Low-dose aspirin in patients with stable cardiovascular disease: a meta-analysis

Objective

Many recommendations for aspirin in stable cardiovascular disease are based on analyses of all antiplatelet therapies at all dosages and in both stable and unstable patients. Our objective was to evaluate the benefit and risk of low-dose aspirin (50-325 mg/d) in patients with stable cardiovascular disease.

Methods

Secondary prevention trials of low-dose aspirin in patients with stable cardiovascular disease were identified by searches of the MEDLINE database from 1966 to 2006. Six randomized trials were identified that enrolled patients with a prior myocardial infarction (MI) (n = 1), stable angina (n = 1), or stroke/transient ischemic attack (n = 4). A random effects model was used to combine results from individual trials.

Results

Six studies randomized 9853 patients. Aspirin therapy was associated with a significant 21% reduction in the risk of cardiovascular events (nonfatal MI, nonfatal stroke, and cardiovascular death) (95% confidence interval [CI], 0.72-0.88), 26% reduction in the risk of nonfatal MI (95% CI, 0.60-0.91), 25% reduction in the risk of stroke (95% CI, 0.65-0.87), and 13% reduction in the risk of all-cause mortality (95% CI, 0.76-0.98). Patients treated with aspirin were significantly more likely to experience severe bleeding (odds ratio 2.2, 95% CI, 1.4-3.4). Treatment of 1000 patients for an average of 33 months would prevent 33 cardiovascular events, 12 nonfatal MIs, 25 nonfatal strokes, and 14 deaths, and cause 9 major bleeding events. Among those with ischemic heart disease, aspirin was most effective at reducing the risk of nonfatal MI and all-cause mortality; however, among those with cerebrovascular disease, aspirin was most effective at reducing the risk of stroke.

Conclusion

In patients with stable cardiovascular disease, low-dose aspirin therapy reduces the incidence of adverse cardiovascular events and all-cause mortality, and increases the risk of severe bleeding.     

Prognostic value of low-level cardiac troponin-I elevations in patients without definite acute coronary syndromes

Background

Low-level cardiac troponin-I (cTn-I) elevations predict adverse cardiovascular outcomes in patients with definite acute coronary syndromes (ACS), as defined by the presence of chest pain accompanied by ischemic electrocardiographic changes. However, their prognostic value in other clinical situations remains unclear.

Methods

We studied 366 patients with suspected myocardial infarction (MI) but without definite ACS, including 57 patients with low-level cTn-I elevations (1.0 to 3.0 ng/mL) and 309 patients with cTn-I <1.0 ng/mL. All cTn-I measurements were made with the Dade Stratus II analyzer. We determined the adjusted 1-year risk of nonfatal MI or death from coronary heart disease (CHD death) in each group by using Cox proportional hazards models.

Results

Among patients with cTn-I elevations between 1.0 and 3.0 ng/mL, 6 (11%) had a nonfatal MI or CHD death at 1 year compared with 12 (4%) patients in the cTn-I <1.0 ng/mL group [hazard ratio (HR), 3.5; 95% CI, 1.4 to 8.8]. After adjusting for baseline clinical characteristics, cTn-I levels between 1.0 and 3.0 ng/mL remained strongly associated with nonfatal MI or CHD death (adjusted HR, 3.4; 95% CI, 1.3 to 9.4). This association persisted even in the 215 patients who presented without chest pain (adjusted HR, 4.3; 95% CI, 1.4 to 13).

Conclusions

Low-level cTn-I elevations identify a subset of patients at increased risk for future cardiovascular events, even when obtained outside the context of definite ACS or presentation with chest pain.     

Aspirin resistance and adverse clinical events in patients with coronary artery disease

Purpose

We sought to determine the clinical significance of aspirin resistance measured by a point-of-care assay in stable patients with coronary artery disease (CAD).

Methods

We used the VerifyNow Aspirin (Accumetrics Inc, San Diego, Calif) to determine aspirin responsiveness of 468 stable CAD patients on aspirin 80 to 325 mg daily for ≥4 weeks. Aspirin resistance was defined as an Aspirin Reaction Unit ≥550. The primary outcome was the composite of cardiovascular death, myocardial infarction (MI), unstable angina requiring hospitalization, stroke, and transient ischemic attack.

Results

Aspirin resistance was noted in 128 (27.4%) patients. After a mean follow-up of 379 ± 200 days, patients with aspirin resistance were at increased risk of the composite outcome compared to patients who were aspirin-sensitive (15.6% vs 5.3%, hazard ratio [HR] 3.12, 95% confidence intervals [CI], 1.65-5.91, P < .001). Cox proportional hazard regression modeling identified aspirin resistance, diabetes, prior MI, and a low hemoglobin to be independently associated with major adverse long-term outcomes (HR for aspirin resistance 2.46, 95% CI, 1.27-4.76, P = .007).

Conclusions

Aspirin resistance, defined by an aggregation-based rapid platelet function assay, is associated with an increased risk of adverse clinical outcomes in stable patients with CAD.     

Influence of Obesity on Outcomes in Atrial Fibrillation: Yet Another Obesity Paradox

Background

Obese patients have favorable outcomes in congestive heart failure, hypertension, peripheral vascular disease, and coronary artery disease. Obesity also has been linked with increased incidence of atrial fibrillation, but its influence on outcomes in atrial fibrillation patients has not been investigated. The objective of this research is to investigate the effect of obesity on outcomes in atrial fibrillation.

Methods

The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study was one of the largest multicenter trials of atrial fibrillation, with 4060 patients. Subjects were randomized to rate versus rhythm-control strategy. We performed a post hoc analysis of the National Heart, Lung and Blood Institute limited access dataset of atrial fibrillation patients who had body mass index (BMI) data available in the AFFIRM study. BMI data were not available on 1542 patients. Patients with BMI ≥18.5 were split into normal (18.5-25), overweight (25-30), and obese (>30) categories as per BMI (kg/m²). Multivariate Cox proportional hazards regression was used on the eligible 2492 patients. End points were all-cause mortality and cardiovascular mortality.

Results

Over three fourths of all patients in our cohort were overweight or obese. There were 304 deaths (103 among normal weight, 108 among overweight, and 93 among obese) and 148 cardiovascular deaths (54 among normal weight, 41 among overweight, and 53 among obese) over a mean period of 3 years of patient follow-up. On multivariate analysis, overweight (hazard ratio [HR] 0.64; 95% confidence interval [CI], 0.48-0.84; P = .001) and obese (HR 0.80; 95% CI, 0.68-0.93; P = .005) categories were associated with lower all-cause mortality as compared with normal weight. Overweight (HR 0.40; 95% CI, 0.26-0.60; P <.001) and obese patients (HR 0.77; 95% CI, 0.62-0.95; P = .01) also had lower cardiovascular mortality as compared with the normal weight patients.

Conclusions

Although in prior studies, obesity has been associated with increased risk of atrial fibrillation, an obesity paradox exists for outcomes in atrial fibrillation. Obese patients with atrial fibrillation appear to have better long-term outcomes than nonobese patients.     

Impact of female sex on long-term outcomes in patients with ST-elevation myocardial infarction treated by primary percutaneous coronary intervention

Background

Conflicting information exists about whether sex differences affect long-term outcomes in patients undergoing primary percutaneous coronary intervention (PCI).

Methods

This retrospective study enrolled consecutive patients with ST-elevation myocardial infarction undergoing primary PCI within 24 hours from symptom onset. Hazard ratios (HRs) of events with 95% confidence interval (CI) were calculated in the overall population and in a propensity score matched cohort of women and men.

Results

Among 481 patients, median age 66 years old, 138 (28.7%) were women. Women were older than men (72 vs 63 years, P < 0.001), had a higher prevalence of hypertension (68% vs 54%, P = 0.006), diabetes (27% vs 19%, P = 0.04), and Killip class ≥ 3 at admission (19% vs 10%, P = 0.007). After a median follow-up of 1041 days women experienced a significant higher incidence of the composite of death, nonfatal myocardial infarction, and hospitalization for heart failure (31.9% vs 18.4%, unadjusted HR 1.86; 95% CI, 1.26-2.74; P = 0.002), driven mainly by heart failure (unadjusted HR 2.47; 95% CI, 1.12-5.41; P = 0.024), without significant differences in death (unadjusted HR 1.49; 95% CI, 0.88-2.53; P = 0.13), or nonfatal myocardial infarction (unadjusted HR 1.59; 95% CI, 0.78-3.27; P = 0.19) and no increase in target lesion revascularization (9.4% vs 12.5%, unadjusted HR 0.77; 95% CI, 0.42-1.44; P = 0.42). After propensity score matching the hazard of the composite endpoint was largely attenuated (HR 1.32; 95% CI, 0.84-2.06; P = 0.23).

Conclusions

Women undergoing primary PCI experience worse long-term outcomes than men, but this difference is largely explained by their more adverse baseline cardiovascular profile.     

Racial disparity in long-term mortality rate after hospitalization for myocardial infarction: the Atherosclerosis Risk in Communities study

Background

The underlying reasons why African American patients have a significantly higher mortality rate than European American patients after a myocardial infarction (MI) remain unclear. This study examined the racial disparity in mortality rates after MI and possible explanatory factors.

Methods

A prospective analysis was conducted within the Atherosclerosis Risk in Communities (ARIC) study, a community-based study of 15,792 middle-aged adults. From 1987 to 1998, 642 patients (471 European American and 171 African American) hospitalized for MI without prior history of MI were identified. Of these 642 patients, 129 (82 European American and 47 African American) died during follow-up.

Results

Cox proportional hazard models were used to analyze the racial difference in mortality rate after MI. After adjusting for age and sex, the relative hazard (RH) comparing African American patients to European American patients was 1.80 (95% CI, 1.24-2.61). The RH decreased after adjusting for vascular risk factors (1.29; 95% CI, 0.83-2.00), socioeconomic position (1.31; 95% CI, 0.83-2.09), severity of MI (1.60; 95% CI, 1.05-2.45), and treatment (1.36; 95% CI, 0.92-2.00). In the final model, which included all factors aforementioned, the RH for race was 1.00 (95% CI, 0.56-1.77).

Conclusions

Our findings suggested that vascular risk factors, socioeconomic position, and treatment play major roles in the racial disparity in mortality rate after MI.     

Glucose metabolism in patients with essential hypertension

Purpose

Arterial hypertension is an insulin-resistant condition that has been associated with an increased incidence of diabetes. We assessed the prevalence of glucose abnormalities in a population of patients with essential hypertension.

Methods

In this cross-sectional study, 420 consecutively referred essential hypertensive patients were studied at 16 hypertension clinics in university and community hospitals of Spain. Fasting and 2-hour plasma glucose and insulin levels were determined in nondiabetic patients.

Results

An abnormal glucose metabolism was diagnosed in 68.5% (95% confidence interval [CI], 63.7%-72.9%) of the patients. Isolated insulin resistance, defined by a homeostasis model assessment-estimated insulin resistance (HOMA-IR) equal to or above 3.8, was shown in 9.3% (95% CI, 6.7%-12.5%); impaired fasting glucose in 11.2% (95% CI, 8.6%-14.7%); impaired glucose tolerance in 22.5% (95% CI, 18.5%-26.9%); silent undiagnosed type 2 diabetes in 11.5% (95% CI, 8.6%-14.5%); and known diabetes mellitus in 13.9% (95% CI, 10.4%-17.2%) of the patients. According to the European Group for the Study of Insulin Resistance and the Adult Treatment Program III criteria, the metabolic syndrome was diagnosed in 41.5% (95% CI, 35.9%-47.3%) and 47.9% (95% CI, 43.1%-52.8%) of the patients, respectively. The prevalence of left ventricular hypertrophy (defined by a left ventricular mass index [LVMI] >125 g/m²) was 44.2%. The relation between HOMA-IR and LVMI was statistically nonsignificant, and the LVMI values in the HOMA-IR quartiles were similar. Only 27 patients (6.4%) showed good control of cardiovascular risk factors. In most patients (273, 65%; 95% CI, 60.3%-69.4%) 2 or more cardiovascular risk factors were identified as not being under control.

Conclusions

Two thirds of the patients attending hypertension clinics with essential hypertension show an abnormal glucose metabolism. The metabolic syndrome can be identified in a substantial number of these patients, and 2 or more cardiovascular risk factors are not controlled in the majority of patients.     

Mortality after Hospitalization with Mild, Moderate, and Severe Hyponatremia

Background

Hyponatremia is the most common electrolyte abnormality in hospitalized individuals.

Methods

To investigate the association between serum sodium concentration and mortality, we conducted a prospective cohort study of 98,411 adults hospitalized between 2000 and 2003 at 2 teaching hospitals in Boston, Massachusetts. The main outcome measures were in-hospital, 1-year, and 5-year mortality. Multivariable logistic regression and Cox proportional hazards models were used to compare outcomes in patients with varying degrees of hyponatremia against those with normal serum sodium concentration.

Results

Hyponatremia (serum sodium concentration <135 mEq/L) was observed in 14.5% of patients on initial measurement. Compared with patients with normonatremia (135-144 mEq/L), those with hyponatremia were older (67.0 vs 63.1 years, P <.001) and had more comorbid conditions (mean Deyo-Charlson Index 1.9 vs 1.4, P <.001). In multivariable-adjusted models, patients with hyponatremia had an increased risk of death in hospital (odds ratio 1.47, 95% confidence interval [CI], 1.33-1.62), at 1 year (hazard ratio 1.38, 95% CI, 1.32-1.46), and at 5 years (hazard ratio 1.25, 95% CI, 1.21-1.30). The increased risk of death was evident even in those with mild hyponatremia (130-134 mEq/L; odds ratio 1.37, 95% CI, 1.23-1.52). The relationship between hyponatremia and mortality was pronounced in patients admitted with cardiovascular disease, metastatic cancer, and those admitted for procedures related to the musculoskeletal system. Resolution of hyponatremia during hospitalization attenuated the increased mortality risk conferred by hyponatremia.

Conclusion

Hyponatremia, even when mild, is associated with increased mortality.     

The clinical profile and outcomes associated with coronary collaterals in patients with coronary artery disease

Background

The clinical correlates of coronary collaterals and the effects of coronary collaterals on prognosis are incompletely understood.

Methods

We performed a study of 55,751 patients undergoing coronary angiography to evaluate the correlates of angiographically apparent coronary collaterals, and to evaluate their association with survival.

Results

The characteristic most strongly associated with the presence of collaterals was a coronary occlusion (odds ratio [OR], 28.9; 95% confidence interval [CI], 27.1-30.6). Collaterals were associated with improved adjusted survival overall (hazard ratio [HR] 0.89; 95% CI, 0.85-0.95), and in both acute coronary syndrome (ACS) (HR 0.90; 95% CI, 0.84-0.96) and non-ACS (HR 0.84; 95% CI, 0.77-0.92) patients. Collaterals were associated with improved survival in those receiving angioplasty (HR 0.78; 95% CI, 0.71-0.85) and those with low risk anatomy treated medically (HR 0.84; 95% CI, 0.72-0.98), but not for those treated with coronary bypass graft surgery or those with high-risk anatomy treated without revascularization.

Conclusions

The major correlate of coronary collaterals is the presence/extent of obstructive coronary artery disease. Collaterals are associated with better survival overall and in both ACS and non-ACS presentations, but not for those treated with coronary artery bypass graft (CABG) or those with high-risk anatomy who are not revascularized.     

Resting heart rate and cause-specific death in a 16.5-year cohort study of the Japanese general population

Background

Several prospective studies have reported resting heart rate (HR) to be a risk factor for certain cause-specific death, together with sex- or age-specific differences in the effects of HR on death. However, there have been few prospective data from non-Western populations.

Methods

Cohort study, over 16.5 years to date of death or end of follow-up (November 15, 1998) involving 8800 men and women ≥30 years of age randomly selected throughout Japan, who participated in the National Survey on Circulatory Disorders in 1980. Resting HR was determined from 3 consecutive intervals between R waves on the 12-lead electrocardiogram.

Results

For middle-aged men (30 to 59 years of age), in the highest quartile of HR, there was a significant positive association with cardiovascular (RR, 2.55; 95% CI, 1.22 to 5.31) and all-cause death (RR, 1.45; 95% CI, 1.06 to 2.00). For middle-aged women, in the highest quartile, there was a significant positive association with noncancer, noncardiovascular (RR, 2.41; 95% CI, 1.04 to 5.59), and all-cause death (RR, 1.94; 95% CI, 1.26 to 3.01). Resting HR also showed a significant positive association with cardiac events but not to stroke. These relations were not evident for elderly subjects (≥60 years of age). Results were not affected when deaths within the first 5 years of follow-up were excluded, except for noncancer, noncardiovascular death.

Conclusions

High resting HR is an independent predictor of long-term death in the Japanese general population.     

Prevalence of obesity and associated risk factors in Northeastern China

Aim

To investigate the prevalence of obesity and associated risk factors in the Northeastern Chinese city of Dehui.

Methods

A cross-sectional study involving random sampling methods generated 3598 completed questionnaires by permanent residents of Dehui. Binary multivariate logistic regression analysis was used to identify factors that were significantly associated with obesity.

Results

Based on the 2000 WHO diagnostic criterion regarding populations in the Asia-Pacific region, the prevalence of obesity was 37.71% (34.77% of females; 41.11% of males). Elevated body mass index (BMI) was significantly associated with cardiovascular disease (CVD)-associated conditions (P < 0.05), and increased prevalence of abnormally high transaminase levels (P < 0.05). Binary logistic regression analysis demonstrated the following variables were associated with obesity: increased age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: 1.0-1.02), high total cholesterol (TC) (OR: 1.26, 95% CI: 1.03-1.54), high triglycerides (TG) (OR: 1.38, 95% CI: 1.16-1.64), hypertension (OR: 1.62, 95% CI: 1.39-1.90), fatty liver (OR: 2.91, 95% CI: 2.41-3.49), living in an urban setting (OR: 2.84, 95% CI: 2.39-3.38), and advanced education (OR: 1.22, 95% CI: 1.06-1.40).

Conclusions

Obesity is prevalent among the adult population in Northeastern China and is significantly associated with CVD risk factors such as hypertension, dyslipidemia, as well as transaminase abnormalities.     

Long-Acting Calcium Antagonists in Patients with Coronary Artery Disease: A Meta-Analysis

Background

The use of calcium channel blockers (CCBs) in patients with coronary artery disease remains controversial, with reports of increased risk of myocardial infarction and all-cause mortality. Short-acting CCBs have an unfavorable hemodynamic profile. The role of long-acting CCBs in patients with coronary artery disease is unknown.

Methods

MEDLINE/CENTRAL/EMBASE database were searched from 1966 to August 2008 for randomized controlled trials of long-acting CCBs in patients with coronary artery disease with follow-up for at least 1 year. We extracted from the studies the baseline characteristics and 6 outcomes: all-cause mortality, cardiovascular mortality, nonfatal myocardial infarction, stroke, angina pectoris, and heart failure.

Results

Of the 100 randomized controlled trials of CCBs in patients with coronary artery disease, 15 studies evaluating 47,694 patients fulfilled our inclusion criteria. When compared with the comparison group (including placebo), CCBs were not associated with an increased risk of all-cause mortality (relative risk [RR] 0.99; 95% confidence interval [CI], 0.94-1.05), cardiovascular mortality (RR 1.03; 95% CI, 0.95-1.11), nonfatal myocardial infarction (RR 0.96; 95% CI, 0.87-1.06), or heart failure (RR 0.86; 95% CI, 0.71-1.05), and with a 21% reduction in the risk of stroke (95% CI, 0.70-0.89) and 18% reduction in the risk of angina pectoris (95% CI, 0.72-0.94). When compared with placebo, CCBs resulted in a 28% reduction in the risk of heart failure (95% CI, 0.73-0.92). The results were similar for both dihydropyridines and nondihydropyridine CCBs.

Conclusions

In patients with coronary artery disease, long-acting CCBs (either dihydropyridines or nondihydropyridines), were associated with a reduction in the risk of stroke, angina pectoris, and heart failure, with similar outcomes for other cardiovascular events as the comparison group.     

Biomarkers to predict recurrent cardiovascular disease: the Heart and Soul Study

Purpose

The study purpose was to evaluate the ability of 6 biomarkers to improve the prediction of cardiovascular events among persons with established coronary artery disease.

Background

Cardiovascular risk algorithms are designed to predict the initial onset of coronary artery disease but are less effective in persons with preexisting coronary artery disease.

Methods

We examined the association of N-terminal prohormone brain natriuretic peptide (Nt-proBNP), cystatin C, albuminuria, C-reactive protein (CRP), interleukin-6, and fibrinogen with cardiovascular events in 979 Heart and Soul Study participants with coronary artery disease after adjusting for demographic, lifestyle, and behavior variables; cardiovascular risk factors; cardiovascular disease severity; medication use; and left ventricular ejection fraction. The outcome was a composite of stroke, myocardial infarction, and coronary heart disease death during an average of 3.5 years of follow-up.

Results

During follow-up, 142 participants (15%) developed cardiovascular events. The highest quartiles (vs lower 3 quartiles) of 5 biomarkers were individually associated with cardiovascular risk after multivariate analysis: Nt-proBNP hazard ratio (HR) = 2.13 (95% confidence interval [CI], 1.43-3.18); cystatin C HR = 1.72 (95% CI, 1.10-2.70); albuminuria HR = 1.71 (95% CI, 1.15-2.54); CRP HR = 2.00 (95% CI, 1.40-2.85); and interleukin-6 HR = 1.76 (95% CI, 1.22-2.53). When all biomarkers were included in the multivariable analysis, only Nt-proBNP, albuminuria, and CRP remained significant predictors of events: HR = 1.88 (95% CI, 1.23-2.85), HR = 1.63 (95% CI, 1.09-2.43), and HR = 1.82 (95% CI, 1.24-2.67), respectively. The area under the receiver operator curve for clinical predictors alone was 0.73 (95% CI, 0.68-0.78); adding Nt-proBNP, albuminuria, and CRP significantly increased the area under the receiver operator curve to 0.77 (95% CI, 0.73-0.82, P <.005).

Conclusion

Among persons with prevalent coronary artery disease, biomarkers reflecting hemodynamic stress, kidney damage, and inflammation added significant risk discrimination for cardiovascular events.     

Long-term outcomes of left bundle branch block in high-risk survivors of acute myocardial infarction: The VALIANT experience

BACKGROUND: In survivors of myocardial infarction (MI), new left bundle branch block (LBBB) is associated with adverse outcomes, but its impact is not well described in post-MI patients with left ventricular (LV) systolic dysfunction and/or heart failure (HF). OBJECTIVES: The aim of this study was to determine if new LBBB is an independent predictor of long-term fatal and nonfatal outcomes in high-risk survivors of MI by reviewing data from the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial. METHODS: In VALIANT, 14,703 patients with LV systolic dysfunction and/or HF were randomized to valsartan, captopril, or both a mean of 5 days after MI. Baseline ECG data were available from 14,259 patients. We assessed the predictive value of new LBBB for death and major cardiovascular outcomes after 3 years, adjusting for multiple baseline covariates including LV ejection fraction. RESULTS: At follow-up, patients with new LBBB (608 [4.2%]) compared with patients without new LBBB had more comorbidities and increased adjusted risk of death (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.2-1.6), cardiovascular death (HR 1.4, 95% CI 1.2-1.7), HF (HR 1.3, 95% CI 1.1-1.6), MI (HR 1.5, 95% CI 1.2-1.9), and the composite of death, HF, or MI (HR 1.4, 95% CI 1.2-1.6). CONCLUSION: In post-MI survivors with LV systolic dysfunction and/or HF, new LBBB was an independent predictor of all major adverse cardiovascular outcomes during long-term follow-up. This readily available ECG marker should be considered a major risk factor for long-term cardiovascular complications in high-risk patients after MI.     

Migraines, angiographic coronary artery disease and cardiovascular outcomes in women

Purpose

There are conflicting data regarding the association between migraines and cardiovascular events. We evaluated the relationship between migraine headaches, angiographic coronary artery disease, and cardiovascular events in women.

Subjects and Methods

The Women’s Ischemia Syndrome Evaluation (WISE) study is a National Heart, Lung and Blood Institute (NHLBI)-sponsored prospective, multicenter study aiming to improve ischemia evaluation in women. A total of 944 women presenting with chest pain or symptoms suggestive of myocardial ischemia were enrolled and underwent complete demographic, medical, and psychosocial history, physical examination, and coronary angiography testing. A smaller subset of 905 women, representing a mean age of 58 years, answered questions regarding a history of migraines. We prospectively followed 873 women for 4.4 years for cardiovascular events and all-cause mortality.

Results

Women reporting a history of migraines (n = 220) had lower angiographic coronary severity scores, and less severe (≥ 70% luminal stenosis) angiographic coronary artery disease compared to women without a history of migraines (n = 685). These differences remained statistically significant after adjustment for age and other important cardiac risk factors. On prospective follow-up of a median of 4.4 years, women with a history of migraines were not more likely to have a cardiovascular event (hazard ratio [HR] 1.2; 95% confidence interal [CI], 0.93-1.58) and migraines did not predict all-cause mortality (HR 0.96; 95% CI, 0.49-1.99).

Conclusion

Among women undergoing coronary angiography for suspected ischemia, those reporting migraines had less severe angiographic coronary artery disease. We could not support an association between migraines and cardiovascular events or death. Further research studying the common pathophysiology underlying migraines and cardiovascular disease is warranted.     

Racial differences in the outcomes of patients with diastolic heart failure

Background

More than half of all patients with congestive heart failure have preserved left ventricular systolic function. This is particularly common in African American patients, yet there have been few studies examining the long-term natural history of this disorder in African-American and white patients.

Methods

We studied 2740 white and 563 African American patients with class II to IV symptoms and preserved systolic function (ejection fraction >40) identified in the Duke Cardiovascular Databank from 1984 to1996. Unadjusted and adjusted 5-year survival rate comparisons were performed with Kaplan-Meier and Cox proportional hazards models, respectively.

Results

The 5-year survival rates were 68% for African American patients and 70% for white patients (P = .55). However, after adjusting for known risk factors, African American patients had a significantly higher mortality risk than white patients (hazard ratio [HR], 1.34; 95% CI, 1.13-1.60). This racial difference in survival rate was most prominent in patients with a non-ischemic etiology (HR, 1.6; 95% CI, 1.2-2.0) as compared with patients with ischemic heart failure (HR, 1.1; 95% CI, 0.9-1.4).

Conclusion

Among patients with heart failure and preserved left ventricular systolic function, African American patients have a worse long-term prognosis than white patients. These results are important because of the prevalence of this condition in African American patients and their potential heterogeneous response to many heart failure therapies.     

Obesity paradox in patients with hypertension and coronary artery disease

Purpose

An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.

Methods

A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66 ± 9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m² (thin), 20 to 25 kg/m² (normal weight), 25 to 30 kg/m² (overweight), 30 to 35 kg/m² (class I obesity), and 35 kg/m² or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.

Results

With patients of normal weight (BMI 20 to <25 kg/m²) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P <.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P <.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5 ± 21.9 mm Hg/−9.8 ± 12.4 mm Hg vs −20.7 ± 23.1 mm Hg /−10.6 ± 12.5 mm Hg, P <.001).

Conclusion

In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.     

Impaired fasting glucose and recurrent cardiovascular disease among survivors of a first acute myocardial infarction: Evidence of a sex difference? The Western New York experience

Background and aims

There is little epidemiological evidence regarding the association of impaired glucose metabolism with recurrent cardiovascular events. We therefore examined potential sex differences in the effect of impaired fasting glucose (IFG) on recurrent cardiovascular disease (CVD) in a community-based study of survivors of a first acute myocardial infarction (MI).

Methods and results

This report focuses on 1226 incident MI cases (28.4% women) discharged alive from area hospitals in the Western New York Acute MI Study (1996-2004). Deaths and underlying cause of death were determined via query of the National Death Index (Plus) Retrieval Program with follow-up through December 31, 2004. Outcomes reported included fatal or non-fatal coronary heart disease (CHD) or coronary revascularization surgery and total stroke. Traditional CHD risk factors and other explanatory variables were determined by clinical examination after the first acute event. Impaired fasting glucose was defined as fasting blood glucose between 100 and 125 mg/dl. During a mean follow-up of 4.5 years, there were 91 recurrent events (26.1%) in women and 173 recurrent events (19.7%) in men. After multivariable adjustment, the hazard ratios for recurrent cardiovascular events were 1.96 (95% CI: 1.15-3.16) and 2.59 (1.56-4.30) in women with IFG and with diabetes, respectively, compared to normoglycemic women. Among men, neither IFG nor diabetes was independently related to risk of recurrence.

Conclusions

In this study, IFG was a strong risk factor for recurrent cardiovascular events only among women. These results suggest that increased cardiovascular risk in MI survivors begins at lower glucose levels in women than men.     

Early and long-term outcomes after percutaneous coronary intervention of unprotected left main coronary disease with drug-eluting stents in patients with non-ST-elevation acute coronary syndrome

Background

Patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) and unprotected left main coronary disease (ULMCD) are among the highest risk patients but current consensus guidelines do not address the optimal timing and mode of revascularization for these individuals.

Methods

In this single-centre registry, we evaluated the clinical outcomes of 151 consecutive patients with NSTE-ACS and ULMCD who underwent percutaneous coronary intervention with drug-eluting stents from 2005 to 2009.

Results

Overall in-hospital major adverse cardiac event (MACE) rate was 5.3%, mortality rate was 0.7%. At 30 months ± 15 months, 30 patients (19.9%) experienced MACE. The 4-year cumulative survival rate of no MACE was 73.2% and cumulative survival rate was 90.6%. Left ventricular ejection fraction (hazard ratio [HR] 0.947; 95% confidence interval [CI], 0.898-0.998; P = 0.043) and SYNTAX [SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery] score ≥ 33 (HR 1.28; 95% CI, 1.025-1.433; P = 0.029) were associated with MACE, while only left ventricular ejection fraction (HR 0.82; 95% CI, 0.69-0.973; P = 0.023) was associated with mortality.

Conclusions

Our study demonstrates the feasibility of percutaneous coronary intervention with drug-eluting stents in patients with NSTE-ACS and ULMCD. The early and long-term outcomes were acceptable. Left ventricular ejection fraction and SYNTAX score ≥ 33 predict MACE and only left ventricular ejection fraction predicts mortality.     

Prognostic value of predischarge electrocardiographic measurement of infarct size after thrombolysis: insights from GUSTO I Economics and Quality of Life substudy

Background

Current methods for risk stratification after acute myocardial infarction (MI) include several noninvasive studies. In this cost-containment era, the development of low-cost means should be encouraged. We assessed the ability of an electrocardiogram (ECG) MI-sizing score to predict outcomes in patients enrolled in the Economics and Quality of Life (EQOL) sub study of the Global Utilization of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries -I (GUSTO-I) trial.

Methods

We classified patients by electrocardiographic Selvester QRS score at hospital discharge: those with a score 0-9 versus ≥10. Endpoints were 30-day and 1-year mortality, resource use, and quality-of-life measures.

Results

Patients with a QRS score <10 were well-matched with those with QRS score ≥10 with the exception of a trend to more anterior MI in the higher scored group. Patients with QRS score ≥10 had increased risk of death at 30-days (8.9% vs. 2.9% P < .001), and this difference persisted at 1 year (12.6% vs. 5.4%, P = .001). Recurrent chest pain, use of angiography, and angioplasty were similar during follow-up. However, there was a trend toward less coronary bypass surgery in patients with a QRS score ≥10. Readmission rates were higher at 30 days but similar at 1 year.

Conclusions

Stratification of patients after acute MI by a simple measure of MI size identifies populations with different long-term prognoses; patients with a QRS score ≥10 (approximately 30% of the left ventricle infarcted) at discharge have poorer outcomes in both the short- and long-term. The standard 12-lead ECG provides a simple, economical means of risk stratification at discharge.