Preoperative plasma N-terminal pro-brain natriuretic peptide concentration and perioperative cardiovascular risk in elderly patients.

BACKGROUND: The prediction of perioperative cardiovascular complications is important in the medical management of patients undergoing noncardiac surgery. Several indices have been developed, but a simpler, more practical and accurate method is needed. The purpose of this study was to determine whether the N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration before operation can be used to predict perioperative cardiovascular complications in elderly patients undergoing noncardiac surgery. METHODS AND RESULTS: The study group comprised 279 patients older than 60 years who were scheduled for elective surgery. The plasma NT-proBNP concentration, clinical cardiac indices and left ventricular ejection fraction were measured prior to operation. The postoperative cardiac outcomes were followed and predictors for postoperative cardiac risk were identified. Cardiovascular complications occurred in 25 patients (9.0%). Age, the incidence of prior ischemic heart disease or congestive heart failure, and the plasma NT-proBNP concentration were significantly higher in patients with perioperative cardiovascular complications than in those without. Using receiver operating characteristic analysis to predict perioperative cardiovascular events, a cut-off value of 201 pg/ml was identified as the optimal predictor of perioperative complications, showing a sensitivity of 80.0% and specificity of 81.1%. Multivariate analysis revealed that NT-proBNP >201 pg/ml (odds ratio (OR) 7.6, 95% confidence interval (CI) 2.2-26.6, p=0.003) and revised cardiac index > or =2 (OR 6.3, 95% CI 1.7-23.8, p=0.007) were independent predictors for perioperative cardiovascular complications. CONCLUSIONS: Elevated NT-proBNP levels are independently associated with an increase in the risk of perioperative cardiovascular complications in elderly patients undergoing noncardiac and nonvascular operations.     

Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients

OBJECTIVES: To determine the prevalence and predictors of adverse postoperative outcomes in older surgical patients undergoing noncardiac surgery. DESIGN: Prospective cohort study of consecutive patients undergoing noncardiac surgery in 1997. SETTING: A medical school-affiliated teaching community hospital. PARTICIPANTS: Patients age 70 and older undergoing noncardiac surgery. Patients presenting for surgery requiring only local anesthesia or monitored anesthesia care were excluded. MEASUREMENTS: Potential pre- and intra-operative risk factors were measured and evaluated for their association with the occurrence of predefined in-hospital postoperative adverse outcomes. Univariate predictors of postoperative outcomes were first measured using the chi-square or Fisher's exact tests followed by multivariate logistic regression. Odds ratios (OR) with 95% confidence interval (CI), and two-sided P-values were reported. RESULTS: Five hundred forty-four consecutive patients were studied. Overall, 21% of patients developed one or more postoperative adverse outcomes and 3.7% died during the in-hospital postoperative period. Of all the adverse outcomes, cardiovascular complications (10.3%) were the leading cause of morbidity, followed by neurological (7.7%) and pulmonary complications (5.5%). By multivariate logistic regression analysis, American Society of Anesthesiologists (ASA) classification (OR = 2.7, CI = 1.6-4.4), emergency surgery (OR = 2.0, CI = 1.1-3.4), and intraoperative tachycardia (OR = 3.8, CI = 1.9-7.6) were the most important predictors of postoperative adverse outcomes. Of all the preoperative physical symptoms and signs, decreased functional status (OR = 3.0, CI = 1.4-6.4) and clinical signs of congestive heart failure (OR = 2.1, CI = 1.1-5.1) were the two most important predictors of postoperative adverse neurological and cardiac outcomes, respectively. The median hospital stay was 4 days. The patients who developed postoperative adverse outcomes had significantly longer median hospital stays (9 days) than those without complications (3 days), (P < .0001). CONCLUSION: Our study demonstrates that the postoperative mortality rate in geriatric surgical patients undergoing noncardiac surgery is low. Despite the prevalence of preoperative chronic medical conditions, most patients do well postoperatively. The ASA classification (a reflection of the severity of preoperative comorbidities), emergency surgery, and intraoperative tachycardia increase the odds of developing any postoperative adverse events. Future studies aimed at modifying some of the potentially reversible risk factors, such as preoperative heart function and intraoperative heart rate are warranted.     

The risk of developing coronary artery disease or congestive heart failure, and overall mortality, in type 2 diabetic patients receiving rosiglitazone, pioglitazone, metformin, or sulfonylureas: a retrospective analysis

Oral anti-diabetic agents have been associated with adverse cardiovascular events in type 2 diabetes (DM2). We investigated the risk of coronary artery disease (CAD), congestive heart failure (CHF), and mortality using multivariable Cox models in a retrospective cohort of 20,450 DM2 patients from our electronic health record (EHR). We observed no differences in CAD risk among the agents. Metformin was associated with a reduced risk of CHF (HR 0.76, 95% CI 0.64–0.91) and mortality (HR 0.54, 95% CI 0.46–0.64) when compared to sulfonylurea. Pioglitazone was also associated with a lower risk of mortality when compared to sulfonylurea (HR 0.59, 95% CI 0.43–0.81). No other significant differences were found between the oral agents. In conclusions, our results did not identify an increased CAD risk with rosiglitazone in clinical practice. However, the results do reinforce a possible increased risk of adverse events in DM2 patients prescribed sulfonylureas.     

Cardiovascular Outcomes in Patients With Mitochondrial Disease in the United States: A Propensity Score Analysis

Mitochondrial disease comprises a wide range of genetic disorders caused by mitochondrial dysfunction. Its rarity, however, has limited the ability to assess its effects on clinical outcomes. To evaluate this relationship, we collected data from the 2016 National Inpatient Sample, which includes data from >7 million hospital stays. We identified 705 patients (mean age, 22 ± 20.7 yr; 54.2% female; 67.4% white) whose records included the ICD-10-CM code E88.4. We also identified a propensity-matched cohort of 705 patients without mitochondrial disease to examine the effect of mitochondrial disease on major adverse cardiovascular events, including all-cause in-hospital death, cardiac arrest, and acute congestive heart failure.Patients with mitochondrial disease were at significantly greater risk of major adverse cardiovascular events (odds ratio [OR]=2.42; 95% CI, 1.29–4.57; P=0.005), systolic heart failure (OR=2.37; 95% CI, 1.08–5.22; P=0.027), and all-cause in-hospital death (OR=14.22; 95% CI, 1.87–108.45; P<0.001).These findings suggest that mitochondrial disease significantly increases the risk of inpatient major adverse cardiovascular events.     

Predicting adverse postoperative outcomes in patients aged 80 years or older

OBJECTIVE: The identification of reversible factors that are associated with postoperative morbidity in geriatric surgical patients is critical to improving perioperative outcomes in such patients. Our study aimed to compare the relative importance of intraoperative versus preoperative factors in predicting adverse postoperative outcomes in geriatric patients. DESIGN: Retrospective cohort study of consecutive patients undergoing noncardiac surgery in 1995. SETTING: Two University of California, San Francisco, teaching hospitals--Moffitt/Long and Mount Zion medical centers. PARTICIPANTS: All men and women 80 years of age or older undergoing noncardiac surgery. MEASUREMENTS: Medical records of all patients were reviewed to measure predefined pre- and intraoperative risk factors and postoperative outcomes. Predictors of postoperative outcomes were identified by multivariate logistic regression analyses. RESULTS: Three hundred sixty-seven patients were studied. The most prevalent preoperative risk factors were a history of hypertension and coronary artery, pulmonary, and neurologic diseases. Postoperative in-hospital mortality rate was 4.6%, and 25% of patients developed adverse postoperative outcomes, of which neurological and cardiovascular complications were the leading causes of morbidity (15% and 12%, respectively). By multivariate logistic regression, a history of neurological disease (odds ratio [OR] 4.0, 95% confidence interval [CI] 2.3 - 6.9, P = .0001), congestive heart failure (OR 2.7, 95% CI 1.4 - 5.3, P = .004), and a history of arrhythmia (OR 2.3, 95% CI 1.2 - 4.3, P = .01) increased the odds of adverse postoperative events. The only intraoperative event shown to be predictive of postoperative complications was the use of vasoactive agents (OR 8.0, 95% CI 1.6 - 40.5, P = .009). CONCLUSIONS: In this group of geriatric surgical patients, the overall postoperative in-hospital mortality rate was 4.6%, and 25% of the patients developed adverse postoperative outcomes involving either the neurological, cardiovascular, or pulmonary systems. Intraoperative events appeared to be less important than preoperative comorbidities in predicting adverse postoperative outcomes.     

Pulse pressure and risk for myocardial infarction and heart failure in the elderly

OBJECTIVES: We sought to determine whether pulse pressure (PP), a measure of arterial stiffness, is an independent predictor of the incidence of coronary heart disease (CHD), congestive heart failure (CHF) and overall mortality among community-dwelling elderly. BACKGROUND: Current hypertension guidelines classify cardiovascular risk on the basis of elevated systolic blood pressure (SBP) or diastolic blood pressure (DBP) without considering their combined effects. Recent studies suggest that PP is a strong predictor of cardiovascular end points, but few data are available among community elderly. METHODS: The study sample included 2,152 individuals age > or =65 years, who were participants in the Established Populations for Epidemiologic Study of the Elderly program, free of CHD and CHF at baseline and still alive at one year after enrollment. Blood pressure was measured at baseline. Incidence of CHD, incidence of CHF and total mortality were monitored in the following 10 years. RESULTS: There were 328 incident CHD events, 224 incident CHF events and 1,046 persons who died of any cause. Pulse pressure showed a strong and linear relationship with each end point. After adjusting for demographics, comorbidity and CHD risk factors, a 10-mm Hg increment in PP was associated with a 12% increase in CHD risk (95% confidence interval [CI], 2% to 22%), a 14% increase in CHF risk (95% CI, 5% to 24%), and a 6% increase in overall mortality (95% CI, 0% to 12%). While SBP and mean arterial pressure (MAP) also showed positive associations with the end points, PP yielded the highest likelihood ratio chi-square. When PP was entered in the model in conjunction with other blood pressure parameters (SBP, DBP, MAP or hypertension stage, respectively), the association remained positive for PP but became negative for the other blood pressure variables. The effect of PP persisted after adjusting for current medication use and was present in normotensive individuals and individuals with isolated systolic hypertension but not in individuals with diastolic hypertension. CONCLUSIONS: Elevated PP is a powerful independent predictor of cardiovascular end points in the elderly.     

Comparison of the Diastolic Stress Test With a Combined Resting Echocardiography and Biomarker Approach to Patients With Exertional Dyspnea: Diagnostic and Prognostic Implications

ObjectivesThis study sought to establish the diagnostic and prognostic value of a strategy for prediction of abnormal diastolic response to exercise (AbnDR) using clinical, biochemical, and resting echocardiographic markers in dyspneic patients with mild diastolic dysfunction.BackgroundAn AbnDR (increase in left ventricular filling pressure) may indicate heart failure with preserved ejection fraction as the cause of symptoms in dyspneic patients, despite a nonelevated noncardiac at rest. However, exercise testing may be inconclusive in patients with noncardiac limitations to physical activity.MethodsIn 171 dyspneic patients (64 ± 8 years) with suspected heart failure with preserved ejection fraction but resting peak early diastolic mitral inflow velocity/peak early diastolic mitral annular velocity ratio (E/e′) <14, a complete echocardiogram (including assessment of myocardial deformation and rotational mechanics) and blood assays for biomarkers were performed. Echocardiography following maximal exercise was undertaken to assess AbnDR (exertional E/e′ >14). Patients were followed over 26.2 ± 4.6 months for endpoints of cardiovascular hospitalization and death.ResultsAbnDR was present in 103 subjects (60%). Independent correlates of AbnDR were resting E/e′ (odds ratio [OR]: 8.23; 95% confidence interval [CI]: 3.54 to 9.16; p < 0.001), left ventricular untwisting rate (OR: 0.60; 95% CI: 0.42 to 0.86; p = 0.006), and galectin-3—a marker of fibrosis (OR: 1.80; 95% CI: 1.21 to 2.67; p = 0.004). The use of resting E/e′ >11.3 and galectin-3 <1.17 ng/ml to select patients for further diagnostic processing would have allowed exercise testing to be avoided in 65% of subjects, at the cost of misclassification of 13%. The composite outcome of cardiovascular hospitalization or death occurred in 47 patients (27.5%). The predictive value of an AbnDR response and the combined strategy (resting echocardiography and galectin-3 or exercise testing in case of an inconclusive first step) showed similar event prediction (36 vs. 34; p = 0.95).ConclusionsThe implementation of a 2-step algorithm (echocardiographic evaluation of resting E/e′ followed by the assessment of galectin-3) may improve the diagnosis and prognostic assessment of individuals with suspected heart failure with preserved ejection fraction who are unable to perform a diagnostic exercise test.     

Adverse drug reactions related to hospital admission in Slovak elderly patients

The aims of the present study were: to evaluate the prevalence of adverse drug reactions (ADRs) leading to hospitalization in elderly patients; to analyze the drugs which have been identified as having causal relationship with ADRs and to identify risk factors which predispose the patient to such ADRs. The study has been performed in 600 patients aged> or =65 years, hospitalized in a general hospital between 1 December 2003 and 31 March 2005. The ADRs recorded in patient's documentation as one of the reasons for hospital admission were evaluated. ADRs leading to hospital admission were recorded in 47 (7.8%) patients. ADRs in 43 patients represented A-type ADRs which are preventable. The most frequent ADRs were cardiovascular disorders. According to the results of multivariate analysis ischemic heart disease (odds ratio (OR)=4.50; 95% confidence interval (CI)=1.36-14.88), depression (OR, 2.49; 95% CI, 1.08-5.77) and heart failure (OR, 2.08; 95% CI, 1.13-3.81) were the most important patient-related characteristics predicting ADRs leading to hospitalization. The majority of ADRs in elderly patients could be avoided. Regular re-evaluation of the medication as well as taking into account the specific features of elderly patients represent the most important tools for ADR prevention.     

Serum uric acid shows a J-shaped trend with coronary mortality in non-insulin-dependent diabetic elderly people. The CArdiovascular STudy in the ELderly (CASTEL)

The relationship between serum uric acid (SUA) and risk of coronary heart disease (CHD) mortality remains controversial, particularly in diabetic subjects. The aim of the present study is to evaluate whether SUA independently predicts CHD mortality in non-insulin-dependent elderly people from the general population and to investigate the interactions between SUA and other risk factors. Five hundred and eighty-one subjects aged ≥65 years with non-insulin-dependent diabetes mellitus were prospectively studied in the frame of the CArdiovascular STudy in the ELderly (CASTEL). Historical and clinical data, blood tests and 12-year fatal events were recorded. SUA as a continuous item was divided into tertiles and, for each tertile, adjusted relative risk (RR) with 95% confidence intervals (CI) was derived from multivariate Cox analysis. CHD mortality was predicted by SUA in a J-shaped manner. Mortality rate was 7.9% (RR 1.28, CI 1.05–1.72), 6.0% (reference tertile) and 12.1% (RR 1.76, CI 1.18–2.27) in the increasing tertiles of SUA, respectively, without any difference between genders. In diabetic elderly subjects, SUA independently predicts the risk of CHD mortality in a J-shaped manner.     

高龄重症社区获得性肺炎并心血管事件患者预后不良因素分析

目的:分析高龄重症社区获得性肺炎(CAP)合并心血管事件患者预后不良因素,探讨临床诊疗策略。方法:将116例高龄重症CAP并发心血管事件患者按照住院30d内的预后分为治愈出院组(54例)和预后不良组(62例)。分析2组患者性别、年龄、入院时CURB65评分(包括意识障碍、尿素氮、呼吸频率、血压、年龄)、肺炎严重指数(PSI评分)及CRB65评分(包括意识障碍、呼吸频率、血压、年龄)、重症肺炎评判主要标准及次要标准构成情况、住院前心血管事件发生史、住院期间心血管事件类别、辅助治疗措施、初始疗效、并发症情况等,将组间差异有统计学意义的指标纳入多因素Logistic回归分析,分析高龄重症CAP并心血管事件患者预后不良的危险因素。结果:住院期间新发心律失常47例(40. 52%)、急性心肌梗死33例(28. 45%)、心绞痛21例(18. 10%)、急性心力衰竭15例(12. 93%)。2组患者年龄、入院时CURB65评分、PSI评分、CRB65评分、住院前心血管事件发生史、住院期间心血管事件类别、初始疗效比较,差异有统计学意义(均P 0. 05)。多因素Logistic分析显示,年龄(OR=4. 156)、入院时CURB65评分5分(OR=3. 632)、PSIⅤ级(OR=4. 589)、CRB65评分4分(OR=2. 445)、住院前有心血管事件史(OR=4. 625)、住院期间发生急性心肌梗死(OR=4. 514)、初始治疗无效(OR=3. 422)为高龄重症CAP并发心血管事件患者预后不良的危险因素。结论:高龄重症CAP并发心血管事件患者预后不良率高,临床应采取措施加以防范,降低不良事件风险率,改善患者预后。     

Are calcium antagonists beneficial in diabetic patients with hypertension?

PURPOSE: We analyzed the available data to assess the effects of calcium antagonists in hypertensive patients with diabetes mellitus. METHODS: We performed a MEDLINE search of English-language articles published until April 2003, using the terms diabetes mellitus, hypertension or blood pressure, and therapy. Pertinent articles cited in the identified papers were also reviewed. We included prospective randomized studies of more than 12 months' duration that evaluated the effect of drug treatment on morbidity and mortality in diabetic patients with hypertension. We estimated the effect of treatment with calcium antagonists on morbidity and mortality in comparison with placebo, conventional therapy, and therapy that blocks the renin-angiotensin system. RESULTS: We identified 14 studies that reported outcomes in diabetic hypertensive patients. Compared with placebo, calcium antagonists reduced cardiovascular morbidity and mortality. Compared with conventional therapy, calcium antagonists had similar effects on coronary heart disease and total mortality, but may have reduced the risk of stroke (odds ratio [OR] = 0.87; 95% confidence interval [CI]: 0.74 to 1.02; P = 0.08). However, they resulted in a lesser reduction of the risk of heart failure (OR = 1.33; 95% CI: 1.17 to 1.50). Calcium antagonists were less effective than blockers of the renin-angiotensin system in preventing heart failure (OR = 1.43; 95% CI: 1.10 to 1.84), but had similar effects on stroke, coronary heart disease, and total mortality. CONCLUSION: Calcium antagonists are safe and effective in reducing most types of cardiovascular morbidity and mortality in diabetic hypertensive patients, although their use is associated with a lesser reduction of risk of heart failure as compared with other treatments for hypertension.     

Exercise counseling

Objective: To assess how often physicians counsel patients about exercise and to identify which primary care internists infrequently counsel about it. Design: Cross-sectional survey of a random sample of primary care internists in Massachusetts. Questions covered physicians’ attitudes, beliefs, and practices with respect to counseling about exercise; physicians’ perceived barriers to counseling about exercise; physicians’ personal exercise frequency; and physician demographics.Participants: Of 1,000 physicians, 687 were eligible and 422 returned usable questionnaires (response rate 61%). Results: Data describing physician demographics, practice setting, measures of personal fitness, and beliefs regarding exercise were entered into a logistic regression model. The characteristic that best identified physicians who infrequently counsel about exercise was their perceived lack of success at counseling (OR 22.83, 95% CI 8.36–62.31). Other independent predictors of infrequent counseling were physicians’ lack of conviction that exercise is very important (OR4.86,95% CI 1.70–13.91), physician ages 40years (OR 308, 95% CI 1.33–7.15), and higher physician resting heart rate (OR 345, 95% CI 1.46–8.18). Conclusions: Several factors were found to be independently associated with the likelihood of a physician’ counseling about exercise. These included physician perceived success at counseling, physician belief that exercise is important, physician age, and physician resting heart rate. These results suggest possible strategies to improve physicians’ counseling efforts. Received from the Section of General Internal Medicine, Evans Memorial Department of Clinical Research, Department of Medicine, the University Hospital, Boston University Medical Center, Boston, Massachusetts.     

Ankle brachial pressure index usefulness as predictor factor for coronary heart disease in diabetic patients

Ankle brachial pressure index (ABPI) is a non-invasive marker of atherosclerosis, helpful to identify subjects at high-risk for coronary heart disease (CHD) among large populations with cardiovascular disease (CVD) risk factors. The diagnostic role of ABPI has been also recognized in patients with diabetes. In the present study, the role of an ABPI score < 0.90 in predicting CHD has been evaluated in a large series of patients with Type 2 diabetes mellitus and compared to other known CVD risk factors. Nine hundred and sixty-nine (mean age was 66.1 yr) consecutive patients with Type 2 diabetes mellitus were evaluated. The patients were followed-up for 18.3+/-5.2 months (range 12- 24) and all events of CHD, defined as myocardial infarction, unstable and resting angina or coronary atherosclerosis at the instrumental investigation (at the coronary angiography and/or perfusion stress testing) were recorded. A rate of 17.5% of CHD events were recorded in diabetic population during the follow-up period. The relative risk of CHD was significantly increased for male patients [odds ratio (OR): 1.6; 95% confidence interval (CI): 1.1-2.2], patients with age > or = 66 yr (OR: 1.8; 95% CI: 1.3-2.5), body mass index (BMI) > 30 (OR: 1.5; 95% CI: 1.1-2.1), waist circumference > 88 cm for females and 102 cm for males (OR: 1.5; 95% CI: 1.0-2.1), proteinuria > or = 30 microg per min (OR: 1.6; 95% CI: 1.1-2.3), LDL-cholesterol > or = 100 mg/dl (OR: 2.1; 95% CI: 1.5-3.0), glycated hemoglobin > 7% (OR: 1.6; 95% CI: 1.1-2.3), insulin therapy (OR: 1.9; 95% CI: 1.3-2.9), and ABPI < 0.90 (OR: 3.7; 95% CI: 2.2- 6.2). BMI was higher in patients with ABPI < 0.90 than in those with ABPI > or = 0.90 (p<0.05). At the multivariate analysis, ABPI < 0.90 was the best factor independently associated with CHD (p<0.001). APBI < 0.90 is strongly associated to CHD in Type 2 diabetic patients. We recommend to use ABPI in diabetic patients and to carefully monitor diabetic subjects with an ABPI lower than 0.90.     

纤维蛋白原与高敏C反应蛋白对稳定性冠心病患者心血管事件的预测价值

目的探讨高水平的纤维蛋白原（fibrinogen,FG）和高敏C反应蛋白（hs—CRP）对稳定性冠心病患者心血管事件的预测价值。方法对185例经冠状动脉造影检查证实的稳定性冠心病患者（2002年1月至11月入院患者）分别按FG、hs—CRP水平分组,随访3年,评估发生心血管事件（猝死、心肌梗死、慢性心力衰竭及其他心血管事件）。结果在3年的随访中,发生非致死性心血管事件21例和心血管原因导致的死亡10例。在调整了血脂、体重指数、吸烟、高血压等因素后,FG〉4．0g／L组与FG≤4．0g／L组比较,发生心血管事件的相对危险度为1．97,95％可信区间（CI）为1．68—2．40。hs—CRP〉3．0mg／L组与hs—CRP≤3．0mg／L比较,经调整后发生心血管事件的相对危险度为2．32,95％CI为1．76—2．89。FG〉4．0g／L伴hs—CRP〉3．0mg／L者与FG≤4．0g／L且hs—CRP≤3．0mg／L者比较,发生心血管事件的相对危险度为3．84（P〈0．05）,95％CI为2．80—4．99。结论FG和hs—CRP不仅均为冠心病患者心血管事件重要的独立预测因子,且FG联合hs—CRP检测可增加对冠心病患者心血管事件的预测价值。     

血压不同控制水平对老年男性高血压患者心血管事件的影响

目的了解老年男性高血压降压过程中有无"J"型曲线现象,探讨老年高血压降压的合适范围。方法选择老年男性高血压患者846例,根据收缩压和舒张压水平分别分为:≤120 mm Hg(1mm Hg=0.133 kPa(S1组)213例,1 21～130 mm Hg(S2组)21 5例,131～140 mm Hg(S3组)219例,1 41～150 mm Hg(S4组)121例,>1 50mm Hg(S5组)78例;≤60 mm Hg(D1组)107例,61～70 mm Hg(D2组)258例,71～80 mm Hg(D3组)339例,81～90 mm Hg(D4组)125例,>90 mm Hg(D5组)17例。分析不同血压水平与心血管事件的关系。结果 S5组心血管死亡、致死脑卒中、非致死心肌梗死(MI)和脑卒中发生率最高,S4组心血管死亡、冠心病死亡、致死脑卒中和非致死MI发生率最低,组间比较差异显著(P<0.05,P<0.01)。D5组全因死亡、心血管死亡、冠心病死亡、致死脑梗死、非致死MI和脑卒中发生率最高,D4组全因死亡、心血管死亡、冠心病死亡发生率最低,组间比较差异显著(P<0.05)。结论老年男性高血压降压过程中可见"J"型曲线,降压合适范围为140～150/80～90 mm Hg。     

Predictors of on-duty coronary events in male firefighters in the United States

Coronary heart disease (CHD) accounts for 39% of "on-duty" deaths in firefighters in the United States. No studies have examined the factors that distinguish fatal from nonfatal work-associated CHD events. Male firefighters experiencing on-duty CHD events were retrospectively investigated to identify cardiovascular risk factors predictive of case fatality; 87 fatalities (death within 24 hours of the event) were compared with 113 survivors who retired with disability pensions for heart disease after on-duty nonfatal events. Cardiovascular risk factors were then examined for associations with case fatality. Predictors of CHD death in multivariate analyses were a previous diagnosis of CHD (or peripheral/cerebrovascular disease) (odds ratio [OR] 4.09, 95% confidence intervals [CI] 1.58 to 10.58), current smoking (OR 3.68, 95% CI 1.61 to 8.45), and hypertension (OR 4.15, 95% CI 1.83 to 9.44). Age < or =45 years, diabetes mellitus, and serum cholesterol level were not significant predictors of case fatality. In conclusion, previous CHD, current smoking, and hypertension are strong predictors of fatality in male firefighters experiencing on-duty CHD events. Accordingly, prevention efforts should include early detection and control of hypertension, smoking cessation/prohibition, and the restriction of most firefighters with significant CHD from strenuous duties.     

Predictors of mortality after acute hip fracture

To identify determinants of mortality after hip fracture, we performed a multicenter, retrospective study of 390 Medicare beneficiaries. Independent predictors of 30-day mortality included a history of congestive heart failure (odds ratio [OR] 32; 95% confidence interval [CI] 5, 192), angina (OR 26; 95% CI 4, 184), or chronic pulmonary disease (OR 11; 95% CI 2, 62). Postoperative use of aspirin was- associated with a reduced risk of mortality (OR 0.24; 95% CI 0.08, 0.70). Cardiovascular events were the presumed cause of 63% of in-hospital deaths. Aspirin may have significant potential to reduce mortality in this population and deserves further study. Presented in abstract form at the Society for General Internal Medicine 19th annual meeting, Washington, DC, May 2–4, 1996. Supported by the Iowa Foundation for Medical Care and the Health Care Financing Agency for which the authors worked. The views expressed in this article are those of the authors and do not represent an official position of the Iowa Foundation for Medical Care or the Health Care Financing Agency.     

Risk of cardiovascular disease and mortality in overweight and obese patients with type 2 diabetes: an observational study in 13,087 patients

Aims/hypothesis  The aim of this study of type 2 diabetic patients in the Swedish National Diabetes Register was to study the associations of BMI, overweight (BMI 25–29.9 kg/m²) and obesity (BMI ≥ 30 kg/m²) with cardiovascular disease in type 2 diabetes, as these associations have not previously been clarified. Methods  Patients aged 30–74 years with no previous CHD or stroke (N = 13,087) were followed for a mean of 5.6 years until 2003 for fatal or non-fatal CHD, stroke, cardiovascular disease (CHD or stroke) and total mortality. In total, 1,922 cardiovascular-disease events occurred, based on 64,864 person-years. Results  The relative risks of CHD, stroke, cardiovascular disease and total mortality for a 5 unit increase in BMI at baseline were 15%, 11%, 13% and 27%, respectively, using Cox regression analysis, after adjusting for age, sex, diabetes duration, hypoglycaemic treatment and smoking (model 1), and were 9%, 4% (not significant), 7% and 20%, respectively, when adjusting also for HbA_1c, blood pressure, antihypertensive drugs, lipid-reducing drugs and microalbuminuria (model 2). Adjusted hazard ratios (model 1) for CHD, cardiovascular disease and total mortality with overweight were 1.27 (95% CI 1.09–1.48), 1.24 (1.09–1.41) and 1.16 (0.94–1.45), respectively, and 1.49 (1.27–1.76), 1.44 (1.26–1.64) and 1.71 (1.36–2.14) with obesity, as compared with normal weight. Significant hazard ratios were attenuated when adjusted according to model 2. For a 1 unit increase in BMI during follow-up, the relative risk of CHD (model 2) was 1.13 (1.04–1.23; p = 0.005). Conclusions/interpretation  Both overweight and obesity independently increased the risk of CHD and cardiovascular disease in patients with type 2 diabetes. The CHD risk was higher with increasing BMI than with stable or decreasing BMI during the study.     

The brain in congestive heart failure

In the present paper we discuss two issues about relationships between congestive heart failure and the brain. First, major acute cerebrovascular events are very frequent among elderly people, but stroke does not appear to be frequently associated with congestive heart failure. Second, some cardiovascular conditions may determine progressive damage of cerebral tissue, with consequent impairment of cognitive functions. The association of cognitive impairment and cardiovascular diseases may dramatically increase morbility and mortality risks in the elderly. Recent studies seem to show that hypotension and congestive heart failure are risk factors for dementia in elderly people. In view of this data, an Italian multicentric study on congestive heart failure in hospitalized elderly patients (CHF Italian Study I) included a brief screening of cognitive abilities (MMSE). The presence of congestive heart failure induced a significant decrease of MMSE scores: mean MMSE score after statistical adjustment for the other variables was about one point lower in patients with congestive heart failure respect to elderly patients affected by heart disease but without congestive heart failure. A novel multicentric study (CHF Italian Study II) has been performed to identify cognitive functions more specifically impaired during congestive heart failure in the elderly. Preliminary data relative to 385 patients, confirmed that congestive heart failure may induce a generalized impairment of cognitive functions. These data have relevant clinical implications because they demonstrate that a multidisciplinary approach is necessary in these patients, both for prevention and rehabilitation therapy.