Relative validity of the 10-year cardiovascular risk estimate in a population cohort of the REGICOR study

Introduction and objectives

Cardiovascular risk screening requires accurate risk functions. The relative validity of the Framingham-based REGICOR adapted function is analyzed and the population distribution of cardiovascular 10-year cardiovascular events is described by risk group.

Methods

A population cohort of 3856 participants recruited between 1995 and 2000, aged 35 to 74 years from Girona without symptoms of cardiovascular diseases, was followed between 2006 and 2009. Standardized laboratory and blood pressure measurements, questionnaires, and case definitions were used. The follow-up combined cross-linkage of our databases with our regional mortality registry, reexamination, and telephone contact with participants. Coronary disease endpoints alone were considered.

Results

A total of 27 487 person-years were obtained (mean follow-up 7.1 years), and the follow-up was achieved in 97% of participants (120 coronary disease events). Validity was good: the regression coefficients estimated with the cohort data did not differ from those obtained in the original Framingham function. Function calibration was good: the observed incidence of cardiovascular events in the decile groups of risk did not differ from the function prediction (P = .127 in women, and P = .054 in men). The C statistic (discrimination) was 0.82 (95% confidence interval, 0.76-0.88) in women, and 0.78 (95% confidence interval, 0.73-0.83) in men. More than 50% of cardiovascular events occurred in participants whose 10-year risk was 5% to 14.9%.

Conclusions

The studied function accurately predicts coronary disease events at 10 years. Risk stratification could be simplified in 4 groups: low (<5%), moderate (5%-9.9%), high (10%-14.9%) and very high (≥15%).Full English text available from: www.revespcardiol.org     

Raloxifene and Risk for Stroke Based on the Framingham Stroke Risk Score

Purpose

Raloxifene reduces vertebral fracture and invasive breast cancer risks, but increases fatal strokes in postmenopausal women at increased coronary risk. We assessed whether this risk is concentrated in postmenopausal women already at high stroke risk.

Methods

Raloxifene Use for The Heart (RUTH) enrolled 10,101 postmenopausal women (mean age 67 years) with or at increased coronary heart disease risk; Multiple Outcomes of Raloxifene Evaluation (MORE) enrolled 7705 osteoporotic postmenopausal women (mean age 66 years). A Framingham Stroke Risk Score (FSRS) was calculated for all women with no prior cerebrovascular events (n = 16,858). The validity of the FSRS was assessed in the placebo groups, and then raloxifene-associated stroke risk was analyzed by FSRS subgroups.

Results

FSRS predicted an increased stroke risk in the placebo group of both clinical trials. There was no difference in the incidence of nonfatal strokes between the raloxifene and placebo groups in MORE or RUTH, regardless of baseline Framingham stroke risk. In RUTH, women with FSRS <13 showed no increase in raloxifene-associated fatal stroke risk (hazard ratio [HR] 1.08; 95% confidence interval [CI], 0.49-2.37). Those with FSRS ≥13 had a 75% increased risk of raloxifene-associated fatal stroke (HR 1.75; 95% CI, 1.01-3.02; interaction P = .33). In MORE, where 80% of women had a FSRS <13, no increase in fatal (HR 0.57; 95% CI, 0.19-1.68) stroke risk was observed.

Discussion

Risk of fatal stroke associated with raloxifene was greater in women at high stroke risk. These results might be useful for identifying postmenopausal women at high risk of first stroke who should avoid raloxifene therapy.     

Duration of evidence-based medical therapy and the hazard for atherothrombotic events following percutaneous coronary intervention

Background

Patients who undergo coronary artery stent procedures are at risk for late atherothrombotic events, including stent thrombosis. The relationship between the duration during which evidence-based medical therapies are utilized after coronary artery stenting and the risk of late atherothrombotic events is not well characterized.

Methods

In a retrospective cohort study linking a hospital-based percutaneous coronary intervention registry with a health maintenance organization claims dataset, we related the duration of medical therapy utilization during follow up to the hazard for death, myocardial infarction, unstable angina, transient ischemic attack or stroke following a coronary artery stent procedure. Multivariable Cox models were employed in which medical treatments were entered as time-varying covariates; data were stratified by stent type and time period.

Results

The median [interquartile range, IQR] duration of follow up was 832 [460, 1420] days. During this time, 86 ischemic events occurred in 84 of 386 patients at a median [IQR] of 260 [110, 658] days. The incidence of atherothrombotic events following coronary artery stenting was highest during the first post-procedure year and declined substantially thereafter. Multivariable predictors of incident ischemic events included multivessel coronary artery disease (HR 2.01 [95% CI 1.30-3.11], p = 0.0018) and longer duration angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), beta blocker or statin therapy (HR 0.52 [95% CI 0.28-0.99], p = 0.045).

Conclusions

The use of longer-term ACE inhibitor/ARB, beta blocker or statin therapy was associated with a significantly lower risk; these risk reductions were of greater magnitude than those associated with clopidogrel.     

Impact of Gender on Risk Stratification by Stress Echocardiography

Objective

To compare the prognostic value of stress echocardiography results in men and women with known and suspected coronary artery disease.

Methods

We analyzed the data of 8737 patients (5529 men and 3208 women) who underwent stress echocardiography (exercise in 523 patients, dipyridamole in 6227 patients, dobutamine in 1987) for evaluating known (n = 3857) or suspected (n = 4880) coronary artery disease. Patients were followed up for the occurrence of overall mortality or nonfatal myocardial infarction.

Results

During a median follow-up of 25 months, 1218 cardiac events (693 deaths and 525 infarctions) occurred. Moreover, 2263 patients (1731 men [31%] and 532 women [17%]; P < .0001) underwent coronary revascularization and were censored. Stress echocardiography results added prognostic information to that of clinical findings and resting wall motion score index in men and women with both known and suspected coronary artery disease. In patients with known coronary artery disease, women had a higher (P = .01) event rate than men in the presence of ischemia. The annual event rate was worse for nondiabetic women (P = .007) but not diabetic women; age had a neutral prognostic effect in the 2 sexes. In patients with suspected coronary artery disease, men without ischemia had a higher (P < .0001) event rate than women. The annual event rate was worse in men aged less than 65 years (P < .0001) or more than 65 years (P = .04), and those with (P = .03) or without (P < .0001) diabetes.

Conclusion

Prognosis is at least comparable in men and women with ischemia and in those with coronary artery disease and no ischemia at stress echocardiography. In these clinical settings, availability for major procedures should be similar for both genders.     

Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials

Purpose

Drug-eluting stents are commonly used for percutaneous coronary intervention. Despite excellent clinical efficacy, the association between drug-eluting stents and the risk for late thrombosis remains imprecisely defined.

Methods

We performed a meta-analysis on 14 contemporary clinical trials that randomized 6675 patients to drug-eluting stents (paclitaxel or sirolimus) compared with bare metal stents. Eight of these trials have reported more than a year of clinical follow-up.

Results

The incidence of very late thrombosis (>1 year after the index procedure) was 5.0 events per 1000 drug-eluting stent patients, with no events in bare metal stent patients (risk ratio [RR] = 5.02, 95% confidence interval [CI], 1.29 to 19.52, P = .02). Among sirolimus trials, the incidence of very late thrombosis was 3.6 events per 1000 sirolimus stent patients, with no events in bare metal stent patients (RR = 3.99, 95% CI, .45 to 35.62, P = .22). The median time of late sirolimus stent thrombosis was 15.5 months, whereas with bare metal stents it was 4 months. Among paclitaxel trials, the incidence of very late thrombosis was 5.9 events per 1000 paclitaxel stent patients, with no events in bare metal stent patients (RR = 5.72, 95% CI, 1.08 to 32.45, P = .049). The median time of late paclitaxel stent thrombosis was 18 months, whereas it was 3.5 months in bare metal stent patients.

Conclusions

Although the incidence of very late stent thrombosis more than 1 year after coronary revascularization is low, drug-eluting stents appear to increase the risk for late thrombosis. Although more of this risk was seen with paclitaxel stents, it remains possible that sirolimus stents similarly increase the risk for late thrombosis compared with bare metal stents.     

Warfarin Use and Outcomes in Patients with Atrial Fibrillation Complicating Acute Coronary Syndromes

Background

We examined warfarin use at discharge (according to Congestive heart failure, Hypertension, Age > 75 years, Diabetes, Prior Stroke/transient ischemic attack score and bleeding risk) and its association with 6-month death or myocardial infarction in patients with post-acute coronary syndrome atrial fibrillation.

Methods

Of the 23,208 patients enrolled in the Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy, Platelet IIb/IIIa Antagonist for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network A, and Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors trials, 4.0% (917 patients) had atrial fibrillation as an in-hospital complication and were discharged alive. Cox proportional hazards models were performed to assess 6-month outcomes after discharge.

Results

Overall, 13.5% of patients with an acute coronary syndrome complicated by atrial fibrillation received warfarin at discharge. Warfarin use among patients with atrial fibrillation had no relation with estimated stroke risk; similar rates were observed across Congestive heart failure, Hypertension, Age > 75 years, Diabetes, Prior Stroke/transient ischemic attack (CHADS₂) scores (0, 13%; 1, 14%; ≥ 2, 13%) and across different bleeding risk categories (low risk, 11.9%; intermediate risk, 13.3%; high risk, 11.1%). Among patients with in-hospital atrial fibrillation, warfarin use at discharge was independently associated with a lower risk of death or myocardial infarction within 6 months of discharge (hazard ratio 0.39; 95% confidence interval, 0.15-0.98).

Conclusion

Warfarin is associated with better 6-month outcomes among patients with atrial fibrillation complicating an acute coronary syndrome, but its use is not related to CHADS₂ score or bleeding risk.     

Screening for abdominal aortic aneurysm by means of transthoracic echocardiography

Introduction and objectives

The increasing incidence of abdominal aortic aneurysm (AAA), mainly due to the aging population, and its mortality of 85-90% in the event of rupture justify opting for early diagnosis and elective treatment to repair it. The main aim of this paper is to analyze the utility of transthoracic echocardiography (TTE) in the study of infrarenal aorta and AAA screening.

Methods

The study included 512 patients (309 men and 203 women) consecutively assessed by TTE and, where possible, abdominal ultrasound for any reason in a cardiology department.

Results

An AAA was detected in 25 patients (5.1%), the minimum age at diagnosis was 55 years, the ratio of men to women was 7.3:1 and the mean diameter of the aneurysms was 39.5 ± 12.2 mm. Risk factors associated with AAA were to current and former smoking, age, and presence of femoral murmur. The TTE results were equivalent to those of abdominal ultrasound. All patients with AAA studied by coronary angiography showed significant coronary lesions.

Conclusions

It is feasible and useful to complement conventional TTE with the study of the infrarenal aorta for AAA screening in patients visited at the department of cardiology. This study should be performed mainly in patients ≥55 years old or with risk factors to develop an AAA.Full English text available from:www.revespcardiol.org     

Hyperuricemia and increased risk of ischemic heart disease in a large Chinese cohort

Aims

There is an ongoing discussion on whether serum uric acid (SUA) predicts ischemic heart disease (IHD) independently of other metabolic factors, which, if confirmed, would signify a role for uric acid in the pathogenesis of cardiovascular disease. We investigated whether such a relation exists for ethnic Chinese with low CVD risk.

Methods and results

Enrolled, between 1994 and 1996, were 128,569 adults ≥ 20 years from four ‘MJ’ Health Check-up Clinics in Taiwan. Excluded were those with heart disease, previous stroke(s), renal disease, and/or cancer. Physical examinations, biospecimen collections, and structured questionnaires were executed according to standardised protocols. We identified IHD events according to the ICD-9-CM codes 410-414 using hospitalisation records obtained from the National Health Insurance and the Death Certification Registry databases. The Cox proportional hazard model was used to estimate the hazard ratios (HRs) between SUA and IHD events. A total of 2049 subjects (1239 men, 810 women) developed IHD from baseline to Dec. 31, 2002. Men had a higher IHD incidence than did women (2.84 vs. 1.61 1/1000 person-years; p < 0.0001). The risk-factor-adjusted HRs (95% confidence-interval [CI]) for hyperuricemiae (SUA ≥ 7.0/≥6.0 mg/dL) were 1.25 (1.11-1.40) for men and 1.19 (1.02-1.38) for women. In the low-risk population (lacking the NCEP-ATPIII metabolic syndrome components), a significant association was still observed (adjusted HR: 1.54 [1.09-2.17]).

Conclusion

The hyperuricemia was independently associated with the development of IHD not only in the general population but also in those without any metabolic risk factor for NCEP ATPIII. Hyperuricemia may be considered as a potential risk factor for IHD.     

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.     

Impact of coronary artery calcium on cardiovascular risk categorization and lipid-lowering drug eligibility in asymptomatic hypercholesterolemic men

Background

Application of coronary artery calcium (CAC) for stratifying coronary heart disease (CHD) risk may change the proportion of subjects eligible for risk reduction treatment and decrease cost-effectiveness of primary prevention. We therefore aimed to analyze the impact of CAC on CHD risk categorization.

Methods

We measured CAC with electron beam computed tomography in 500 asymptomatic untreated hypercholesterolemic men and re-calibrated 10-year Framingham CHD risk by adding CAC score information (post CAC test risk) via an algorithm integrating relative risk and expected distribution of CAC in the population tested. Proportions of low (< 10%), intermediate (10-20%) and high (> 20%) risk categories, and of eligibility for lipid-lowering treatment, were compared between Framingham risk and post CAC test risk.

Results

In the overall population, post CAC test risk calculation changed risk categorization defined by Framingham assessment alone, with 10% more low risk and 10% less intermediate risk (p < 0.01). Risk reclassifications were bidirectional since 30% of high and 30% of intermediate Framingham risk were downgraded to intermediate and low risk categories respectively, while 11% of low and 14% of intermediate Framingham risk were upgraded to intermediate and high-risk categories respectively. Post CAC test risk did not change the proportion of Framingham-based lipid-lowering treatment eligibility in the overall population but decreased it by 8% in intermediate Framingham risk subgroup (p < 0.05).

Conclusions

Addition of CAC to risk prediction resulted rather in downgrading than in upgrading risk and did not change treatment eligibility, except in intermediate risk subjects, less frequently eligible for treatment.     

Influence of body mass index on extent of coronary atherosclerosis and cardiac events in a cohort of patients at risk of coronary artery disease

Background and Aim

To estimate if a meaningful relationship exists between body mass index (BMI) and the entity of coronary atherosclerosis, coronary events and mortality in a cohort of consecutive patients with suspected coronary artery disease (CAD).

Methods and results

In this prospective study, we enrolled 1299 consecutive patients (905 [69.7%] males) who had undergone coronary angiography. Our sample consisted of 477 patients (36.8%) of normal weight; 567 (43.6%) overweight and 255 (19.6%) obese, according to the WHO classification. Conventional cardiovascular risk factors, BMI, endothelial function and subclinical inflammation were studied. Different angiographic CAD scores were used to quantify coronary atherosclerotic burden. In overweight and obese patients, respect to normal weight population, there is a higher prevalence of hypertension, hypercholesterolemia and diabetes mellitus, but BMI was not significantly associated with greater extent of coronary atherosclerosis. At follow-up (mean: 40; range: 24-82 months) obese and overweight patients showed a higher incidence of coronary events compared to the normal weight population (74.9% [obese] versus 62.7% [overweight] versus 53.2% [normal weight]; adjusted relative risk [obese versus overweight]: 1.08 [95% confidence interval: 1.02-1.23]; P < 0.05; and adjusted RR [obese versus normal weight]: 1.17 [95% CI: 1.10-1.42], P < 0.01). Mortality from cardiac events was not significant within the categories. The Cox regression model showed flow mediated dilation (P < 0.0001), high-sensitive C reactive protein (P = 0.022) and BMI (P = 0.045) as independent predictors of acute coronary events.

Conclusion

BMI is not associated with the extent of coronary atherosclerosis and mortality. The higher incidence of coronary events in obese subjects is only partly explained by conventional associated risk factors. Impaired endothelial function and sub-clinical inflammation could be involved in this association but BMI itself is related to cardiovascular events suggesting that other unknown (or not considered) pathways are involved.     

Tratamiento y control de los factores de riesgo según el riesgo coronario en la población española del estudio DARIOS

Introduction and objectives

The treatment and control of cardiovascular risk factors both play key roles in primary prevention. The aim of the present study is to analyze the proportion of primary prevention patients aged 35-74 years being treated and controlled in relation to their level of coronary risk.

Methods

Pooled analysis with individual data from 11 studies conducted in the first decade of the 21st century. We used standardized questionnaires and blood pressure measures, glycohemoglobin and lipid profiles. We defined optimal risk factor control as blood pressure <140/90 mmHg and glycohemoglobin <7%. In hypercholesterolemia, we applied both the European Societies and Health Prevention and Promotion Activities Programme criteria.

Results

We enrolled 27 903 participants (54% women). Drug treatments were being administered to 68% of men and 73% of women with a history of hypertension (P < .001), 66% and 69% respectively, of patients with diabetes (P = .03), and 39% and 42% respectively, of those with hypercholesterolemia (P < .001). Control was good in 34% of men and 42% of women with hypertension (P < .001); 65% and 63% respectively, of those with diabetes (P = .626); 2% and 3% respectively, of patients with hypercholesterolemia according to European Societies criteria (P = .092) and 46% and 52% respectively, of those with hypercholesterolemia according to Health Prevention and Promotion Activities Programme criteria (P < .001). The proportion of uncontrolled participants increased with coronary risk (P < .001), except in men with diabetes. Lipid-lowering treatments were more often administered to women with ≥10% coronary risk than to men (59% vs. 50%, P = .024).

Conclusions

The proportion of well-controlled participants was 65% at best. The European Societies criteria for hypercholesterolemia were vaguely reached. Lipid-lowering treatment is not prioritized in patients at high coronary risk.Full English text available from: www.revespcardiol.org     

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.     

Prediction of complications in pregnant women with cardiac diseases referred to a tertiary center

Background

Prediction of adverse maternal and neonatal events in women with heart disease is not well established. We aimed to assess cardiac, obstetrical and neonatal complications in pregnant women with heart disease referred to our tertiary care center and validate a previously proposed risk index.

Methods

We included 227 women with cardiac disease followed for 312 pregnancies at our tertiary center from 1992 to 2007. Cardiac risk was assessed using the previously proposed Cardiac Disease in Pregnancy (CARPREG) score and its association with maternal and neonatal outcomes was determined.

Results

Maternal cardiac lesions were predominantly congenital (81.4%). CARPREG risk was low (score = 0) in 66.3% and intermediate (score = 1) in 33.7% pregnancies. Maternal cardiac events complicated 7.4% pregnancies, with pulmonary edema occurring most frequently (3.8%). An intermediate score was associated with a higher rate of cardiac events (19.0% vs. 1.4%, odds ratio [OR] 15.6, 95% confidence interval (95%CI) 4.5-54.4, p < 0.0001). Adverse events occurred in 27.5% neonates. Preterm deliveries occurred in 16.7% pregnancies, more commonly in patients with intermediate scores (OR 2.4, 95%CI 1.2-4.6, p = 0.01). The sensitivity and negative predictive values of a low score were respectively 87% and 99% for total cardiac events and both 100% for primary cardiac events including pulmonary edema and sustained arrhythmia.

Conclusion

The CARPREG risk index has a high sensitivity and negative predictive value with regards to cardiac complications in pregnant women with heart disease. It may, therefore, be routinely used to improve the assessment of cardiac risk before and during pregnancy.     

Prevalence and characteristics of lipid abnormalities in patients treated with statins in primary and secondary prevention in Spain. DYSIS-Spain Study

Introduction and objectives

Patients at high risk of suffering cardiovascular events require medical treatment to optimize their lipid profile. The present analysis evaluates the lipid profiles among Spanish patients receiving statin therapy in the international DYSIS study.

Methods

DYSIS is a multinational cross-sectional study carried out in Canada and Europe (n = 22,063). In Spain, 3710 patients treated with statin therapy for at least 3 months were included. We compared data relating to demographic parameters and cardiovascular risk profile.

Results

Complete lipid profiles of 3617 patients were recorded. Regarding the high cardiovascular risk patients with complete lipid profiles (n = 2273), 78.9% had a disorder in at least one of the three main lipid parameters: low-density lipoprotein cholesterol (LDLc), high-density lipoprotein cholesterol (HDLc) and/or triglycerides. LDLc was not within target levels in 61.4% of these high risk patients; HDLc was abnormal in 25.3%, and triglycerides were elevated in 37.8%. Overall, LDLc was outside the target range in 63.1%, and 20.7% (n = 668) of those treated with statins were normal for all parameters.

Conclusions

Most patients in this study who received statin therapy, particularly those at high cardiovascular risk, were not at the normal lipid parameter levels according to cardiovascular guidelines. Although it is necessary to wait for the final results of current studies on the use of combined lipid-modifying treatments, the management of lipid levels in Spain still has potential for improvement.Full English text available from: www.revespcardiol.org     

Clinical impact of screening for sleep related breathing disorders in atrial fibrillation

Objective

The aim of this study was to quantify daytime symptoms in atrial fibrillation (AF) patients with and without sleep related breathing disorders (SRBD).

Background

SRBD are common in patients with AF but little is known about daytime symptoms among those with SRBD.

Methods

Patients with AF admitted to clinics of two tertiary referral hospitals for a variety of different cardiovascular diseases were screened with a trans-nasal airflow measurement device allowing measurement of the apnea-hypopnea-index. Data on cardiac risk factors, left ventricular ejection fraction (LVEF) and cardiac medication were collected. Presence of SRBD was defined as an AHI ≥ 15/h. The Epworth sleepiness scale (ESS) was used to quantify daytime symptoms.

Results

Of 102 screened patients 8 were excluded due to device malfunction (n = 1), dislocation of nasal cannula (n = 6), or hyperthyroidism (n = 1). Among the remaining 94 patients, 40 (43%) were diagnosed with SRBD. Patients with and without SRBD had similar age, body mass index, LVEF and cardiac medication. The prevalence of coronary artery disease was higher in patients with SRBD than in those without (50 vs. 17%; p = 0.0007). ESS score was low and similar in both groups (no SRBD: median 4, interquartile range (IQR) 2-4 vs. SRBD: 5, IQR 3-8; p = 0.14). Only 6/40 (5%) of the patients underwent overnight polysomnography and 2 (5%) started CPAP ventilation during follow-up.

Conclusions

Even though SRBD are common in patients with AF, the prevalence of daytime symptoms is rare. Consequently, most patients will not initiate CPAP ventilation after positive SRBD screening.     

Impact of cardiac rehabilitation on depression and its associated mortality

Purpose

Depression following major cardiac events is associated with higher mortality, but little is known about whether this can be reduced through treatment including cardiac rehabilitation and exercise training. We evaluated the impact of cardiac rehabilitation on depression and its associated mortality in coronary patients.

Patients and Methods

We evaluated 522 consecutive coronary patients (381 men, 141 women; aged 64 ± 10 years) enrolled in cardiac rehabilitation from January 2000 to July 2005 and a control group of 179 patients not completing rehabilitation. Depressive symptoms were assessed by questionnaire at baseline and following rehabilitation, and mortality was evaluated after a mean follow-up of 1296 ± 551 days.

Results

Prevalence of depressive symptoms decreased 63% following rehabilitation, from 17% to 6% (P <.0001). Depressed patients following rehabilitation had an over 4-fold higher mortality than nondepressed patients (22% vs 5%, P = .0004). Depressed patients who completed rehabilitation had a 73% lower mortality (8% vs 30%; P = .0005) compared with control depressed subjects who did not complete rehabilitation. Reductions in depressive symptoms and its associated mortality were related to improvements in fitness; however, similar reductions were noted in those with either modest or marked increases in exercise capacity.

Conclusion

In patients following major coronary events, cardiac rehabilitation is associated with both reductions in depressive symptoms and the excess mortality associated with it. Moreover, only mild improvements in levels of fitness appear to be needed to produce these benefits on depressive symptoms and its associated mortality.     

Diabetes and Coronary Heart Disease as Risk Factors for Mortality in Older Adults

Background

Type 2 diabetes has been described as a coronary heart disease (CHD) “risk equivalent.” We tested whether cardiovascular and all-cause mortality rates were similar between participants with prevalent CHD vs diabetes in an older adult population in whom both glucose disorders and preexisting atherosclerosis are common.

Methods

The Cardiovascular Health Study is a longitudinal study of men and women (n = 5784) aged ≥65 years at baseline who were followed from baseline (1989/1992-1993) through 2005 for mortality. Diabetes was defined by fasting plasma glucose ≥7.0 mmol/L or use of diabetes control medications. Prevalent CHD was determined by confirmed history of myocardial infarction, angina, or coronary revascularization.

Results

Following multivariable adjustment for other cardiovascular disease risk factors and subclinical atherosclerosis, CHD mortality risk was similar between participants with CHD alone vs diabetes alone (hazard ratio [HR] 1.04, 95% confidence interval [CI], 0.83-1.30). The proportion of mortality attributable to prevalent diabetes (population-attributable risk percent = 8.4%) and prevalent CHD (6.7%) was similar in women, but the proportion of mortality attributable to CHD (16.5%) as compared with diabetes (6.4%) was markedly higher in men. Patterns were similar for cardiovascular disease mortality. By contrast, the adjusted relative hazard of total mortality was lower among participants with CHD alone (HR 0.85, 95% CI, 0.75-0.96) as compared with those who had diabetes alone.

Conclusions

Among older adults, diabetes alone confers a risk for cardiovascular mortality similar to that from established clinical CHD. The public health burden of both diabetes and CHD is substantial, particularly among women.     

Preventing heart disease by controlling hypertension: impact of hypertensive subtype,stage, age,and sex

Background

Hypertension is related to significant morbidity and mortality rates from coronary heart disease (CHD). This report examines the relative and absolute impact on risk for CHD by controlling hypertension to high normal and optimal levels.

Methods

Among all subjects with untreated or inadequately treated hypertension in the National Health and Nutrition Examination Survey (NHANES) III who were 30 to 74 years of age and without prior CHD, the 10-year risk of CHD was calculated. With the use of sampling weights, the number of CHD events by age group, hypertension subtype (isolated diastolic hypertension [IDH], systolic-diastolic hypertension [SDH], and isolated systolic hypertension [ISH]), and stage of hypertension was estimated. Risk was recalculated and the number of events reestimated, assuming a reduction in blood pressure (BP) to high normal and optimal levels. The number and proportion (population-attributable risk, or PAR%) of events that could be prevented were determined from the differences in events and risk between uncontrolled and controlled BP levels. Derived from this was the number of persons needing treatment per CHD event prevented.

Results

Control of hypertension to high normal levels could prevent approximately one fifth (PAR = 19%) of CHD events in men and one third (PAR = 31%) of CHD events in women, whereas control to optimal levels may prevent 37% and 56% of CHD events, respectively (P < .01 for differences between men and women). Of CHD events that could be prevented, the greatest proportion occurred from controlling BP among older persons, men, and those with stage 1 hypertension (vs stages 2 and 3) or with ISH (vs IDH or SDH). The number of persons with hypertension needing treatment to prevent one CHD event ranged from 20.5 in men to 38.6 in women when controlled to high normal BP and 10.7 in men and 21.3 in women when controlled to optimal BP.

Conclusions

The greatest impact from control of hypertension occurs in older persons, men, and those with ISH, whereas the greatest PAR% occurred in women. Optimal control of BP could prevent more than one third of CHD events in men and more than half of events in women. Greater efforts to control hypertension in these populations may have a substantial impact in preventing CHD events.     

Disparities in the use of primary prevention and defibrillator therapy among blacks and women

Objectives

This study determines whether there are racial or gender disparities in the use of implantable cardioverter-defibrillator therapy for primary prevention of sudden cardiac death.

Background

Primary prevention of sudden death with implantable cardioverter-defibrillator therapy has been shown to improve survival for high-risk patients with coronary artery disease and left ventricular dysfunction.

Methods

The Center for Medicare and Medicaid Services Medicare database from the year 2002 was used to identify patients who were potential candidates for implantable cardioverter-defibrillator therapy on the basis of a combination of International Classification of Diseases, Ninth Revision, Clinical Modification codes that reflected the presence of an ischemic cardiomyopathy. This cohort was analyzed to determine which patients received implantable cardioverter-defibrillator therapy during the same year. The clinical characteristics of the potential implantable cardioverter-defibrillator candidates were compared with those who actually received an implantable cardioverter-defibrillator.

Results

A total 132 565 Medicare patients hospitalized during 2002 were identified as having an ischemic cardiomyopathy; 10 370 (8%) of these patients underwent implantable cardioverter-defibrillator implantation during the same year. The percentage of patients who underwent implantable cardioverter-defibrillator implantation was higher for men compared with women (10.2% vs 3.5%; P<.001) and whites compared with blacks (8.1 vs 5.4; P<.001). After multivariate analysis, age, gender, and race remained independent predictors of implantable cardioverter-defibrillator implantation. Women with an ischemic cardiomyopathy were 65% less likely to receive implantable cardioverter-defibrillator therapy compared with men (P<.001), and black patients were 31% less likely to receive implantable cardioverter-defibrillator therapy compared with patients of other races (P < .001).

Conclusions

Use of implantable cardioverter-defibrillator therapy for primary prevention of sudden death among the elderly population identified as having an ischemic cardiomyopathy was significantly lower among women compared with men, and among blacks compared with whites. Further exploration of gender and racial barriers to appropriate implantable cardioverter-defibrillator use for primary prevention is needed.