Comparative analysis of red cell distribution width and high sensitivity C-reactive protein for coronary heart disease mortality prediction in multi-ethnic population: Findings from the 1999–2004 NHANES

Background

Red cell distribution width (RDW) has been shown to predict all-cause and cardiovascular (CVD) mortality. However, the predictive ability of RDW for future coronary heart disease (CHD) mortality in comparison to high sensitivity C-reactive protein (hs-CRP) has not been assessed in a population cohort free of CVD.

Methods

Analysis was performed on 8,513 adult participants (age > 20 years) free of CVD from the National Health and Nutrition Examination Surveys 1999–2004. Cox-proportional hazard analyses were used to assess the role of RDW and hs-CRP in CHD mortality and in subgroups based on high and low RDW and hs-CRP.

Results

On adjustment for traditional risk factors (age, sex, systolic blood pressure, anti-hypertensive medication use, total cholesterol, high density lipoprotein cholesterol, lipid lowering therapy, smoking, diabetes mellitus, anemia, mean corpuscular volume and nutritional deficiencies), RDW [hazard ratio (HR) 1.26 95% Confidence Interval (CI) [1.12–1.42] p < 0.001] remained an independent predictor, while hs-CRP [HR 1.18 95% CI [0.98–1.41] p = 0.077] did not. On comparative analysis, high RDW (> 12.6%) was predictive of CHD mortality irrespective of hs-CRP status [hs-CRP ≤ 3 mg/L (HR 1.17 95% CI [1.01–1.36] p = 0.031)] and hs-CRP > 3 mg/L (HR 1.44 95% CI [1.23–1.68] p < 0.001). Hs-CRP was not predictive in either high or low RDW subgroup.

Conclusion

RDW but not hs-CRP was associated with CHD mortality independent of traditional risk factors in a cohort with no pre-existing CVD. RDW may be considered a stronger biomarker for CHD death than hs-CRP and needs further prospective evaluation in CVD risk assessment.     

Changes in all-cause and cardiovascular disease mortality in three different Finnish population cohorts with and without diabetes

Background

We aimed to assess changes in cardiovascular (CVD) and all-cause mortality among diabetic and non-diabetic individuals between three large study cohorts with baseline assessments of 10 years apart and followed up for 10 years.

Methods

Six population surveys were carried out in 1972, 1977, 1982, 1987, 1992 and 1997 in Finland. For the analyses we combined the 1972 and 1977 cohorts (cohort 1), the 1982 and 1987 cohorts (cohort 2) and similarly also the 1992 and 1997 cohorts (cohort 3).

Results

Age-adjusted hazard ratio (HR) of all-cause mortality and CVD in men without diabetes showed that both had a statistically significant decreased risk of all-cause mortality compared to the first cohort. No statistically significant changes in all-cause mortality were observed in men and women with diabetes between the latter two cohorts compared with the first after controlling for several covariates. In both men and women without diabetes, cohort 2 (men, HR = 0.65; 95% CI 0.51–0.82; women, HR = 0.54; 95% CI 0.32–0.89) and cohort 3 (men, HR = 0.32; 95% CI 0.22–0.47; women, HR = 0.31; 95% CI 0.14–0.68) showed a statistically significant decreased risk of CVD mortality compared to cohort 1. Age-adjusted HRs in regard to CVD mortality in men (HR = 0.22; 95% CI 0.07–0.69) and women (HR = 0.22; 95% CI 0.05–0.99) with diabetes of cohort 3 were statistically significantly lower than in cohort 1.

Conclusions

There seems to be a decrease in CVD mortality in people with diabetes indicating that treatment of diabetes and cardiovascular risk factors in diabetes patients may have improved during the last decade.     

The obesity paradox in men with coronary heart disease and heart failure: The role of muscle mass and leptin

Aims

We have investigated the role of muscle mass, natriuretic peptides and adipokines in explaining the obesity paradox.

Background

The obesity paradox relates to the association between obesity and increased survival in patients with coronary heart disease (CHD) or heart failure (HF).

Methods

Prospective study of 4046 men aged 60–79 years followed up for a mean period of 11 years, during which 1340 deaths occurred. The men were divided according to the presence of doctor diagnosed CHD and HF: (i) no CHD or HF ii), with CHD (no HF) and (iii) with HF.

Results

Overweight (BMI 25–9.9 kg/m²) and obesity (BMI ≥ 30 kg/m²) were associated with lower mortality risk compared to men with normal weight (BMI 18.5–24.9 kg/m²) in those with CHD [hazards ratio (HR) 0.71 (0.56,0.91) and 0.77 (0.57,1.04); p = 0.04 for trend] and in those with HF [HR 0.57 (0.28,1.16) and 0.41 (0.16,1.09; p = 0.04 for trend). Adjustment for muscle mass and NT-proBNP attenuated the inverse association in those with CHD (no HF) [HR 0.78 (0.61,1.01) and 0.96 (0.68,1.36) p = 0.60 for trend) but made minor differences to those with HF [p = 0.05]. Leptin related positively to mortality in men without HF but inversely to mortality in those with HF; adjustment for leptin abolished the BMI mortality association in men with HF [HR 0.82 (0.31,2.20) and 0.99 (0.27,3.71); p = 0.98 for trend].

Conclusion

The lower mortality risk associated with excess weight in men with CHD without HF may be due to higher muscle mass. In men with HF, leptin (possibly reflecting cachexia) explain the inverse association.     

Self-reported habitual snoring and risk of cardiovascular disease and all-cause mortality

Objective

Inconsistent findings have reported the association between self-reported habitual snoring and risk of cardiovascular disease (CVD) and all-cause mortality. We conducted a meta-analysis to investigate whether self-reported habitual snoring was an independent predictor for CVD and all-cause mortality using prospective observational studies.

Methods

Electronic literature databases (PubMed, Medline, Embase, Cochrane Library, Wanfang database, and China National Knowledge Infrastructure) were searched for publications prior to September 2013. Only prospective studies evaluating baseline habitual snoring and subsequent risk of CVD and all-cause mortality were selected. Pooled adjust hazard risk (HR) and corresponding 95% confidence intervals (CI) were calculated for categorical risk estimates.

Results

Eight studies with 65,037 subjects were analyzed. Pooled adjust HR was 1.26 (95% CI 0.98–1.62) for CVD, 1.15 (95% CI 1.05–1.27) for coronary heart disease (CHD), and 1.26 (95% CI 1.11–1.43) for stroke comparing habitual snoring to non-snorers. Pooled adjust HR was 0.98 (95% CI 0.78–1.23) for all-cause mortality in a random effect model comparing habitual snoring to non-snorers. Habitual snoring appeared to increase greater stroke risk among men (HR 1.54; 95% CI: 1.09–2.17) than those in women (HR 1.22; 95% CI: 1.05–1.41).

Conclusions

Self-reported habitual snoring is a mild but statistically significant risk factor for stroke and CHD, but not for CVD and all-cause mortality. However, whether the risk is attributable to obstructive sleep apnea syndrome or snoring alone remains controversial.     

Heart rate on admission independently predicts in-hospital mortality in acute ischemic stroke patients

Background

Higher heart rate (HR) is associated with worse outcomes – in particular death – in long term follow-up of patients with vascular diseases. We investigated the association between HR measured on admission and early in-hospital mortality in acute ischemic stroke patients.

Methods

Over a period of 30 months all patients admitted to our hospital with acute ischemic stroke but without atrial fibrillation were prospectively enrolled. Univariate and multiple logistic regression analyses were conducted to estimate the impact of HR on in-hospital mortality. HR was analyzed as continuous and categorical variable (tertiles).

Results

A total of 1335 patients (median age 73 (IQR 65–81), median National Institutes of Health Stroke Scale score 4 (IQR 2–8), median length of stay 5 days (IQR 4–7), female sex 46%) were studied. In-hospital mortality was 2.6%. When analyzed as categorical variable, HR ≥ 83 bpm was independently associated with in-hospital mortality after adjustment for predictors of poor outcome compared to the reference tertile (HR ≤ 69 bpm) (adjusted odds ratio 4.42, 95% CI 1.36–14.42, p = 0.01). When HR was modeled as continuous variable, relative risk for in-hospital death was elevated by 40% for every additional 10-bpm (p = 0.003). These results were not changed by including beta-blockers as covariate into the multiple regression model.

Conclusions

HR on admission is independently associated with in-hospital mortality in acute ischemic stroke patients suggesting early negative effects of autonomic imbalance. HR may represent a therapeutic target to improve outcome after ischemic stroke.     

Adherence to dietary guidelines and cardiovascular disease risk in the EPIC-NL cohort

Background

Global and national dietary guidelines have been created to lower chronic disease risk. The aim of this study was to assess whether greater adherence to the WHO guidelines (Healthy Diet Indicator (HDI)); the Dutch guidelines for a healthy diet (Dutch Healthy Diet-index (DHD-index)); and the Dietary Approaches to Stop Hypertension (DASH) diet was associated with a lower risk of cardiovascular disease (CVD), coronary heart disease (CHD) or stroke.

Methods

A prospective cohort study was conducted among 33,671 healthy Dutch men and women aged 20–70 years recruited into the EPIC-NL study during 1993–1997. We used Cox regression adjusted for relevant confounders to estimate the hazard ratios per standard deviation increase in score and 95% confidence intervals (CI) of the associations between the dietary guidelines and CVD, CHD and stroke risk.

Results

After an average follow-up of 12.2 years, 2752 CVD cases were documented, including 1630 CHD cases and 527 stroke cases. We found no association between the HDI (0.98, 95% CI 0.94; 1.02) or DHD-index (0.96, 95% CI 0.92; 1.00) and CVD incidence. Similar results were found for these guidelines and CHD or stroke incidence. Higher adherence to the DASH diet was significantly associated with a lower CVD (0.92, 95% CI 0.89; 0.96), CHD (0.91, 95% CI 0.86; 0.95), and stroke (0.90, 95% CI 0.82; 0.99) risk.

Conclusion

The HDI and the DHD-index were not associated with CVD risk, while the DASH diet was significantly associated with a lower risk of developing CVD, CHD and stroke.     

Excess mortality in women compared to men after PCI in STEMI: An analysis of 11,931 patients during 2000–2009

Background

Ambiguity exists whether gender affects outcome in patients undergoing percutaneous coronary intervention (PCI).

Methods

To evaluate the relationship between gender and outcome in a large cohort of PCI patients, 11,931 consecutive patients who underwent PCI for various indications during 2000–2009 were studied using survival analyses and Cox regression models.

Results

Most patients (n = 8588; 72%) were men. Women were older and more often had a history of hypertension and diabetes mellitus. Men smoked more frequently, had a more extensive cardiovascular history (previous MI, PCI and CABG), a higher prevalence of renal impairment and multi-vessel disease. In STEMI patients, women had higher 31-day mortality rates than men (11.6% vs. 6.5%, respectively, p < 0.001). This difference remained after adjustment for confounders (aHR at 30-days 1.54 and 95% CI 1.22–1.96). Likewise, higher mortality was observed at 1-year (15.1% vs. 9.3%) and 4-year follow-up (21.6% vs. 15.0%, aHR 1.30 and 95% CI 1.10–1.53). There were no differences in mortality between women and men in NSTE-ACS (aHR at 4-years 1.05 and 95% CI 0.85–1.28) or stable angina (HR at 4-years 0.85 and 95% CI 0.68–1.08).

Conclusion

Women undergoing PCI for STEMI had higher mortality than men. The excess mortality in women appeared in the first month after PCI and could only partially be explained by a difference in baseline characteristics. No gender differences in outcome in patients undergoing PCI for NSTE-ACS and stable angina were observed.     

Prediabetes is not an independent risk factor for incident heart failure,other cardiovascular events or mortality in older adults: Findings from a population-based cohort study

Background

Whether prediabetes is an independent risk factor for incident heart failure (HF) in non-diabetic older adults remains unclear.

Methods

Of the 4602 Cardiovascular Health Study participants, age ≥ 65 years, without baseline HF and diabetes, 2157 had prediabetes, defined as fasting plasma glucose (FPG) 100–125 mg/dL. Propensity scores for prediabetes, estimated for each of the 4602 participants, were used to assemble a cohort of 1421 pairs of individuals with and without prediabetes, balanced on 44 baseline characteristics.

Results

Participants had a mean age of 73 years, 57% were women, and 13% African American. Incident HF occurred in 18% and 20% of matched participants with and without prediabetes, respectively (hazard ratio {HR} associated with prediabetes, 0.90; 95% confidence interval {CI}, 0.76–1.07; p = 0.239). Unadjusted and multivariable-adjusted HRs (95% CIs) for incident HF associated with prediabetes among 4602 pre-match participants were 1.22 (95% CI, 1.07–1.40; p = 0.003) and 0.98 (95% CI, 0.85–1.14; p = 0.826), respectively. Among matched individuals, prediabetes had no independent association with incident acute myocardial infarction (HR, 1.02; 95% CI, 0.81–1.28; p = 0.875), angina pectoris (HR, 0.93; 95% CI, 0.77–1.12; p = 0.451), stroke (HR, 0.86; 95% CI, 0.70–1.06; p = 0.151) or all-cause mortality (HR, 0.99; 95% CI, 0.88–1.11; p = 0.840).

Conclusions

We found no evidence that prediabetes is an independent risk factor for incident HF, other cardiovascular events or mortality in community-dwelling older adults. These findings question the wisdom of routine screening for prediabetes in older adults and targeted interventions to prevent adverse outcomes in older adults with prediabetes.     

Five-year outcomes of surgical or percutaneous myocardial revascularization in diabetic patients

Background

The study compares five-year clinical outcomes of CABG vs PCI in a real world population of diabetic patients with multivessel coronary disease since it is not clear whether to prefer surgical or percutaneous revascularization.

Methods

Between July 2002 and December 2008, 2885 multivessel coronary diabetic patients underwent revascularization (1466 CABG and 1419 PCI) at hospitals in Emilia-Romagna Region, Italy and were followed for 1827 ± 617 days by record linkage of two clinical registries with the regional administrative database of hospital admissions and the mortality registry. Five-year incidences of MACCE (mortality, acute myocardial infarction [AMI], stroke, and repeat revascularization [TVR]) were assessed with Kaplan–Meier estimates, Cox proportional hazards regression and cumulative incidence functions of death and TVR, to evaluate the competing risk of AMI on death and TVR. The same analyses were applied to the propensity score matched subgroup of patients undergoing CABG or PCI with DES and with complete revascularization.

Results

PCI had higher mortality for all causes (HR: 1.8, 95% CI 1.4–2.2 p < 0.0001), AMI (HR: 3.3, 95% CI 2.4–4.6 p < 0.0001) and TVR (HR: 4.5, 95% CI 3.4–6.1 p < 0.0001). No significant differences emerged for stroke (HR: 0.8, 95% CI 0.5–1.2 p = 0.26).The higher incidence of AMI caused higher mortality in PCI group. Results did not change comparing CABG with PCI patients receiving complete revascularization or DES only.

Conclusions

Diabetics show a higher incidence of MACCE with PCI than with CABG: thus diabetes and its degree of control should be considered when choosing the type of revascularization.     

Alcohol intake and risk of stroke: A dose–response meta-analysis of prospective studies

Background

Alcohol intake is inconsistently associated with the risk of stroke morbidity and mortality. The purpose of this study was to summarize the evidence regarding this relationship by using a dose–response meta-analytic approach.

Methods

We performed electronic searches of PubMed, EMBASE, and the Cochrane Library to identify relevant prospective studies. Only prospective studies that reported effect estimates with 95% confidence intervals (CIs) of stroke morbidity and mortality for more than 2 categories of alcohol intake were included.

Results

We included 27 prospective studies reporting data on 1,425,513 individuals. Low alcohol intake was associated with a reduced risk of total stroke (risk ratio [RR], 0.85; 95% CI: 0.75–0.95; P = 0.005), ischemic stroke (RR, 0.81; 95% CI: 0.74–0.90; P < 0.001), and stroke mortality (RR, 0.67; 95% CI: 0.53–0.85; P = 0.001), but it had no significant effect on hemorrhagic stroke. Moderate alcohol intake had little or no effect on the risks of total stroke, hemorrhagic stroke, ischemic stroke, and stroke mortality. Heavy alcohol intake was associated with an increased risk of total stroke (RR, 1.20; 95% CI: 1.01–1.43; P = 0.034), but it had no significant effect on hemorrhagic stroke, ischemic stroke, and stroke mortality.

Conclusions

Low alcohol intake is associated with a reduced risk of stroke morbidity and mortality, whereas heavy alcohol intake is associated with an increased risk of total stroke. The association between alcohol intake and stroke morbidity and mortality is J-shaped.     

Prognostic significance of mitral regurgitation in long-term all-cause mortality in patients aged ≥ 80 years with acute coronary syndrome

Background

Mitral regurgitation (MR) has been shown to be associated with a poor prognosis in the patients with acute myocardial infarction, whether or not percutaneous coronary intervention (PCI) is employed. However, the long-term prognostic significance of MR in octogenarian patients with acute coronary syndrome (ACS) remains unknown. We sought to determine the impact of MR on long-term all-cause mortality and to further reveal whether PCI could influence the prognosis in octogenarian MR patients with ACS.

Methods

In this study, we included a total of 353 consecutive hospitalized patients, aged ≥ 80 years, with ACS during the period of 5-year follow-up. Association between MR and long-term all-cause mortality was analyzed both in a overall cohort and in a matched cohort developed from a propensity score analysis.

Results

MR was independently associated with long-term all-cause mortality in the overall and matched cohorts (hazard ratio (HR) 1.58, 95% CI 1.01–2.47, P = 0.043; HR 1.90, 95% CI 1.15–3.13, P = 0.013). In the subgroup treated with PCI, MR also exhibited higher long-term all-cause mortality, PCI remained an independent determinant of improving long-term survival rate by reducing the mortality by 15.1% in ACS patients with MR aged ≥ 80 years.

Conclusions

Our study demonstrates that MR is independently associated with long-term all-cause mortality, and PCI is an independent determinant for improving the long-term survival rate in the octogenarian ACS patients with MR.     

Pattern of atrial fibrillation and risk of outcomes: The Loire Valley Atrial Fibrillation Project

Background

Risk of stroke and thromboembolism (TE) in patients with non-valvular atrial fibrillation (NVAF) is categorised in stroke risk stratification scores. The role of pattern of NVAF in risk prediction is unclear in contemporary ‘real world’ cohorts.

Methods and results

Patients with NVAF in a four-hospital-institution between 2000 and 2010 were included. Stroke/TE event rates were calculated according to pattern of AF, i.e. paroxysmal, persistent and permanent. Risk factors were investigated by Cox regression.Among 7156 NVAF patients, 4176 (58.4%) patients with paroxysmal, 376 (5.3%) with persistent and 2604 (36.3%) with permanent patterns of NVAF were included. In non-anticoagulated patients, overall stroke/TE event rate per 100 person-years was 1.29 (95% CI 1.13–1.47). Compared with paroxysmal NVAF, rates of stroke/TE, bleeding and all-cause mortality (p < 0.001) were significantly higher in permanent NVAF patients but not in persistent NVAF patients.In multivariate analyses, previous stroke (hazard ratio, HR 2.58, 95% CI 2.08–3.21), vascular disease (HR 1.34, 1.12–1.61), heart failure (HR 1.20, 1.00–1.44), age ≥ 75 years (HR 2.75, 2.16–3.50) and age 65–74 years (HR 1.60, 1.22–2.09) independently increased stroke/TE risk, but not persistent (HR 1.13, 0.76–1.70) and permanent (HR 1.44, 0.96–2.16) NVAF patterns.

Conclusion

In this large ‘real world’ NVAF cohort, rates of stroke, TE, death and bleeding differed significantly by patterns of NVAF. However, only previous stroke, age, heart failure and vascular disease (not pattern of NVAF) independently increased risk of adverse outcomes in multivariate analyses. Thus, stroke risk is similar across all patterns of NVAF and antithrombotic therapy should be based on clinical risk factors, not on arrhythmia pattern.     

Prognostic implications of quantitative evaluation of baseline Q-wave width in ST-segment elevation myocardial infarction

Objectives

To evaluate quantitative relationships between baseline Q-wave width and 90-day outcomes in ST-segment elevation myocardial infarction (STEMI).

Background

Baseline Q-waves are useful in predicting clinical outcomes after MI.

Methods

3589 STEMI patients were assessed from a multi-centre study.

Results

1156 patients of the overall cohort had pathologic Q-waves. The 90-day mortality and the composite of mortality, congestive heart failure (CHF), or cardiogenic shock (p < 0.001 for both outcomes) rose as Q-wave width increased. After adapting a threshold ≥ 40 ms for inferior and ≥ 20 ms for lateral/apical MI in all patients (n = 3065) with any measureable Q-wave we found hazard ratios (HR) for mortality (HR: 2.44, 95% confidence interval (CI) (1.54–3.85), p < 0.001) and the composite (HR: 2.32, 95% CI (1.70–3.16), p < 0.001). This improved reclassification of patients experiencing the composite endpoint versus the conventional definition (net reclassification index (NRI): 0.23, 95% CI (0.09-0.36), p < 0.001) and universal MI definition (NRI: 0.15, 95% CI (0.02–0.29), p = 0.027).

Conclusions

The width of the baseline Q-wave in STEMI adds prognostic value in predicting 90-day clinical outcomes. A threshold of ≥ 40 ms in inferior and ≥ 20 ms for lateral/apical MI enhances prognostic insight beyond current criteria.     

Gender-related differences of diabetic patients undergoing percutaneous coronary intervention with drug-eluting stents: A real-life multicenter experience

Background

Gender-based differences in diabetic patients are understudied in the field of percutaneous coronary intervention (PCI) with drug-eluting stents.

Methods

Data were obtained from a multicenter registry of 2420 consecutive patients with diabetes mellitus (DM) who underwent PCI with paclitaxel- or sirolimus-eluting stents between 2003 and 2009. Among them, 679 (28.1%) women were compared to 1741 (71.9%) men in terms of clinical aspects and major adverse cardiac events (MACE), including all-cause death, myocardial infarction (MI) and target lesion revascularization (TLR). Target vessel revascularization (TVR) and any revascularization were also reported.

Results

Women were less numerous, older, used more insulin and showed more tortuous coronary arteries, while men were more frequently smokers and received larger stents. At the median follow-up of 24.3 months (interquartile range 12.3–39.7), MACE, TVR and any revascularization did not significantly differ between females and males (19.9% vs 18.7%, 12.2% vs 13.4%, 14.1% vs 15.1%, respectively). At multivariable analysis of the overall cohort, female gender was not a predictor of MACE (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.92–2.36, p = 0.11), death (HR 1.04, 95% CI 0.84–1.24, p = 0.86), MI (HR 1.48, 95% CI 0.92–2.36, p = 0.11), and TLR (HR 1.14, 95% CI 0.85–1.52, p = 0.38).

Conclusion

In this registry of diabetic patients treated by drug-eluting stents, women were less represented, older and needed more insulin compared to men who, on the other hand, received larger stents. Gender-related outcomes were similar and female sex did not predict MACE.     

Hemorrhagic stroke the first 30 days after an acute myocardial infarction: Incidence,time trends and predictors of risk

Background/objectives

Hemorrhagic stroke is a rare but serious complication after an acute myocardial infarction (AMI). The aims of our study were to establish the incidence, time trends and predictors of risk for hemorrhagic stroke within 30 days after an AMI in 1998–2008.

Methods

We collected data from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA). All patients with a myocardial infarction 1998–2008 were included, n = 173,233. The data was merged with the National Patient Register in order to identify patients suffering a hemorrhagic stroke. To identify predictors of risk we used Cox models.

Results

Overall the incidence decreased from 0.2% (n = 94) in 1998–2000 to 0.1% (n = 41) in 2007–2008. In patients with ST-elevation myocardial infarction the corresponding incidences were 0.4% (n = 76) in 1998–2000 and 0.2% (n = 21) in 2007–2008, and after fibrin specific thrombolytic treatment 0.6% and 1.1%, respectively, with a peak of 1.4% during 2003–2004. In total 375 patients (0.22%) suffered a hemorrhagic stroke within 30 days of the AMI. The preferred method of reperfusion changed from thrombolysis to percutaneous coronary intervention (PCI). Older age (hazard ratio (HR) > 65- ≤ 75 vs ≤ 65 years 1.84, 95% confidence interval (CI) 1.38–2.45), thrombolysis (HR 6.84, 95% CI 5.51–8.48), history of hemorrhagic stroke (HR 12.52, CI 8.36–18.78) and prior hypertension (HR 1.52, CI 1.23–1.86) independently predicted hemorrhagic stroke within 30 days.

Conclusions

The rate of hemorrhagic stroke within 30 days of an AMI has decreased by 50% between 1998 and 2008. The main reason is the shift in reperfusion method from thrombolysis to PCI.     

Prognostic significance of cardiovascular biomarkers and renal dysfunction in outpatients with systolic heart failure: A long term follow-up study

Objective

To assess whether the prognostic significance of cardiovascular (CV) biomarkers, is affected by renal dysfunction (RD) in systolic heart failure (HF).

Background

It is unknown, whether the prognostic significance of CV biomarkers, such as N-terminal-pro-brain-natriuretic-peptide (NT-proBNP), high-sensitive troponin T (hsTNT), pro-atrial natriuretic peptide (proANP), copeptin and pro-adrenomedullin (proADM), is affected by renal function in HF.

Methods

Clinical data and laboratory tests from 424 patients with systolic HF were collected prospectively. The patients were followed for 4.5 years (interquartile range: 2–7.7 years). CV biomarkers were analyzed on frozen plasma, and renal function was estimated by the Modification of Diet in Renal Disease (MDRD) formula. Cox proportional hazard models for mortality risk were constructed and tests for interaction between each CV biomarker and RD were performed.

Results

Median age was 73 years (51–83), 29% were female, LVEF was 30% (13–45), 74% were NYHA classes I–II and estimated glomerular filtration rate (eGFR) was 68 ml/min/1.73 m² (18–157). A total of 252 patients died. All five biomarkers – log(NT-proBNP) (HR: 2.13, 95% CI: 1.57–2.87:, P < 0.001), hsTNT (HR: 3.07, 95% CI: 1.90–4.96 P < 0.001), proANP (HR: 1.02, 95% CI: 1.01–1.03, P < 0.001), copeptin (HR: 1.02, 95% CI: 1.01–1.03, P = 0.008) and proADM (HR: 2.37, 95% CI: 1.66–3.38, P < 0.001) – were associated with mortality risk, but not affected by RD (P > 0.05 for all interactions).

Conclusion

Established and new CV biomarkers are closely associated with renal function in HF. However, their prognostic significance is not affected by RD, and all CV biomarkers can be used for risk stratification independently of renal function.     

Depression,antidepressants, and the risk of coronary heart disease: A population-based cohort study

Background

Evidence supporting a predictive role for depression in the pathgenesis of coronary heart disease (CHD) has mainly come from studies in Western countries. Conflicting data exist regarding the association between antidepressant use and the incidence of CHD. This population-based study tracked the risk of composite coronary events in a cohort with newly diagnosed depression compared to an age- and gender-matched cohort without depression. The association between antidepressant use and risk of coronary events in individuals with depression was also investigated.

Methods

In total, 39,685 individuals (7937 with depression and 31,748 without depression) aged 20–99 years selected from a random sample of 10⁶ beneficiaries of the Taiwan National Health Insurance Program were followed up for up to 9 years with a median follow-up period of 8.76 years. Coronary events were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes. Antidepressant use was identified using Anatomical Therapeutic Chemical classification codes.

Results

The multivariable-adjusted hazard ratio (HR) for newly detected coronary events was 1.49 (95% confidence interval (CI) = 1.29–1.74, p < 0.001) for individuals with depression compared to age- and gender-matched individuals without depression. Use of selective serotonin reuptake inhibitors and tricyclic antidepressants did not significantly impact the risk of the composite coronary events among individuals with depression.

Conclusions

Depression is associated with an increased risk for CHD. No evidence supporting an association between antidepressants and coronary events was found.     

Residual risk of cardiovascular mortality in patients with coronary heart disease: The EUROASPIRE Risk Categories

Background

The EUROASPIRE I, II and III surveys revealed high prevalences of modifiable risk factors in the high priority group of coronary patients all over Europe. The potential to further reduce coronary heart disease (CHD) morbidity and mortality rates is still considerable. We report here on the relative risk of cardiovascular disease (CVD) death associated with common modifiable risk factor levels based on the mortality follow-up of patients participating in the first two EUROASPIRE surveys. We also present a novel simple risk classification system (ERC) that can be used in the management of patients with existing CHD.

Methods

The study cohort consisted of a consecutive sample of CHD patients aged ≤ 70 years from 12 European countries. Baseline data gathered in 1995–2000 through standardized methods, were linked to cardiovascular mortality in 5216 patients according to an accelerated failure time model.

Results

During 28,143 person-years of follow-up, 332 patients died from cardiovascular disease denoting a CVD mortality risk of 12.3 per 1000 person-years in men and 10.2 per 1000 person-years in women. In multivariate analysis, fasting glucose, total cholesterol and smoking emerged as the strongest independent modifiable predictors of cardiovascular mortality.

Conclusions

The results of the mortality follow-up of the EUROASPIRE I and II CHD patients emphasize the continuing risk from elevated glucose and total cholesterol levels and underline the importance of smoking cessation in secondary prevention. The ERC risk tool that we developed may prove helpful to obtain these goals in the setting of secondary prevention.     

The contribution of diet and lifestyle to socioeconomic inequalities in cardiovascular morbidity and mortality

Background

The role of differences in diet on the relationship between socioeconomic factors and cardiovascular diseases remains unclear. We studied the contribution of diet and other lifestyle factors to the explanation of socioeconomic inequalities in cardiovascular diseases.

Methods

We prospectively examined the incidence of coronary heart disease (CHD) and stroke events amongst 33,106 adults of the EPIC-NL cohort. Education and employment status indicated socioeconomic status. We used Cox proportional models to estimate hazard ratios ((HR (95% confidence intervals)) for the association of socioeconomic factors with CHD and stroke and the contribution of diet and lifestyle.

Results

During 12 years of follow-up, 1617 cases of CHD and 531 cases of stroke occurred. The risks of CHD and stroke were higher in lowest (HR = 1.98 (1.67;2.35); HR = 1.55 (1.15;2.10)) and lower (HR = 1.50 (1.29;1.75); HR = 1.42 (1.08;1.86)) educated groups than in the highest. Unemployed and retired subjects more often suffered from CHD (HR = 1.37 (1.19;1.58); HR = 1.20 (1.05;1.37), respectively), but not from stroke, than the employed. Diet and lifestyle, mainly smoking and alcohol, explained more than 70% of the educational differences in CHD and stroke and 65% of employment status variation in CHD. Diet explained more than other lifestyle factors of educational and employment status differences in CHD and stroke (36% to 67% vs. 9% to 27%).

Conclusion

The socioeconomic distribution of diet, smoking and alcohol consumption largely explained the inequalities in CHD and stroke in the Netherlands. These findings need to be considered when developing policies to reduce socioeconomic inequalities in cardiovascular diseases.     

Proximal coronary artery intervention: Stent thrombosis,restenosis and death

Background

Percutaneous coronary intervention (PCI) of lesions in the proximal left anterior descending coronary artery (LAD) may confer a worse prognosis compared with the proximal right coronary artery (RCA) and left circumflex coronary artery (LCX).

Methods

From May 2005, to May 2011 we identified all PCIs for proximal, one-vessel coronary artery disease in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). We evaluated restenosis, stent thrombosis (ST) and mortality in the LAD as compared to the RCA and LCX according to stent type, bare metal (BMS) or drug-eluting stents (DES).

Results

7840 single vessel proximal PCI procedures were identified. Mean follow-up time was 792 days. No differences in restenosis or ST were seen between the LAD and the RCA. The frequency of restenosis and ST was higher in the proximal LAD compared to the proximal LCX (restenosis: hazard ratio (HR) 2.28, confidence interval (CI) 1.56–3.34 p < 0.001; ST: HR 2.32, CI 1.11–4.85 p = 0.024). We found no difference in mortality related to coronary artery. In the proximal LAD, DES implantation was associated with a lower restenosis rate (HR 0.39, CI 0.27–0.55 p < 0.001) and mortality (HR 0.58, CI 0.41–0.82 p = 0.002) compared with BMS. In the proximal RCA and LCX, DES use was not associated with lower frequency of clinical restenosis or mortality.

Conclusions

Following proximal coronary artery intervention restenosis was more frequent in the LAD than in the LCX. Solely in the proximal LAD we found DES use to be associated with a lower risk of restenosis and death weighted against BMS.