen framework to help patients minimize loss of independence and improve quality of life across the following domains: (1) health care values and preferences; (2) functional status, mobility, and frailty; (3) cognition and supplemental oxygen education; (4) physical symptoms; (5) psychological and social impact; and (6) caregiver support. Guidance on deimplementation and future directions are also summarized.

Conclusions and relevance: Supplemental oxygen therapy should follow a person-centered approach that empowers patients and caregivers; helps patients improve independence and quality of life by optimizing function, mobility, and social well-being; weighs benefits and burdens; and engages in shared decision-making when the evidence is unclear.

Keywords 
oxygen Caregivers heart disease Chronic Disease

Management of Atrial Fibrillation

Author/s: 
Francis J Alenghat, Jason T Alexander, Gaurav A Upadhyay

Atrial fibrillation has a lifetime prevalence of 15% to 40% and predisposes patients to stroke and cardiac dysfunction. This JAMA Clinical Guidelines Synopsis focuses on recommendations for long-term management of AF, including new paradigms for rhythm control and stroke risk reduction.

Keywords 
atrial fibrillation coronary artery disease heart disease Cardiology Rhythm Disorders heart failure

Apolipoprotein B in cardiovascular risk assessment

Author/s: 
Ahmad, maud, Sniderman, Allan D., Hegele, Robert A.

Apolipoprotein (apo) B measurement is a recommended alternative to low-density lipoprotein cholesterol (LDL-C)
The 2021 Canadian Cardiovascular Society guideline on dyslipidemia recommends that physicians may use levels of either non-high-density lipoprotein cholesterol (HDL-C) or apo B instead of LDL-C for screening and targets of treatment.1 Non-HDL-C represents total cholesterol minus cholesterol from HDL particles; apo B represents the total number of atherogenic particles, since 1 apo B molecule is found on each LDL, very low–density lipoprotein, intermediate-density lipoprotein and lipoprotein(a) particle.2

Keywords 
Cardiovascular Diseases heart disease

Apolipoprotein B in cardiovascular risk assessment

Author/s: 
Ahmad, maud, Sniderman, Allan D., Hegele, Robert A.

Apolipoprotein (apo) B measurement is a recommended alternative to low-density lipoprotein cholesterol (LDL-C)
The 2021 Canadian Cardiovascular Society guideline on dyslipidemia recommends that physicians may use levels of either non-high-density lipoprotein cholesterol (HDL-C) or apo B instead of LDL-C for screening and targets of treatment.1 Non-HDL-C represents total cholesterol minus cholesterol from HDL particles; apo B represents the total number of atherogenic particles, since 1 apo B molecule is found on each LDL, very low–density lipoprotein, intermediate-density lipoprotein and lipoprotein(a) particle.2

Keywords 
Cardiovascular Diseases heart disease

Association of Nonfasting vs Fasting Lipid Levels With Risk of Major Coronary Events in the Anglo-Scandinavian Cardiac Outcomes Trial–Lipid Lowering Arm

Author/s: 
Mora, Samia, Chang, C. Lan, Moorthy, M. Vinayaga, Sever, Peter S.

IMPORTANCE:

Recent guidelines have recommended nonfasting for routine testing of lipid levels based on comparisons of nonfasting and fasting populations. However, no previous study has examined the association of cardiovascular outcomes with fasting vs nonfasting lipid levels measured in the same individuals.

OBJECTIVE:

To compare the association of nonfasting and fasting lipid levels with prospectively ascertained coronary and vascular outcomes and to evaluate whether a strategy of using nonfasting instead of fasting lipid level measurement would result in misclassification of risk for individuals undergoing evaluation for initiation of statin therapy.

DESIGN, SETTING, AND PARTICIPANTS:

This post hoc prospective follow-up of a randomized clinical trial included 8270 of 10 305 participants from the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA) with nonfasting and fasting lipid levels measured 4 weeks apart (including 6855 participants with no prior vascular disease) (median follow-up, 3.3 years; interquartile range, 2.8-3.6 years). Data were collected from February 1, 1998, to December 31, 2002, and analyzed from February 1, 2016, to November 30, 2018. Multivariable Cox models, adjusted for cardiovascular risk factors, were calculated for 40-mg/dL (1-mmol/L) higher values of nonfasting and fasting lipids.

MAIN OUTCOMES AND MEASURES:

The trial's primary end point consisted of major coronary events (nonfatal myocardial infarction [MI] and fatal coronary heart disease [212 events]). Secondary analyses examined atherosclerotic cardiovascular disease (ASCVD) events (including MI, stroke, and ASCVD death [351 events]).

RESULTS:

Among the 8270 participants (82.1% male; mean [SD] age, 63.4 [8.5] years), nonfasting samples had modestly higher triglyceride levels and similar cholesterol levels compared to fasting samples. Associations of nonfasting lipid levels with coronary events were similar to those for fasting lipid levels. For example, adjusted hazard ratios (HRs) per 40-mg/dL of low-density lipoprotein cholesterol were 1.32 (95% CI, 1.08-1.61; P = .007) for nonfasting levels and 1.28 (95% CI, 1.07-1.55; P = .008) for fasting levels. For the primary prevention group, adjusted HRs were 1.42 (95% CI, 1.13-1.78; P = .003) for nonfasting levels and 1.37 (95% CI, 1.11-1.69; P = .003) for fasting levels. Results were consistent by randomized treatment arm (atorvastatin calcium, 10 mg/d, or placebo) and similar for ASCVD events. Concordance of fasting and nonfasting lipid levels for classifying participants into appropriate ASCVD risk categories was high (94.8%).

CONCLUSIONS AND RELEVANCE:

Measurement of nonfasting and fasting lipid levels yields similar results in the same individuals for association with incident coronary and ASCVD events. These results suggest that routine measurement of nonfasting lipid levels may help facilitate ASCVD risk screening and treatment, including consideration of when to initiate statin therapy.

Keywords 
fasting statin therapy cholesterol heart disease
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