Kidney function and discrimination of cardiovascular risk in middle‐aged men

Objective. To define the optimal glomerular filtration rate (GFR) cut off for discriminating the risk of myocardial infarction or cardiovascular death. Design. Prospective longitudinal observational study. Setting. A community‐based cohort. Participants. A total of 2176 nondiabetic 50‐year‐old men without cardiovascular disease. Methods. The men were followed until age 70. GFR was estimated at baseline using the Cockcroft–Gault formula. The optimal GFR cut‐off points for discriminating risk of a fatal or nonfatal myocardial infarction and cardiovascular death were defined as the GFR levels maximizing integrated discrimination improvement (IDI). Main outcome measures. Fatal or nonfatal myocardial infarction, cardiovascular death. Results. During follow‐up, 264 men experienced a fatal or nonfatal myocardial infarction, and 218 died of cardiovascular disease. The IDI‐defined optimal GFR cut offs in this study were 98 mL min^?1 for discriminating myocardial infarction risk and 92 mL min^?1 for discriminating risk of cardiovascular death. In Cox proportional hazard models adjusting for established risk factors, the myocardial infarction risk was substantially higher in men with GFR below versus above 98 mL min^?1 [hazard ratio (HR) 1.7, 95% confidence interval (CI) 1.3–2.3, P < 0.001], and the risk of cardiovascular death was doubled in men with GFR below versus above 92 mL min^?1 (HR 2.1, 95% CI 1.5–3.0, P < 0.001). Conclusion. The GFR cut‐off point for optimal discrimination of cardiovascular risk in the general population may be higher than previously suggested.     

Hepatitis C virus coinfection independently increases the risk of cardiovascular disease in HIV‐positive patients

Patients infected with HIV are at increased risk for cardiovascular disease despite successful antiretroviral therapy. Likewise, chronic hepatitis C virus (HCV) infection is associated with extrahepatic complications, including cardiovascular disease. However the risk of cardiovascular disease has not been formally examined in HIV/HCV‐coinfected patients. A retrospective study was carried out to assess the influence of HCV coinfection on the risk of cardiovascular events in a large cohort of HIV‐infected patients recruited since year 2004. A composite event of cardiovascular disease was used as an endpoint, including myocardial infarction, angina pectoris, stroke or death due to any of them. A total of 1136 patients (567 HIV‐monoinfected, 70 HCV‐monoinfected and 499 HIV/HCV‐coinfected) were analysed. Mean age was 42.7 years, 79% were males, and 46% were former injection drug users. Over a mean follow‐up of 79.4 ± 21 months, 3 patients died due to cardiovascular disease, whereas 29 suffered a first episode of coronary ischaemia or stroke. HIV/HCV‐coinfected patients had a greater incidence of cardiovascular disease events and/or death than HIV‐monoinfected individuals (4% vs 1.2%, P = 0.004) and HCV‐monoinfected persons (4% vs 1.4%, P = 0.5). After adjusting for demographics, virological parameters and classical cardiovascular disease risk factors (smoking, hypertension, diabetes, high LDL cholesterol), both HIV/HCV coinfection (HR 2.91; CI 95%: 1.19–7.12; P = 0.02) and hypertension (HR 3.65; CI 95%: 1.34–9.94; P = 0.01) were independently associated with cardiovascular disease events and/or death in HIV‐infected patients. Chronic hepatitis C and hypertension are independently associated with increased cardiovascular disease risk in HIV‐infected patients. Therefore, treatment of chronic hepatitis C should be prioritized in HIV/HCV‐coinfected patients regardless of any liver fibrosis staging.     

Effect of pravastatin on cardiovascular events and mortality in 1516 women with coronary heart disease: results from the Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) study

Background The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) study showed that cholesterol-lowering therapy prevented further events in patients with coronary heart disease and average cholesterol levels. The aim of this subgroup analysis was to assess the effects of pravastatin in women. Methods A total of 1516 women (756 assigned to take pravastatin) in a cohort of 9014 patients with previous myocardial infarction or unstable angina and a baseline plasma cholesterol level of 4.0 to 7.0 mmol/L (155-271 mg/dL) were assigned to receive pravastatin (40 mg/d) or placebo. Major cardiovascular disease events in 6 years were measured. Results Women were at a lesser risk than men for death from any cause (10.3% vs 14.8%, P < .01), death from coronary heart disease (6.6% vs 8.6%, P = .04), and coronary revascularization (13.6% vs 16.2%, P = .05) and at a similar risk of myocardial infarction (9.2% vs 10.5%, P = .26), stroke (3.6% vs 4.7%, P =.11), and hospitalization for unstable angina (25.1% vs 24.5%, P = 0.90). Pravastatin significantly reduced the risk of all prespecified cardiovascular events in all LIPID patients. Relative treatment effects in women did not differ significantly from those in men (P > .05) for any events except hospitalization for unstable angina. There were too few events to demonstrate separately significant effects in women; the estimated relative risk reduction with pravastatin was 11% (95% CI -18%-33%) for coronary heart disease death or nonfatal myocardial infarction, 18% (95% CI -25%-46%) for coronary heart disease death, 16% (95% CI -19%-41%) for myocardial infarction, and 17% (95% CI -2%-33%) for coronary heart disease death, myocardial infarction, or coronary revascularization. Conclusions The study had the largest secondary-prevention female cohort studied thus far, but was not adequately powered to show separate effects in women. Nevertheless, the results were consistent with the main results of this and other trials in showing reduced risks with cholesterol-lowering treatment. (Am Heart J 2003;145:643-51.)     

Effect and cardiovascular safety of adding rosiglitazone to insulin therapy in type 2 diabetes: A meta‐analysis

Aims/Introduction

Recently, the use of rosiglitazone has been limited or withdrawn from the market as a result of cardiovascular risk. However, theoretically adding rosiglitazone to insulin could help insulin to decrease the glucose level. The present meta-analysis was designed to investigate the effect and safety of adding rosiglitazone to insulin therapy in type 2 diabetes.

Materials and Methods

We searched published and unpublished databases through to March 2012. Randomized controlled trials (RCTs) comparing rosiglitazone in combination with insulin (RSG + INS) vs insulin alone (INS) in type 2 diabetes with outcomes including glycated hemoglobin levels, insulin dose, lipid parameters, blood pressure, edema and cardiovascular adverse events were selected.

Results

Nine RCTs with durations of 24–26 weeks involving 1,916 patients were included. The RSG + INS group showed significantly decreased glycated hemoglobin levels by 0.89% (P < 0.00001) with an 8.48-U reduction in daily insulin dose (P <0.00001). However, the risks of hypoglycemia and edema were more frequent in the RSG+INS group (P < 0.0001; P = 0.03, respectively). Total cholesterol level was significantly increased in the RSG+INS group (P < 0.00001), but none of the high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol or triglyceride levels were significantly different between groups. There were no significant differences between groups with regard to the risks of myocardial infarction, heart failure, cardiovascular death or all-cause death.

Conclusions

Rosiglitazone could help type 2 diabetes patients with poorly controlled glucose with insulin therapy to decrease glucose levels and reduce their daily insulin dose, but at the cost of increased total cholesterol level, hypoglycemia and edema risk. Compared with insulin therapy, adding rosiglitazone to insulin did not increase the risks of myocardial infarction, heart failure, cardiovascular death or all-cause death.     

Einfluss der Thiazolidindione auf die diabetestypische Dyslipidämie

Patients with type 2 diabetes face a high risk of cardiovascular morbidity and mortality. In these patients a whole cluster of cardiovascular risk factors is found, with insulin resistance being the most significant. Thiazolidinediones, in activating the peroxisome proliferator-activated receptor gamma, lower the insulin resistance.The two thiazolidinediones available at present, pioglitazone and rosiglitazone, do not differ in their effects on insulin resistance or glucose metabolism. They do, however, reveal very different effects on the dyslipidemia that is characteristic of diabetes, with elevated triglycerides, low high-density lipoprotein (HDL) and atherogenic small dense lipoprotein (LDL) cholesterol. Inter alia, data from a comparative study show that pioglitazone improves diabetic dyslipidemia more efficaciously than rosiglitazone. Despite similar effects on hyperglycemia (HbA1c reduction by 0.6% and 0.7%), both thiazolidinediones differ significantly in their effects on triglycerides (pioglitazone -51.9 mg/dl; rosiglitazone +13.1 mg/dl; p < 0.001), HDL cholesterol (pioglitazone +5.2 mg/dl; rosiglitazone +2.4 mg/dl; p < 0.001) and LDL cholesterol (pioglitazone +12.3 mg/dl; rosiglitazone +21.3 mg/dl; p < 0.001). LDL particle concentration was reduced with pioglitazone (n7.85%) and increased with rosiglitazone (+12%; p > 0.001).Only for pioglitazone the PROactive study, a major outcome trial, documented a significant reduction of cardiovascular outcomes. The principal secondary endpoint of death from any cause, nonfatal myocardial infarction (excluding silent myocardial infarction) or stroke was significantly reduced (16%; p = 0.027).The correlation of improved dyslipidemia, reconfirmed by PROactive, and cardiovascular prevention is yet to be resolved. However, as long as the vascular protective mechanism of pioglitazone is not conclusively resolved, findings may not be transmitted to other thiazolidinediones. For these substances, results from major outcome studies are to be required that prove a reduction of the cardiovascular risk.     

Uncertain effects of rosiglitazone on the risk for myocardial infarction and cardiovascular death

A recent, widely publicized meta-analysis of 42 clinical trials concluded that rosiglitazone was associated with an approximately 43% increased risk for myocardial infarction and an approximately 64% increased risk for cardiovascular death. The sensitivity of these conclusions to several methodological choices was not assessed. The meta-analysis was not based on a comprehensive search for all studies that might yield evidence about rosiglitazone's cardiovascular effects. Studies were combined on the basis of a lack of statistical heterogeneity, despite substantial variability in study design and outcome assessment. The meta-analytic approach that was used required the exclusion of studies with zero events in the treatment and control groups. Alternative meta-analytic approaches that use continuity corrections show lower odds ratios that are not statistically significant. We conclude that the risk for myocardial infarction and death from cardiovascular disease for diabetic patients taking rosiglitazone is uncertain: Neither increased nor decreased risk is established.     

Staged versus index procedure complete revascularization in ST‐elevation myocardial infarction: A meta‐analysis

Background

Complete revascularization of patients with ST‐elevation myocardial infarction and multivessel coronary artery disease reduces adverse events compared to infarct‐related artery only revascularization. Whether complete revascularization should be done as multivessel intervention during index procedure or as a staged procedure remains controversial.

Method

We performed a meta‐analysis of randomized controlled trials comparing outcomes of multivessel intervention in patients with ST‐elevation myocardial infarction and multivessel coronary artery disease as staged procedure versus at the time of index procedure. Composite of death or myocardial infarction was the primary outcome. Mantel‐Haenszel risk ratios were calculated using random effect model.

Results

Six randomized studies with a total of 1126 patients met our selection criteria. At a mean follow‐up of 13 months, composite of myocardial infarction or death (7.2% vs 11.7%, RR: 1.66, 95%CI: 1.09‐2.52, P = 0.02), all cause mortality (RR: 2.55, 95%CI: 1.42‐4.58, P < 0.01), cardiovascular mortality (RR: 2.8, 95%CI: 1.33‐5.86, P = 0.01), and short‐term (<30 days) mortality (RR: 3.54, 95%CI: 1.51‐8.29, P < 0.01) occurred less often in staged versus index procedure multivessel revascularization. There was no difference in major adverse cardiac events (RR: 1.14, 95%CI: 0.88‐1.49, P = 0.33), repeat myocardial infarction (RR: 1.14, 95%CI: 0.68‐1.92, P = 0.61), and repeat revascularization (RR: 0.92, 95%CI: 0.66‐1.28, P = 0.62).

Conclusion

In patients with ST‐elevation myocardial infarction and multivessel coronary artery disease, a strategy of complete revascularization as a staged procedure compared to index procedure revascularization results in reduced mortality without an increase in repeat myocardial infarction or need for repeat revascularization.

     

Percutaneous coronary intervention of moderate to severe calcified coronary lesions: Insights from the National Heart,Lung, and Blood Institute Dynamic Registry

Objectives: To evaluate the efficacy and safety of drug eluting stents (DES) when compared with bare metal stents (BMS) in patients with moderate to severe calcified coronary lesions. Background: Calcified coronary lesions present unique technical challenges during percutaneous coronary intervention (PCI) and it is not known if DES are as safe and as effective in the presence of calcium, as randomized trials typically exclude this common patient subset. Methods: We evaluated patients with PCI of a single calcified lesion enrolled across five recruitment waves in the National Heart, Lung, and Blood Institute Dynamic Registry between 1997 and 2006. Patients were divided into two groups based on the stent type‐ BMS and DES. The primary efficacy outcome was the need for repeat revascularization at 1 year and the primary safety outcome was a composite of death and myocardial infarction at 1 year. Results: Among the 1,537 patients included in the analysis, 884 (57%) underwent PCI with BMS and 653 (43%) with DES. DES use was associated with a significant reduction in the risk of repeat revascularization (10.0% vs. 15.3%; P = 0.003) with no significant higher risk of primary safety outcome (9.3% vs. 10.5%; P = 0.45) when compared to the BMS group. In a propensity score adjusted analysis, DES use was associated with a significantly lower risk in repeat revascularization (HR = 0.57; 95% CI 0.40–0.82; P = 0.002) and no significant difference in the risk of death and myocardial infarction (HR = 0.78; 95% CI 0.53–1.15; P = 0.20) compared to BMS group. Conclusion: In this large multicenter registry of patients with a moderate to severe calcified coronary lesion, use of DES compared to BMS was associated with significant reduction in the risk of repeat revascularization without any increase in death and myocardial infarction. © 2010 Wiley‐Liss, Inc.     

Effect of intensive blood pressure control in patients with type 2 diabetes mellitus over 9 years of follow‐up: A subgroup analysis of high‐risk ACCORDION trial participants

Although guidelines recommend strict blood pressure (BP) control in patients with type 2 diabetes mellitus (T2DM) and elevated cardiovascular risk, the long‐term effects of this approach are unknown. We investigated the effect of intensive BP control on clinical outcomes in patients with T2DM over 9 years of follow‐up. We included Action to Control Cardiovascular Risk in Diabetes ‐ Blood Pressure participants in the standard glucose control arm who had established cardiovascular disease, chronic kidney disease, were ≥75 years of age or who had a 10‐year coronary heart risk ≥15%. Participants were randomized to either intensive (systolic BP < 120 mm Hg) or standard (systolic BP < 140 mm Hg) BP control for an average of 5 years. Observational follow‐up occurred for an average of 4 years thereafter. After an average total follow‐up of 9 years, intensive BP control reduced the composite of cardiovascular death, nonfatal myocardial infarction and nonfatal stroke by 25% (hazard ratio, 0.75; 95% confidence interval, 0.60‐0.95; P = .02). The overall benefit was driven by a reduction in nonfatal myocardial infarction (P = .01). In this post‐hoc analysis, the benefits of a fixed‐duration intensive BP control intervention in patients with T2DM persisted throughout 9 years of follow‐up.     

The impact of micro troponin leak on long‐term outcomes following elective percutaneous coronary intervention

Objective: To evaluate the clinical impact of microleaks of troponin, which are below the reference standard defining troponin elevation, on cardiovascular outcomes in stable coronary patients undergoing elective percutaneous coronary intervention (PCI). Background: Troponin elevation, either pre‐ or post‐PCI, has been shown to predict poor cardiovascular outcomes. However, troponin measurements that are above the limit of detection but below the 99th percentile limit defining elevation (“microleak”) have uncertain clinical significance. Methods: We assessed subsequent myocardial infarction (MI) and death over a mean follow‐up of 4.2 years in 2,272 patients undergoing elective PCI, where baseline troponins were normal and follow‐up troponins were obtained 12–24 hr post‐PCI. Patients were divided into three groups based on post‐PCI troponin levels: Group 1 (n = 1,313) nondetectable; group 2 (n = 587) microleak, and group 3 (n = 372) elevated suggesting myocardial necrosis. Results: The combined endpoint of MI and death was similar in groups 2 and 3 (50.3 vs. 51.9%, respectively, P = NS), which was significantly more than group 1 patients (35.6%, P < 0.01) over the follow‐up period. Multivariate analysis of patients in groups 1 and 2 demonstrated that troponin microleak was an independent predictor of MI and death (P = 0.01). Conclusions: Microleak of troponin following elective PCI suggests myocardial injury and predicts an increased risk of subsequent MI and death. Troponins should be routinely assessed following PCI, and preventive therapies are needed to reduce micro and macro troponin elevation in the PCI setting. © 2009 Wiley‐Liss, Inc.     

Atherosclerotic heart disease: prevalence and risk factors in hospitalized men with haemophilia A

Summary. Atherosclerotic heart disease (ASHD) is a common cause of morbidity and mortality in Western society. Few studies have determined prevalence and predictors of ASHD in haemophilia (HA), a population whose survival is improving with safer blood products and effective treatments for AIDS and hepatitis C. The purpose of this study was to determine prevalence and factors associated with ASHD in haemophilia A patients in Pennsylvania. The prevalence of ASHD (myocardial infarction, angina and coronary disease), cardiac catheterization, coronary angiography, co‐morbidities and in‐hospital mortality were assessed on statewide ASHD discharge data, 2001–2006, from the Pennsylvania Health Care Cost Containment Council (PHC4). The prevalence of haemophilia ASHD admissions fluctuated between 6.5% and 10.5% for 2001–2006, P = 0.62. Compared with HA without ASHD, HA with ASHD were older and more likely to be hypertensive, hyperlipidemic and diabetic, all P < 0.0001, with greater severity of illness, P = 0.013. In contrast, HA and non‐HA with ASHD had similar rates of hypertension, diabetes and ICD‐9 specified ischaemic heart disease, including acute myocardial infarction (MI), P = 0.39, old MI, P = 0.47 and angina, P = 0.63. Rates of catheterization and angiography, P = 0.06 and P = 0.07, were marginally lower, but primary circulatory system admitting diagnoses, P = 0.29, were similar between HA and non‐HA ASHD groups, as was length of stay, P = 0.14, severity of illness, P = 0.64, and in‐hospital deaths, P = 0.75. Haemophilia patients with ASHD have similar cardiovascular risk factors, admitting diagnoses, severity of illness and in‐hospital mortality as the general population. These findings suggest that cardiovascular prevention measures should be promoted in haemophilia.     

Timing,mode, and predictors of death after direct angioplasty for acute myocardial infarction

The timing and mechanisms of early (30 day) mortality in 330 consecutive patients treated with direct angioplasty less than 12 hr after onset of myocardial infarction without antecedent thrombolysis were studied. There were 38 deaths (11.5% of pts), with a majority being due to cardiogenic shock (76%). Other causes included acute closure (11 %), death after emergency bypass surgery (5%), ventricular arrhythmias (5%), and respiratory failure (3%). No deaths from stroke or cardiac rupture were seen, in contrast to trials of thrombolytic agents. Most deaths were seen early, with 47% occurring within 1 day, 35% from days 2–7, and 18% from days 8–30. Death from cardiogenic shock was the most common cause of death throughout this period: 83% of deaths in days 0–3, 88% of deaths in days 4–6, and 43% of deaths in days 8–30. Significant predictors of early death included older age (P <.0001), multi-vessel disease (P <.05), direct angioplasty failure (P <.05), reduced ejection fraction (P <.0001), and anterior myocardial infarction (P <.0005). Gender, prior myocardial infarction, and prior bypass surgery did not affect mortality. Cardiogenic shock is the most common cause of early death after direct angioplasty for myocardial infarction. Patients with one or more risk factors for early death may benefit from additional myocardial salvage or revascularization efforts in the early postinfarct period. Certain causes of death after direct angioplasty (cardiac, rupture, stroke) appear to be less common than data reported for lytic therapy for myocardial infarction. © 1995 Wiley-Liss, Inc.     

Effects of omega-3 fatty acid on major cardiovascular outcomes: A systematic review and meta-analysis

Background:The effects of omega-3 fatty acid on cardiovascular health obtained inconsistent results. A systematic review and meta-analysis were therefore conducted to assess the effects of omega-3 fatty acid supplementation for primary and secondary prevention strategies of major cardiovascular outcomes.Methods:The databases of PubMed, Embase, and the Cochrane library were systematically searched from their inception until September 2020. Relative risks (RRs) with 95% confidence intervals were used to assess effect estimates by using the random-effects model.Results:Twenty-eight randomized controlled trials involving 136,965 individuals were selected for the final meta-analysis. Omega-3 fatty acid was noted to be associated with a lower risk of major cardiovascular events (RR, 0.94; 95% CI, 0.89–1.00; P = .049) and cardiac death (RR, 0.92; 95% CI, 0.85–0.99; P = .022). However, no significant differences was noted between omega-3 fatty acid and the control for the risks of all-cause mortality (RR, 0.97; 95% CI, 0.92–1.03; P = .301), myocardial infarction (RR, 0.90; 95% CI, 0.80–1.01; P = .077), and stroke (RR, 1.02; 95% CI, 0.94–1.11; P = .694).Conclusions:Major cardiovascular events and cardiac death risks could be avoided with the use of omega-3 fatty acid. However, it has no significant effects on the risk of all-cause mortality, myocardial infarction, and stroke.     

Long-term clinical outcomes of drug-eluting stents vs. bare-metal stents in Chinese geriatric patients

Background & Objective Little is known about the relative efficacies of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and bare-metal stents (BMS) in elderly patients. The objective of this study was to evaluate the clinical outcome for geriatric patients who received either DES or BMS. Methods From January 2002 to October 2005, 199 consecutive Chinese geriatric patients (≥ 75 years old) underwent PCI with coronary DES or BMS implantation at our institution. We analyzed the major clinical end points that included all-cause mortality, cardiovascular death, myocardial infarction, target lesion revascularization (TLR), stent thrombosis, and bleeding complications. Results The three-year cumulative rates of all-cause mortality, cardiovascular death, and myocardial infarction were significantly lower in the DES group (6.3%, 3.6%, 5.4%) compared with the BMS group (16.2%, 11.5%, 14.9%; P < 0.05). No significant differences were found in the three-year cumulative rate for target lesion revascularization (6.3% vs. 4.6%, P = 0.61) or stent thrombosis (3.6% vs. 2.3%, P = 0.70). Likewise, there were no statistically significant differences in the cumulative rate for intracranial hemorrhage, or major and minor hemorrhage at three years. Conclusions DES-based PCI was associated with a significant reduction in the three-year cumulative rate of all-cause mortality, cardiovascular death, and myocardial infarction compared with BMS, without increased risk of TLR, stent thrombosis, or bleeding complications at three years in this group of Chinese geriatric patients.     

Sex Differences in Outcomes After Myocardial Infarction in the Community

PurposePrior studies observed that women experienced worse outcomes than men after myocardial infarction but did not convincingly establish an independent effect of female sex on outcomes, thus failing to impact clinical practice. Current data remain sparse and information on long-term nonfatal outcomes is lacking. To address these gaps in knowledge, we examined outcomes after incident myocardial infarction for women compared with men.MethodsWe studied a population-based myocardial infarction incidence cohort in Olmsted County, Minnesota, between 2000 and 2012. Patients were followed for recurrent myocardial infarction, heart failure, and death. A propensity score was constructed to balance the clinical characteristics between men and women; Cox models were weighted using inverse probabilities of the propensity scores.ResultsAmong 1959 patients with incident myocardial infarction (39% women; mean age 73.8 and 64.2 for women and men, respectively), 347 recurrent myocardial infarctions, 464 heart failure episodes, 836 deaths, and 367 cardiovascular deaths occurred over a mean follow-up of 6.5 years. Women experienced a higher occurrence of each adverse event (all P <0.01). After propensity score weighting, women had a 28% increased risk of recurrent myocardial infarction (hazard ratio: 1.28, 95% confidence interval: 1.03-1.59), and there was no difference in risk for any other outcomes (all P >0.05).ConclusionAfter myocardial infarction, women experience a large excess risk of recurrent myocardial infarction but not of heart failure or death independently of clinical characteristics. Future studies are needed to understand the mechanisms driving this association.     

PPAR‐γ Agonism for Cardiovascular and Renal Protection

Diabetes mellitus is an established risk factor for cardiovascular disease and the leading cause of end‐stage renal disease in the Western World. Thiazolidinediones (TZDs) represent a class of antidiabetic agents that exert their glucose‐lowering effects by reducing insulin resistance, through stimulation of a type of nuclear receptor, called peroxisome proliferator‐activated receptor‐γ. Apart from improving glycemic control, TZDs were shown to exert beneficial effects on several components of the metabolic syndrome and cardiovascular risk markers. Furthermore, background and human studies have shown that TZDs reduce urinary albumin and protein excretion and interfere with most of the pathogenentic pathways involved in the development and progression of diabetic nephropathy. On the other hand, currently used TZDs have side effects, most important of which is fluid retention leading to wait gain and heart failure deterioration. With regards to cardiovascular outcomes, the anticipated benefit of TZDs was demonstrated for pioglitazone, whereas a series of previous meta‐analyses linking rosiglitazone treatment with increased risk of myocardial infarction and cardiovascular death raised uncertainty around the cardiovascular safety of rosiglitazone. This article will discuss the effects of TZDs on established and emerging cardiovascular risk factors, the data on possible beneficial renal effects of these compounds, and the existing evidence from large‐scale clinical trials and meta‐analyses on their effects on cardiovascular outcomes, aiming to provide an overview of the cardio‐ and renoprotective properties of these drugs.     

Risk Estimation in Type 2 Myocardial Infarction and Myocardial Injury: The TARRACO Risk Score

BACKGROUND

Despite adverse prognoses of type 2 myocardial infarction and myocardial injury, an effective, practical risk stratification method remains an unmet clinical need. We sought to develop an efficient clinical bedside tool for estimating the risk of major adverse cardiovascular events at 180 days for this patient population.

Moving toward new statin guidelines in a post-JUPITER world: Principles to consider

The recently completed study Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) demonstrates that statin therapy reduces vascular events in apparently healthy men and women with low levels of low-density lipoprotein cholesterol (mean, 104 mg/dL) who are at elevated risk due to high-sensitivity C-reactive protein levels greater than 2 mg/L. Among 17,802 trial participants, rosuvastatin resulted in a 44% reduction in the primary end point of all vascular events (P < 0.00001), a 54% reduction in myocardial infarction (P = 0.0002), a 48% reduction in stroke (P = 0.002), a 46% reduction in need for arterial revascularization (P < 0.001), and a 20% reduction in all-cause mortality (P = 0.02). All subgroups with elevated high-sensitivity C-reactive protein benefited, including those traditionally considered to be at low risk, such as women, nonsmokers, and those with Framingham risk scores less than 10%. Absolute risk reductions within JUPITER result in a number needed to treat at 5 years of 25, a value comparable or superior to that of other interventions routinely used in primary prevention, including statin therapy among those with hyperlipidemia. Although lifestyle interventions remain critical, the screening and treatment strategy tested in JUPITER is likely to impact on new guidelines for cardiovascular disease prevention.     

QT Interval and the Risk of Myocardial Infarction and All-Cause Death: A Cohort Study

QT Interval and the Risk of Myocardial Infarction and All‐Cause Death . Introduction: The relationship between QT interval and cardiovascular disease is controversial. Methods: All male residents aged 20–61 years and female residents aged 20–56 years were invited to the Tromsø Study in 1986–1987. A total of 15,558 participants free of heart disease were prospectively followed over 20 years for myocardial infarction and death. QT interval at baseline was measured on lead I of the electrocardiogram. Hazard ratios (HRs) with 95% confidence intervals (CIs) per standard deviation change in QT interval were calculated using a Cox regression model. Results: We identified 756 cases of myocardial infarction and 1,183 all‐cause deaths. Prolonged QT interval was present in 792 (5%) participants. QT interval was not associated with increased risk of myocardial infarction (HR: 0.95, 95% CI: 0.84–1.07, after adjustment for potential confounders). Heart‐rate‐corrected QT interval was a significant predictor for all‐cause death in men (HR: 1.15, 95% CI: 1.03–1.29), but not in women (HR: 1.04, 95% CI: 0.91–1.18), after adjustment for potential confounders. Conclusions: The findings suggest that the previously observed relationship between QT interval and increased risk of cardiovascular death is not mediated by increased risk of myocardial infarction. The clinical utility of the QT interval to identify individuals at high risk for coronary events is limited in a general population without prior heart disease. (J Cardiovasc Electrophysiol, Vol. 23, pp. 846‐852, August 2012)     

A prospective study on cardiovascular events after acute pulmonary embolism

Aims To evaluate the incidence of cardiovascular events in thelong-term clinical course of patients with a first episode ofsymptomatic, objectively confirmed pulmonary embolism. Methods and results Three hundred and sixty patients with afirst episode of pulmonary embolism were included in a prospectivestudy: 209 with idiopathic pulmonary embolism and 151 with pulmonaryembolism associated with transient risk factors. The study outcomeswere cardiovascular events (recurrent venous thrombo-embolism,acute myocardial infarction, stroke, sudden otherwise unexplaineddeath), cardiovascular death, and death due to any cause. Themedian follow-up was 38 months. Sixty-four patients had at leastone cardiovascular event (5.5% patient-year). Recurrent venousthrombo-embolism occurred in 45 patients (3.9% patient-year),acute myocardial infarction in 12 patients (1.0% patient-year),stroke in six patients (0.5% patient-year), and sudden otherwiseunexplained death in four patients (0.3% patient-year). A cardiovascularevent occurred in 47 patients with idiopathic pulmonary embolism(7.5% patient-year) and in 17 patients with pulmonary embolismassociated with transient risk factors (3.1% patient-year) (RR2.0; 95% CI 1.20–3.34; P=0.006). Twenty patients withidiopathic pulmonary embolism (3.2% patient-year) and two patientswith pulmonary embolism associated with transient risk factors(0.4% patient-year) presented an arterial cardiovascular event(RR 7.2; 95% CI 1.71–30.45; P=0.001). Thirty-three patientsdied (9.2%). Cardiovascular mortality and cancer mortality accountedfor 42.4 and 21.2% of overall mortality, respectively. Idiopathicpulmonary embolism was an independent predictor of cardiovascularevents after adjusting for age. Conclusions Cardiovascular events are more common in patientswith idiopathic pulmonary embolism than in patients with pulmonaryembolism associated with transient risk factors. Cardiovascularevents are the major cause of death in patients with idiopathicpulmonary embolism.