Primary prevention guidelines recommend calculation of lifetime cardiovascular disease (CVD) predicted risk among individuals who may not meet criteria for high short-term (10-year) ATP-III risk for coronary heart disease (CHD). Both extreme obesity and bariatric surgery are more common among women, who often have low short-term predicted CHD risk. The distribution and correlates of lifetime CVD predicted risk, however, have not yet been evaluated among bariatric surgery candidates. Using established 10-year (ATP-III) CHD and lifetime CVD risk prediction algorithms and pre-surgery risk factors, participants from the Longitudinal Assessment of Bariatric Surgery-2 study without prevalent CVD (n=2070) were stratified into 3 groups: low 10-year (<10%)/low lifetime (<39%) predicted risk, low 10-year (<10%)/high lifetime (≥39%) predicted risk, and high 10-year (≥10% predicted risk or diagnosed diabetes.) Participants were predominantly white (86%), women (80%), with a median age of 45 years and median BMI of 45.6 kg/m2. High 10-year CHD predicted risk was common (36.5%), and associated with diabetes, male sex and older age, but not with higher BMI or hs-c-reactive protein. Most (76%) participants with low 10-year predicted risk had high lifetime CVD predicted risk, which was associated with dyslipidemia and hypertension, but not with BMI, waist circumference, HDL cholesterol or hs-C-reactive protein. In conclusion, bariatric surgery candidates without diabetes or existing CVD are likely to have low short-term, but high lifetime CVD predicted risk. Current data support the need for long-term monitoring and treatment of elevated CVD risk factors among bariatric surgery patients, to maximize lifetime CVD risk reduction.
Clinical Trial Registration
Long-term Effects of Bariatric Surgery, #NCT00465829, http://www.clinicaltrials.gov/ct2/results?term=%23NCT00465829
Cardiovascular disease; extreme obesity; bariatric surgery; lipids
The objectives of this study were to describe contemporary post-discharge death rates of patients hospitalized at all Worcester (MA) hospitals after an initial acute myocardial infarction (AMI) and to examine factors associated with a poor prognosis. We reviewed the medical records of patients discharged from 11 central Massachusetts medical centers after an initial AMI during 2001, 2003, 2005, and 2007, identifying 2,452 patients. This population was comprised of predominantly older individuals, men (58%), and whites. Overall, the 3 month, 1 year, and 2 year all-cause death rates were 8.9%, 16.4%, and 23.4%, respectively. Over time, reductions in post-discharge mortality were observed in crude as well as multivariable adjusted analyses. In 2001, the 3 month, 1 year, and 2 year all-cause death rates were 11.1%, 17.1%, and 25.6%, respectively, compared with rates of 7.9%, 12.7%, and 18.6% among patients discharged in 2007. Older age, male sex, hospitalization for an NSTEMI, renal dysfunction, and pre-existing heart failure were associated with an increased risk of dying after hospital discharge. Our results suggest that the post-discharge prognosis of patients with an initial AMI has improved, likely reflecting both enhanced inhospital and post-discharge management practices. In conclusion, patients with an initial AMI can also be identified who are at increased risk for dying after hospital discharge in whom increased surveillance and targeted treatment approaches can be directed.
initial AMI; prognosis; changing trends
Patterns of medical resource use near the end of life may differ across modes of death. We characterized patterns of inpatient resource use and direct costs for patients with HF who died of sudden cardiac death (SCD), HF, other cardiovascular causes, or noncardiovascular causes during the last year of life. Data were from a randomized trial exercise training in patients with HF. Mode of death was adjudicated by an end point committee. We used generalized estimating equations to compare hospitalizations, inpatient days, and inpatient costs incurred during the final year of life among patients who died of different causes, adjusting for clinical and treatment characteristics. Of 2331 patients enrolled in the trial, 231 died after at least 1 year of follow-up with an adjudicated mode of death, including 72 of SCD, 80 of HF, 34 of other cardiovascular causes, and 45 of noncardiovascular causes. Patients who died of SCD were younger, had less severe HF, and incurred fewer hospitalizations, fewer inpatient days, and lower inpatient costs than patients who died of other causes. After adjustment for patient characteristics, inpatient resource use varied by 2 to 4 times across modes of death, suggesting that cost-effectiveness analyses of interventions that reduce mortality from SCD compared with other causes should incorporate mode-specific end-of-life costs. In conclusion, resource use and associated medical costs in the last year of life differed markedly among patients with HF who experienced SCD and patients who died of other causes.
Costs and Cost Analysis; Death; Sudden; Cardiac; Heart Failure
Nomograms to predict normal aortic root diameter for body surface area (BSA) in broad ranges of age have been widely used, but are limited by lack of consideration of gender effects, jumps in upper limits of aortic diameter between age strata, and data from older teenagers. Sinuses of Valsalva diameter was measured by American Society of Echocardiography convention in normal-weight, non-hypertensive, non-diabetic individuals ≥15 years old without aortic valve disease from clinical or population-based samples. Analyses of covariance and linear regression with assessment of residuals identified determinants and developed predictive models for normal aortic root diameter. Among 1,207 apparently normal individuals ≥15 years old (54% female), aortic root diameter was 2.1 to 4.3 cm. Aortic root diameter was strongly related to BSA and height (both r=0.48), age (r=0.36) and male gender (+2.7 mm adjusted for BSA and age) (all p<0.001). Multivariable equations using age, gender, and either BSA or height predicted aortic diameter strongly (both R=0.674, p <0.001) with minimal relation of residuals to age or body size:
for BSA: 2.423+(age [yrs]*0.009) + (bsa [m2]*0.461) -(sex [1=M, 2=F]*.267) SEE = 0.261 cmfor height: 1.519+(age [yrs]*0.010) + (ht [cm]*.010)-(sex [1=M, 2=F]*.247) SEE = 0.215 cm.
In conclusion, aortic root diameter is larger in men and increases with body size and age. Regression models incorporating body size, age and gender are applicable to adolescents and adults without limitations of previous nomograms.
Aortic root; echocardiography; normal limits
Dipyridamole (Dip) is the most common vasodilator employed with positron emission tomography (PET) for the evaluation of individuals with hypertrophic cardiomyopathy (HC). The aim of this study was to evaluate whether PET quantification of regional myocardial perfusion (rMP), myocardial blood flow (MBF) and coronary flow reserve (CFR) are comparable between Dip and the newer vasodilator agent, Regadenoson (Reg) in HC. An additional aim was to evaluate the association between vasodilator-induced ST segment depression on ECG and myocardial flow in HC. N-13 ammonia PET was performed in 57 symptomatic HC patients at rest and during vasodilator stress (peak) with either Dip (0.56 mg/kg during 4-min infusion) or Reg (0.4 mg fixed bolus dose) for assessment of ECG, rMP (17 AHA-summed difference score [SDS]), MBF and CFR. The Dip and Reg groups consisted of 28 and 29 patients respectively. Baseline characteristics, including resting MBF (0.92 ± 0.22 vs. 0.89 ± 0.23 ml/min/g; P = 0.6) were similar between the Dip and Reg groups. During stress, the presence and severity of abnormal rMP (SDS 5.5 ± 5.5 vs. 5.8 ± 6.7, P=0.8), peak MBF (1.81 ± 0.44 vs. 1.82 ± 0.50 ml/min/g; P = 0.9) and CFR (2.02 ± 0.53 vs. 2.12 ± 0.12; P = 0.5) were comparable between Dip and Reg. Fewer patients exhibited side effects with Reg (2 vs.7; p=0.06). Vasodilator-induced ST segment depression showed a high specificity (~92%) but low sensitivity (~34%) to predict abnormal rMP (SDS ≥ 2). In conclusion, measurement of rMP and quantitative flow with PET is similar between Regadenoson and Dipyridamole in patients with symptomatic HC. Regadenoson is tolerated better than Dipyridamole and is easier to administer. Vasodilator-induced ST segment depression is a specific but non-sensitive marker for prediction of abnormal rMP in HC.
PET; hypertrophic cardiomyopathy; Regadenoson; ECG
Renal dysfunction is an independent predictor of cardiovascular events and a negative prognostic indicator after myocardial infarction (MI). Randomized data comparing percutaneous coronary intervention (PCI) to medical therapy in MI patients with renal insufficiency are needed. The Occluded Artery Trial (OAT) compared optimal medical therapy alone to PCI with optimal medical therapy in 2201 high risk patients with an occluded infarct artery >24 hours post-MI with serum creatinine ≤2.5 mg/dl. The primary endpoint was a composite of death, MI, and class IV heart failure (HF). Analyses were carried out utilizing estimated glomerular filtration rates (eGFR) as a continuous variable and by eGFR categories. Long term follow up data (maximum 9 years) were used for this analysis. Lower eGFR (ml/min/1.73m2) was associated with development of the primary outcome (6-year life-table rate 16.9% in eGFR>90; 19.2% in eGFR 60–89; 34.9% in eGFR<60; p-value <0.0001), death, and class IV HF, with no difference in rates of reinfarction. On multivariable analysis, eGFR was an independent predictor of death and HF. There was no effect of treatment assignment on the primary endpoint regardless of eGFR, and there was no significant interaction between eGFR and treatment assignment on any outcome. In conclusion, lower eGFR at enrollment was independently associated with death and HF in OAT participants. Despite this increased risk, the lack of benefit from PCI in the overall trial was also seen in patients with renal dysfunction and persistent occlusion of the infarct artery in the subacute phase post MI.
Myocardial Infarction; Stents and Kidney Disease
B-type natriuretic peptide (BNP) is used widely to exclude heart failure (HF) in patients with dyspnea. However, most studies of BNP have focused on diagnosing HF with reduced ejection fraction (EF). We hypothesized that a normal BNP (≤ 100 pg/ml) is relatively common in HF with preserved EF (HFpEF), a heterogeneous disorder commonly associated with obesity. We prospectively studied 159 consecutive patients enrolled in the Northwestern University HFpEF Program. All subjects had symptomatic HF with EF>50% and elevated pulmonary capillary wedge pressure (PCWP). BNP was tested at baseline in all subjects. We compared clinical characteristics, echocardiographic parameters, invasive hemodynamics, and outcomes among HFpEF patients with normal (≤ 100 pg/ml) vs. elevated (>100 pg/ml) BNP. Of the 159 HFpEF patients, 46 (29%) had BNP ≤ 100 pg/ml. Subjects with normal BNP were younger, more often female, had higher rates of obesity and higher body-mass index, and less commonly had chronic kidney disease and atrial fibrillation. Both EF and PCWP were similar in normal vs. elevated BNP groups (62±7 vs. 61±7% [P=0.67] and 25±8 vs. 27±9 mmHg [P=0.42], respectively). Elevated BNP was associated with enlarged left atrial volume, worse diastolic function, abnormal right ventricular structure/function, and worse outcomes (e.g., adjusted hazard ratio for HF hospitalization = 4.0, 95% confidence interval 1.6-9.7, P=0.003). In conclusion, a normal BNP is present in 29% of symptomatic outpatients with HFpEF who have elevated PCWP, obesity is likely the primary driver of this finding, and although BNP is useful as a prognostic marker in HFpEF, a normal BNP does not exclude the outpatient diagnosis of HFpEF.
B-type natriuretic peptide; diastolic heart failure; obesity; hemodynamics; echocardiography; outcomes
HF-ACTION was a multicenter, randomized, controlled trial designed to examine the safety and efficacy of aerobic exercise training versus usual care in 2,331 patients with systolic heart failure (HF). In HF-ACTION patients with resting transthoracic echocardiographic (echo) measurements, we examined predictive value of 8 echo-Doppler measurements—left ventricular (LV) diastolic dimension, mass, systolic (ejection fraction) and diastolic function (mitral valve [MV] peak early diastolic-to-peak late diastolic [E/A], peak MV early diastolic velocity-to-tissue Doppler peak early diastolic myocardial velocity [E/E’] ratios, and deceleration time), left atrial (LA) dimension, and mitral regurgitation severity (MR)—for primary endpoint of all-cause death or hospitalization and secondary endpoint of cardiovascular disease (CVD) death or HF hospitalization. We also compared prognostic value of echo variables versus peak oxygen consumption (VO2). MV E/A and E/E’ ratios were more powerful independent predictors of clinical endpoints than was LV ejection fraction (LVEF), but less powerful than peak VO2. In multivariate analyses for predicting primary endpoint, adding E/A ratio to a basic demographic/clinical model increased C-index from 0.61 to 0.62, compared with 0.64 after adding peak VO2. For secondary endpoint, 6 echo variables, but not LVEF or LA dimension, provided independent predictive power over basic model. Addition of E/E’ or E/A to the basic model increased C-index from 0.70 to 0.72 and 0.73, respectively (all p <0.0001). Simultaneously adding E/A and peak VO2 to basic model increased C-index to 0.75 (p <0.0005). No echo variable was significantly related to 0-to-3 month change in exercise peak VO2. In conclusion, addition of echo LV diastolic function variables improves prognostic value of a basic demographic/clinical model for CVD outcomes.
Systolic heart failure; echocardiography; exercise training; clinical outcomes
Abdominal aortic calcium (AAC) is associated with incident cardiovascular disease but the age and sex-related distribution of AAC in a community-dwelling population free of standard cardiovascular disease risk factors has not been described. A total of 3285 participants (aged 50.2±9.9 years) in the Framingham Heart Study Offspring and Third Generation cohorts underwent abdominal multidetector computed tomography (MDCT) scanning during 1998-2005. The presence and amount of AAC was quantified (Agatston score) by an experienced reader using standardized criteria. A healthy referent subsample (N=1656, 803 men) free of hypertension, hyperlipidemia, diabetes, obesity and smoking was identified, and participants were stratified by sex and age group (<45, 45-54, 55-64, 65-74, ≥75 years). The prevalence and burden of AAC increased monotonically and supralinearly with age in both sexes but was greater in men than women in each age group. Below age 45 <16% of referent-subsample participants had any quantifiable AAC, while above age 65 nearly 90% of referent participants had >0 AAC. Across the entire study sample, AAC prevalence and burden similarly increased with greater age. Defining the 90th percentile of referent group AAC as “high,” the prevalence of high AAC was 19% for each sex in the overall study sample. AAC also increased across categories of 10-year coronary heart disease risk, as calculated using the Framingham Risk Score, in the entire study sample. We found AAC to be widely prevalent, with the burden of AAC associated with 10-year coronary risk, in a white, free-living adult cohort.
atherosclerosis; aorta; calcification; computed tomography; epidemiology
The prevalence of coronary artery disease (CAD) in patients with peripheral arterial disease (PAD) varies widely in published reports. This is likely due, at least in part, to significant differences in how PAD and CAD were both defined and diagnosed. We describe 78 patients with PAD who underwent pre-operative coronary angiography prior to elective peripheral revascularization and provide a review of published case series. In our patients the number with concomitant CAD varied from 55% in those with lower extremity stenoses to as high as 80% in those with carotid artery disease. The number of coronary arteries narrowed by ≥50% in our patients was 1 in 28%, 2 in 24% and 3 in 19%; 28% did not have any angiographic evidence of CAD. Our review of the literature resulted in identification of 19 case series in which a total of 3969 patients underwent pre-operative coronary angiography prior to elective PAD surgery; in the 2687 that were described according to the location of the PAD, 55% had at least one epicardial coronary artery with ≥70% diameter narrowing. The highest prevalence of concomitant CAD was in patients with severe carotid artery disease (64%). In conclusion, despite sharing similar risk factors the prevalence of obstructive CAD in patients with PAD ranges widely, and appears to differ across PAD locations. Thus, the decision to perform coronary angiography should be based on indications independent of the planned PAD surgery.
peripheral vascular; coronary artery
Functional capacity as assessed by 6-minute walk test distance (6MWTD) has been shown to predict outcomes in selected cohorts with cardiovascular disease. To evaluate the association between 6MWTD and outcomes after transcatheter aortic valve implantation (TAVI) among participants in the Placement of AoRTic TraNscathetER valve (PARTNER) trial, TAVI recipients (n = 484) were stratified into 3 groups according to baseline 6MWTD: unable to walk (n = 218), slow walkers (n = 133), in whom 6MWTD was below the median (128.5 meters), and fast walkers (n = 133) with 6MWTD >128.5 meters. After TAVI, among fast walkers, follow-up 6MWTD decreased by 44 ± 148 meters at 12 months (p <0.02 compared with baseline). In contrast, among slow walkers, 6MWTD improved after TAVI by 58 ± 126 meters (p <0.001 compared with baseline). Similarly, among those unable to walk, 6MWTD distance increased by 66 ± 109 meters (p <0.001 compared with baseline). There were no differences in 30-day outcomes among 6MWTD groups. At 2 years, the rate of death from any cause was 42.5% in those unable to walk, 31.2% in slow walkers, and 28.8% in fast walkers (p = 0.02), driven primarily by differences in noncardiac death. In conclusion, among high-risk older adults undergoing TAVI, baseline 6MWTD does not predict procedural outcomes but does predict long-term mortality. Nonetheless, patients with poor baseline functional status exhibit the greatest improvement in 6MWTD. Additional work is required to identify those with poor functional status who stand to benefit the most from TAVI.
The objective is to determine short and long-term cardiovascular (CV) outcomes in unselected diabetic patients with acute ischemic chest pain (AICP). For diabetic patients presenting to the emergency department with AICP, the short-term CV outcomes remain discordant between trials and registries, whereas the long-term outcomes are not well-described. A consecutive cohort of all residents of Olmsted County, Minnesota, presenting with AICP during the period January 1, 1985 through December 31, 1992 were followed for a median duration of 16.6 years. The primary outcome was long-term all-cause mortality. Other outcomes included a composite of death, MI, stroke, and revascularization (MACCE); and heart failure (HF) events at 30 days and a median of 7.3 years respectively. Of the 2271 eligible patients, 336 (14.8%) were classified with diabetes mellitus (DM). The crude 30-day MACCE rate was 10.1% in diabetic patients and 6.1% in non-diabetic patients (p=0.007). HF events were more common in diabetic patients at 30 days (9.8%, vs.3.1%, p<0.001). At 7.3 years, diabetic patients were more likely to experience MACCE and HF events than non-diabetic patients (71.2% vs. 45.1%, unadjusted HR 2.15, 95 % CI 1.87-2.48, p<0.001) and (45.1%, vs. 18.2%, p<0.001) respectively. Over the follow-up period, 272 (81.9%) diabetic patients died compared to 936 (49.2%) non-diabetic patients (p<0.001). In conclusion, DM is associated with a higher short-term risk of MACCE and HF and a higher long-term risk of mortality in unselected patients with AICP. DM should be included as a high-risk variable in national acute coronary syndrome guidelines.
Diabetes; Outcomes; ACS; Chest Pain; Guidelines
Elevated triglycerides (TG) and low high-density lipoprotein cholesterol (HDL-C) are key metabolic abnormalities in insulin resistance (IR) states, including diabetes mellitus. The TG/HDL-C ratio has been advocated as a simple clinical indicator of IR, but studies have yielded inconsistent results. The total cholesterol/HDL-C ratio is widely used to assess lipid atherogenesis but its utility for assessing IR or its associated coronary heart disease (CHD) risk is unknown. We related the TG/HDL-C and total cholesterol/HDL-C ratios to IR (top quartile of the homeostasis model assessment of insulin resistance) in 3014 individuals (mean age 54 years; 55% women). Logistic regression was used to construct receiver-operating-characteristic curves for predicting IR, with lipid ratios as predictors. Multivariable Cox regression was used to evaluate if adjusting for lipid ratios attenuated the association of IR with CHD. Cross-sectionally, the age- and sex-adjusted correlations of IR were: 0.46 with TG/HDL-C, and 0.38 with total cholesterol/HDL-C. IR Prevalence increased across tertiles of lipid ratios (p<0.0001). The area under the receiver-operating-characteristic curves for predicting IR with TG/HDL-C ratio was 0.745, which was slightly higher than that for total cholesterol/HDL-C ratio (0.707; p<0.001 for comparison). On follow-up (mean 6.4 years), 112 individuals experienced initial CHD events. IR was associated with CHD risk (multivariable-adjusted hazards ratio 2.71, 95% CI 1.79–4.11), which remained significant even after adjustment for the lipid ratios. In conclusion, our observations suggest that the TG/HDL-C ratio is an imperfect surrogate for IR and its associated CHD risk, and it is only slightly better than the total cholesterol/HDL-C ratio for this purpose.
insulin resistance; epidemiology; lipids; coronary risk
Aerobic training (AT) improves the metabolic syndrome (MS) and its component risk factors; however, to our knowledge, no randomized clinical studies have addressed whether resistance training (RT) improves the MS when performed alone or combined with AT. Sedentary, overweight dyslipidemic men and women, aged 18 to 70 years completed a 4-month inactive run-in period and were randomized to 1 of 3 eight-month exercise programs (n = 196). The exercise programs were (1) RT (3 days/week, 3 sets/day of 8 to 12 repetitions of 8 different exercises targeting all major muscle groups); (2) AT (~120 minutes/week at 75% of the maximum oxygen uptake), and (3) AT and RT combined (AT/RT) (exact combination of AT and RT). Of the 196 randomized patients, 144 completed 1 of the 3 exercise programs. The 86 participants with complete data for all 5 MS criteria were used in the present analysis, and a continuous MS z score was calculated. Eight months of RT did not change the MS score. AT improved the MS score (p <0.07) and showed a trend toward significance compared to RT (p <0.10). AT/RT significantly decreased the MS score and was significantly different from RT alone. In conclusion, RT was not effective at improving the MS score; however, AT was effective. Combined AT and RT was similarly effective but not different from AT alone. When weighing the time commitment versus health benefit, the data suggest that AT alone was the most efficient mode of exercise for improving cardiometabolic health.
It is often claimed that only 50% of the incidence of coronary heart disease in the population can be attributed to the standard major risk factors. A careful review of the literature demonstrates that 75–90% of coronary heart disease incidence within in a variety of populations is explained by the standard modifiable risk factors. In conclusion, these data suggest that a more rigorous focus on these conventional risk factors and the lifestyle behaviors that promote them has great potential to reduce the burden of coronary heart disease worldwide.
Although previous studies have suggested associations between plasma palmitoleic acid and coronary heart disease (CHD) risk factors including blood pressure, inflammation, and insulin resistance, little is known about the relation of palmitoleic acid with CHD. This ancillary study of the Physicians’ Health Study was designed to examine whether red blood cell (RBC) membrane cis-palmitoleic acid and cis-vaccenic acid – two fatty acids that can be synthesized endogenously – are associated with CHD risk. We used a risk set sampling method to prospectively select 1000 incident CHD events and 1000 matched controls. RBC membrane fatty acids were measured using gas chromatography. CHD cases were ascertained using annual follow-up questionnaire and validated by an Endpoint Committee through review of medical records. In a conditional logistic regression adjusting for demographics, anthropometric, lifestyle factors, and comorbidity, odds ratios (95% CI) for CHD were 1.0 (ref), 1.29 (0.95–1.75), 1.08 (0.78–1.51), 1.25 (0.90–1.75), and 1.48 (1.03–2.14) across consecutive quintiles of RBC membrane cis- palmitoleic acid (p for trend 0.041). Odds ratio associated with each standard deviation higher RBC membrane cis- palmitoleic acid was 1.19 (95% CI: 1.06–1.35) in a multivariable adjusted model. Lastly, RBC membrane cis-vaccenic acid was inversely associated with CHD risk [OR: 0.79 (95% CI: 0.69–0.91) per standard deviation increase]. In conclusion, our data showed a positive association between RBC membrane cis-palmitoleic acid and CHD risk in male physicians. Furthermore, RBC membrane cis-vaccenic acid was inversely related to CHD.
Coronary artery disease; epidemiology; fatty acids; cis palmitoleic acid
A marked increase in hospitalization for patients with AF has previously been noted. Whether this increase was related to a change in the prevalence of AF, or change in the pattern of practice with respect to the management of AF remains unclear. To determine the trends in hospital utilization after first atrial fibrillation (AF) in a community-based setting, Olmsted County, Minnesota residents diagnosed with first AF during 1980-2000 were identified and followed until 2004. The primary outcome of interest was hospital admission for cardiovascular reasons. Of a total of 4,498 subjects (73±14 years old, 51% men), 2,503 (56%) were admitted to the hospital for cardiovascular causes for at least once during a mean follow-up of 5.5±5.0 years. The risk of first hospitalization was greatest during the first year of AF [cumulative incidence 31%, 95% confidence interval (CI) 30-32%]. First hospitalization was strongly related to age (P<0.0001), but not with sex (P=0.38). During 1980-2000, the age-and sex-adjusted rate of first hospitalization increased, on average, by 2.5% a year (95% CI 1.8-3.2%, P<0.0001), even after multivariable adjustment for comorbidities. When we excluded all hospital admissions for the purposes of AF management, the increase in hospitalization was only 0.8% per year (95% CI 0.05-1.6%, P=0.04), which was no longer significant after multivariable adjustment for comorbidities (P=0.25). In conclusion, the marked increase in hospitalization after first AF diagnosis during 1980-2000 appeared to be largely driven by the changing practice pattern in AF management.
atrial fibrillation; hospitalization; epidemiology
Patients with previous stroke are at high-risk for myocardial infarction (MI). Concern regarding increased risk of bleeding or recurrent stroke in this patient population might alter therapeutic decisions. Data were collected from 281 hospitals in the United States in the NCDR ACTION Registry. Patients with ST-segment elevation MI (STEMI; n = 15,997) or non-STEMI (NSTEMI; n = 25,514) entered into the registry from January 1, 2007 through December 31, 2007 were included. We assessed use of evidence-based medications and procedures in patients with and without previous stroke. Risk-adjusted odds ratio of death, major bleeding not related to coronary artery bypass grafting, and a composite outcome (major adverse cardiac events [MACEs], i.e., death/MI/stroke/cardiogenic shock/congestive heart failure) were calculated using logistic regression. Previous stroke was reported in 5.1% of patients with STEMI and 9.3% of those with NSTEMI. Of patients with STEMI eligible for reperfusion therapy, those with previous stroke were less likely to receive reperfusion therapy compared to patients without previous stroke. Patients with previous stroke had longer door-to-needle and door-to-balloon times. Of patients with STEMI and NSTEMI, those with previous stroke were less likely to receive evidence-based therapies. Death, MACEs, and major bleeding were more common with previous stroke. When adjusted for baseline risk, patients with previous stroke were at increased risk of death (only those with STEMI) and MACEs but not bleeding. In conclusion, patients with STEMI and previous stroke are at increased risk for death and patients with STEMI and NSTEMI are at increased risk of MACE. Despite this, previous stroke patients are less likely to receive guideline-based MI therapies.
We sought to determine whether depressed myocardial contraction fraction (MCF, the ratio of left ventricular (LV) stroke volume to myocardial volume) predicts cardiovascular disease (CVD) events in initially healthy adults. A subset (N=318, 60±9 yrs, 158 men) of the Framingham Heart Study Offspring cohort free of clinical CVD underwent volumetric cardiovascular magnetic resonance (CMR) imaging in 1998–1999. LV ejection fraction (EF), mass and MCF were determined. “Hard” CVD events comprised cardiovascular death, myocardial infarction, stroke or new heart failure. A Cox proportional hazards model adjusting for Framingham Coronary Risk Score (FCRS) was used to estimate hazard ratios for incident hard CVD events for sex-specific quartiles of MCF, LV mass and LVEF. The lowest quartile of LV mass and highest quartiles of MCF and EF served as referent. Kaplan-Meier survival plots and the log rank test were used to compare event-free survival. MCF was greater in women (0.58±0.13) than men (0.52±0.11), p<0.01. Nearly all (99%) participants had EF ≥ 0.55. Over up to 9-year (median 5.2) follow-up, 31 participants (10%) experienced an incident hard CVD event. Lowest-quartile MCF was 7 times more likely to develop hard CVD (hazard ratio 7.11, p=0.010) compared to the lowest quartile, and the elevated hazards persisted even after adjustment for LV mass (hazard ratio=6.09, p=0.020). The highest-quartile LV mass/height2.7 had nearly five-fold risk (hazard ratio 4.68, p=0.016). Event-free survival was shorter in lowest-quartile MCF, p = 0.0006, but not in lowest-quartile LVEF. Conclusion: In a cohort of adults initially without clinical CVD, lowest-quartile MCF conferred an increased hazard for hard CVD events after adjustment for traditional CVD risk factors and LV mass.
magnetic resonance imaging; myocardial contraction fraction; risk factors; left ventricular function
A high prevalence of obesity exists among National Football League (NFL) players as determined by body mass index (BMI). It is not established whether elevated BMI is associated with a greater prevalence of CV risk factors or coronary atherosclerosis in former NFL players as in non-athletes. This study compared cardiovascular (CV) risk factors and coronary atherosclerosis among retired NFL players and two groups of community controls, the population-based Dallas Heart Study and the preventive medicine cohort, the Aerobics Center Longitudinal Study. Retired NFL players (n=201) were matched for ethnicity, age and BMI (Aerobics Center Longitudinal Study, age only). CV risk factors were assessed by survey and screening visit. Coronary atherosclerosis was measured by computed tomography as coronary artery calcium (CAC). Compared to population-based controls, retired NFL players had a significantly lower prevalence of diabetes, hypertension, sedentary lifestyle and the metabolic syndrome, yet a higher prevalence of impaired fasting glucose and hyperlipidemia. However, there was no significant difference in the prevalence of detectable CAC (46 v 48.3%, p=0.69) or distribution of CAC (0-10, 10-100, 100-400, 400+, p=0.11). Comparing retired NFL players to the physically active preventive medicine controls, there was no difference in the amount of CAC. Among retired NFL players, age and hyperlipidemia, not body size, were the most significant predictors of CAC. In conclusion, despite their large body size, retired NFL players do not have a greater prevalence of CV risk factors or amount of CAC than community controls.
obesity; cardiovascular risk factors; coronary artery disease
C-reactive protein (CRP) largely has been studied in white non-Hispanic cohorts. There is limited information on CRP’s range of values, heritability and relation to cardiovascular disease (CVD) risk factors in African Americans. We sought to evaluate the distribution, clinical correlates, heritability and genetic linkage of log-transformed CRP in participants of the middle-aged to elderly African American community-based Jackson Heart Study. The distribution and correlates of CRP were analyzed for the entire study cohort who underwent the first examination (2001–2004). Heritability was estimated for the family cohort nested within the larger Jackson Heart Study (246 families, n=1,317). The relation between CRP and CVD risk factors were tested with multivariable stepwise regression analyses. Heritability was estimated using a variance components method. Linkage analysis was performed using the multipoint variance components approach. The study sample consisted of 4,919 participants (mean age 55±13 years, 63% women); median CRP concentration was 2.7 mg/L. In stepwise models traditional risk factors explained 23.8% of CRP’s variability, with body mass index (BMI, partial R2=13.6%) explaining 57.1% of the variability of CRP due to traditional risk factors. The heritability of CRP (adjusted for age, sex and BMI) was 0.45. The strongest linkage evidence for CRP was observed on chromosome 11 (11p13–11p11.2) with a logarithm of odds score of 2.72. In conclusion, in this large population-based cohort of African Americans, circulating CRP concentration was heritable and associated with several traditional cardiovascular risk factors, particularly BMI.
C-reactive protein; risk factors; genetics; heritability; blood pressure; cholesterol; body mass index; African Americans
Heart failure (HF) is one of the leading causes of hospitalization and death in United States and throughout Europe. While a higher risk of HF with antecedent myocardial infarction (MI) has been reported in offspring whose parents had MI before age 55, it is unclear whether adherence to healthful behaviors could mitigate that risk. The aim of the current study was therefore to prospectively examine if adherence to healthy weight, regular exercise, moderate alcohol consumption, and abstinence from smoking can attenuate such increased HF risk. The information on parental history of MI and lifestyle factors was collected using questionnaires. Subjects adhering to at least three healthy lifestyle factors were classified as having good vs. poor lifestyle score. Incident HF was assessed via yearly follow-up questionnaires and validated in a subsample. During an average follow up of 21.7 (6.5) years, 1,323 new HF cases (6.6%) of which 190 (14.4%) were preceded by MI occurred. Compared to subjects with good lifestyle score and no parental history of premature MI, multivariable adjusted hazard ratios (95% CI) for incident HF with antecedent MI was 3.21 (1.74–5.91) for people with good lifestyle score and parental history of premature MI; 1.52 (1.12–2.07) for individuals with poor lifestyle score and no parental history of premature MI; and 4.60 (2.55–8.30) for people with poor lifestyle score and parental history of premature MI. In conclusion, our data suggest that even in people at higher risk of HF due to genetic predisposition, adherence to healthful lifestyle factors may attenuate such an elevated HF risk.
Epidemiology; Heart Failure; Myocardial Infarction; Lifestyle factors; Risk factors
Alcohol and vagal activity may be important triggers for paroxysmal atrial fibrillation (PAF), but it remains unknown if these associations occur more often than would be expected by chance alone due to the lack of a comparator group in previous studies. We compared the self-reported frequency of these triggers in PAF patients to those with other supraventricular tachycardias (SVT). Consecutive consenting patients presenting for electrophysiology procedures at a single University Medical Center underwent a structured interview regarding arrhythmia triggers. Two hundred and twenty three patients with a documented arrhythmia (133 with PAF and 90 with SVT) completed the survey. After multivariable adjustment, PAF patients had a 4.42 greater odds (95% CI 1.35–14.44) of reporting alcohol consumption (p=0.014) and a 2.02 greater odds (95% CI 1.02–4.00) of reporting vagal activity (p=0.044) as an arrhythmia trigger compared to SVT patients. Among PAF patients, drinking primarily beer was associated with alcohol as a trigger (odds ratio [OR] 4.49, 95% CI 1.41–14.28, p=0.011), while younger age (OR 0.68, 95% CI 0.49–0.95, p=0.022) and a family history of atrial fibrillation (AF) (OR 5.73, 95% CI 1.21–27.23, p=0.028) were each independently associated with having vagal activity provoke an episode. PAF patients with alcohol triggers were more likely to have vagal triggers (OR 10.32, 95% CI 1.05–101.42, p=0.045). In conclusion, alcohol consumption and vagal activity elicit PAF significantly more often than SVT. Alcohol and vagal triggers often were found in the same PAF patients, raising the possibility that alcohol may precipitate AF via vagal mechanisms.
paroxysmal atrial fibrillation; alcohol; vagal; supraventricular tachycardia
Patients with rheumatoid arthritis (RA) suffer from an excess burden of cardiovascular disease (CVD). CV risk scores for the general population may not accurately predict CV risk for patients with RA. A population-based inception cohort of patients who fulfilled 1987 American College of Rheumatology criteria for RA in 1988–2007 was followed until death, migration, or 12/31/2008. CV risk factors and CVD (myocardial infarction, CV death, angina, stroke, intermittent claudication and heart failure) were ascertained by medical record review. The 10 year predicted CVD risk was calculated using the general Framingham and the Reynolds risk scores. Standardized incidence ratios were calculated to compare observed and predicted CVD risks. The study included 525 patients with RA aged ≥30 years without prior CVD. The mean follow-up was 8.4 years, during which 84 patients developed CVD. The observed CVD risk was 2-fold higher than the Framingham risk score predicted in women and 65% higher in men, and the Reynolds risk score revealed similar deficits. Patients aged ≥75 years had observed CVD risk >3 times the Framingham predicted risk. Patients with positive rheumatoid factor or persistently elevated erythrocyte sedimentation rate also experienced more CVD events than predicted. In conclusion, the Framingham and Reynolds risk scores substantially underestimated CVD risk in patients with RA of both sexes, especially in older ages and in patients with positive rheumatoid factor. These data underscore the need for more accurate tools to predict CVD risk in patients with RA.
rheumatoid arthritis; cardiovascular disease; risk scores