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.     

Incidence and mortality of heart failure: A community-based study

Background

Data on the incidence and mortality of heart failure (HF) in community-based populations of developed countries are limited. We estimated the trends of the incidence and, the mortality of HF.

Methods

Prospective population-based study in a white, low-middle class Mediterranean community of 267,231 inhabitants in Spain. Participants were all the patients (= > 14 years), newly diagnosed with HF (4793), according to the Framingham criteria, from January 1, 2000 through December 31, 2007. Main outcome were incidence and mortality following an HF diagnosis.

Results

Incidence of HF increased among both men and women, and among persons with systolic and non-systolic HF. Incidence of HF increased from 296 per 100,000 person-years in 2000 to 390 per 100,000 person-years in 2007 (RR 1.32, CI 95% 1.27-13.7, P < .01). Although, risk-adjusted mortality declined from 2000 to 2007, the prognosis for patients with newly diagnosed HF remains poor. In 2007, risk-adjusted 30-day, 1-year, and 4-years mortality was 12.1%, 28.8%, and 61.4%, respectively. Incidence and mortality of systolic HF were higher than those of non-systolic HF (P < 0.05).

Conclusions

During the last 8 years, in a white, middle class population of the south of Europe, the increased incidence and the decreased mortality of heart failure have resulted in an increased prevalence of heart failure. Incidence and mortality of systolic heart failure were higher than those of non-systolic heart failure.     

Human plasma complement C3 is independently associated with coronary heart disease, but only in heavy smokers (the CODAM study)

Background

Complement C3 is an emerging risk factor for coronary heart disease (CHD) and is particularly increased in the metabolic syndrome. A direct effect of smoking on structure and function of complement C3 has been suggested.

Hypothesis

Smoking behavior may affect the cardiovascular risk that is associated with plasma complement C3.

Methods

The association between plasma C3 and CHD was studied in the CODAM (Cohort on Diabetes and Atherosclerosis Maastricht) study population (n = 562, 61% male) with examination of effect modification by smoking.

Results

The overall prevalence of CHD was 23.3%. Higher plasma C3 levels were associated with a higher CHD prevalence, and there was a significant interaction with heavy smoking (p = 0.01). In never & light smokers, the univariate OR for CHD per 1 s.d. (0.33 g/L) increase in C3 was 1.09 [95% confidence interval (CI) 0.85-1.41] (p = 0.505) whereas in heavy smokers it was 2.05 [1.43-2.93] (p < 0.001). The association in the group of heavy smokers remained significant (OR 2.38 [1.54-3.68], p < 0.001) after adjustment for traditional risk factors for cardiovascular disease and also after further adjustment for other cardiometabolic risk factors, i.e. the metabolic syndrome, CRP and insulin resistance (HOMA2IR) (OR C3 between 2.16 and 2.29, all p ≤ 0.001).

Conclusion

Human plasma complement C3 is associated with prevalent CHD, but only in heavy smokers, and this association is independent of important metabolic cardiovascular risk factors.     

Body mass, fitness and survival in veteran patients: another obesity paradox?

Purpose

The paradox of obesity in patients with heart failure (HF) also has been observed in non-HF veteran patients. Veterans had to have met military fitness requirements at the time of their enlistment. Therefore, we assessed the relation of body mass index (BMI) to mortality in a clinical cohort of non-HF veterans, adjusting for fitness.

Methods

After excluding HF patients (n = 580), the study population comprised 6876 consecutive patients (mean age 58 [±11] years) referred for exercise testing. Patients were classified by BMI category: normal weight (BMI 18.5-24.9 kg/m²), overweight (BMI 25.0-29.9 kg/m²), or obese (BMI ≥30.0 kg/m²). The association between BMI, fitness, other clinical variables, and all-cause mortality was assessed by Cox proportional hazards analysis.

Results

During a mean (±SD) follow-up of 7.5 ± 4.5 years, a total of 1571 (23%) patients died. In a multivariate analysis including clinical, risk factor, and exercise test data, higher BMI was associated with better survival. Expressing the data by BMI category, obese patients were 22% less likely to die (relative risk [RR] = 0.78, 95% confidence interval [CI], 0.69-0.90, P <.001) than patients of normal weight. After further adjustment for cardiorespiratory fitness (CRF), this relationship strengthened such that mortality risk for the obese category was 35% lower (RR = 0.65, 95% CI, 0.57-0.76, P <.001), versus the normal weight category.

Conclusions

As has been observed in HF patients, obesity was associated with a substantially lower mortality risk in a clinical population of non-HF veterans. Higher CRF and obesity in later life may account for an obesity paradox in this population.     

Population-based study of out-of-hospital sudden cardiovascular death: incidence and causes of death in middle-aged adults

Introduction and objectives

The data of mortality of out-of-hospital sudden cardiovascular death in middle-aged adults have been poorly characterized. The aim of this study is to analyze their epidemiological, clinical and pathological characteristics.

Methods

Population observational study of all cardiovascular deaths in people 35-49 years old in Vizcaya between 2003 and 2008. The data of Mortality Register and Forensic Pathology Service were analyzed. The out-of-hospital sudden deaths subjected to forensic autopsy were identified.

Results

216 of the 465 cardiovascular deaths were sudden deaths. The main cause was ischemic heart disease (N = 140/216). Other conditions were: cardiomyopathies (N = 32), cerebrovascular diseases (N = 19) and sudden arrhythmic death in structurally normal hearts (N = 10). The causes varied significantly in relation to gender and age. Ten percent had been diagnosed in life of a cardiovascular disease; 66% had cardiovascular risk factors and 27% had recently consumed ethanol and/or abuse drugs. The incidence of sudden death was 13.2/100,000 inhabitants/year, representing 46% of cardiovascular deaths. The incidence was 3.77 times higher in males than in females and increased with the age.

Conclusions

The incidence of sudden death in Vizcaya was lower than in other industrialized countries. In middle-aged adults out-of-hospital sudden cardiac death is the first manifestation of disease in half of all cardiovascular deaths. One challenge in prevention is the development of strategies to identify the highest risk people within the general population at low risk. Studies based on forensic autopsies improve our understanding of cardiovascular mortality.Full English text availale from: www.revespcardiol.org     

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.     

Higher Cardiovascular Disease Prevalence and Mortality among Younger Blacks Compared to Whites

Background

Blacks have higher rates of cardiovascular disease than whites. The age at which these differential rates emerge has not been fully examined.

Objective

We examined cardiovascular disease prevalence and mortality among black and white adults across the adult age spectrum and explored potential mediators of these differential disease prevalence rates.

Methods

We conducted a cross-sectional analysis of National Health and Nutrition Examination Survey data from 1999-2006. We estimated age-adjusted and age-specific prevalence ratios (PR) for cardiovascular disease (heart failure, stroke, or myocardial infarction) for blacks versus whites in adults aged 35 years and older and examined potential explanatory factors. From the National Compressed Mortality File 5-year aggregate file of 1999-2003, we determined age-specific cardiovascular disease mortality rates.

Results

In young adulthood, cardiovascular disease prevalence was higher in blacks than whites (35-44 years PR 1.9; 95% confidence interval [CI], 1.1-3.4). The black-white PR decreased with each decade of advancing age (P for trend = .04), leading to a narrowing of the racial gap at older ages (65-74 years PR 1.2; 95% CI, 0.8-1.6; ≥75 years PR 1.0; 95% CI, 0.7-1.4). Clinical and socioeconomic factors mediated some, but not all, of the excess cardiovascular disease prevalence among young to middle-aged blacks. Over a quarter (28%) of all cardiovascular disease deaths among blacks occurred in those aged <65 years, compared with 13% among whites.

Conclusions

Reducing black/white disparities in cardiovascular disease will require a focus on young and middle-aged blacks.     

Mortality rates and modes of death in heart failure patients with reduced versus preserved systolic function

Background

There are conflicting reports regarding the characteristics and mortality rates of heart failure patients with preserved (HFPSF) vs. reduced systolic left ventricular function (SHF).

Methods

We evaluated the clinical profiles, mortality rates and modes of death in 481 consecutive symptomatic heart failure patients. In 317(66%) patients LVEF was < 40% (SHF), and in 164(34%) LVEF ≥ 40% (HFPSF).

Results

Compared to the HFPSF group, SHF patients were predominantly younger males with ischemic etiology and less cardiovascular comorbidities such as obesity, hypertension, diabetes mellitus and atrial fibrillation. Over a mean follow-up period of 2 years, 148(31%) patients died. Overall mortality was similar between the two groups: 53(32%) HFPSF patients and 95(30%) SHF patients died (p = 0.6), even after adjusting for baseline variables, including age, gender and comorbidities (hazard ratio 1.09; 95% confidence interval 0.74-1.61; p = 0.67). In contrast to the similar mortality rates, the modes of death were different. SHF patients had higher death rates due to pump failure compared to the HFPSF group {32/95(34%) vs. 9/53(17%) patients, p = 0.03}. A trend towards higher rate of non-cardiac death was observed in HFPSF group {33/53(62%) patients vs. 45/95(47%) patients, respectively, p = 0.08}. The prevalence of arrhythmic death was similar in both groups {17/95(18%) vs. 10/53(19%) patients, p = 0.9}.

Conclusions

Although the characteristics of HFPSF and SHF patients are distinctively different, the mortality rates are similar. The mode of death is different among the two groups of patients, as pump failure death is significantly higher in SHF patients, while non-cardiac mortality is more prevalent in HFPSF patients.     

Prevalence and clinical profile and management of peripheral arterial disease in elderly patients with diabetes

Introduction

Peripheral arterial disease (PAD) increases with age and diabetes. The aim of this study was to assess the prevalence of PAD in an elderly population with diabetes.

Methods

This multicenter and cross-sectional study included patients > 70 years, with an established diagnosis of diabetes. PAD was defined as those patients with a history of revascularization or amputation due to ischemia, or a pathological ankle-brachial index (ABI). Adequate blood pressure (BP), LDL cholesterol and HbA1c control were considered as < 130/80 mm Hg, < 100 mg⁄dL and < 7.0%, respectively.

Results

A total of 1462 patients were included. The most frequent cardiovascular risk factor and cardiovascular disease were hypertension (80.37%) and PAD (60.60% overall; 83.2% of those assisted by vascular surgeons vs 31.9% of those attended by other medical specialists; p < 0.001), respectively. However, when ABI was measured, 70.99% of the study population had PAD (80.2% of those assisted by vascular surgeons vs 59.6% of those attended by other medical specialists; p < 0.001). The predictors for a pathological ABI included male gender, smoking, dyslipidemia, family history of premature cardiovascular disease, sedentary lifestyle, diabetic-related complications, heart and cerebrovascular diseases. Although risk factors control was very poor, it was even lower in patients with PAD.

Conclusions

The prevalence of PAD is high in diabetic elderly patients. The concomitance with other risk factors and cardiovascular diseases was very high. The ABI allowed increasing the diagnosis of PAD.     

Glyburide increases risk in patients with diabetes mellitus after emergent percutaneous intervention for myocardial infarction — A nationwide study

Background

Sulfonylureas have been linked to an increased cardiovascular risk by inhibition of myocardial preconditioning. Whether individual sulfonylureas affect outcomes in diabetic patients after emergent percutaneous coronary intervention for myocardial infarction is unknown.

Methods

All Danish patients receiving glucose-lowering drugs admitted with myocardial infarction between 1997 and 2006 who underwent emergent percutaneous coronary intervention were identified from national registers. Multivariable Cox proportional hazards models were used to analyze the risk of cardiovascular mortality and morbidity associated with sulfonylureas.

Results

A total of 926 patients were included and 163 (17.6%) patients died during the first year of which 155 (16.7%) were cardiovascular deaths. The most common treatment was sulfonylureas which were received by 271 (29.3%) patients, and 129 (13.9%) received metformin. Cox proportional hazard regression analyses adjusted for age, sex, calendar year, comorbidity and concomitant pharmacotherapy showed an increased risk of cardiovascular mortality (hazard ratio [HR] 2.91, 95% confidence interval [CI] 1.26-6.72 ; p = 0.012), cardiovascular mortality and nonfatal myocardial infarction (HR 2.69 , 95% CI 1.21-6.00; p = 0.016), and all-cause mortality (HR 2.46, 95% CI 1.11-5.47; p = 0.027), respectively, with glyburide compared to metformin.

Conclusions

Glyburide is associated with increased cardiovascular mortality and morbidity in patients with diabetes mellitus undergoing emergent percutaneous coronary intervention after myocardial infarction. Early reperfusion therapy is the mainstay in modern treatment of myocardial infarction and the time may have come to discard glyburide in favour of sulfonylureas that do not appear to confer increased cardiovascular risk.     

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

Objective

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

Methods

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

Results

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

Conclusion

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

Airway obstruction in never smokers: results from the Third National Health and Nutrition Examination Survey

Purpose

Chronic obstructive pulmonary disease (COPD) is usually described as a disease of cigarette smoking. COPD is rarely considered in persons with no smoking history except in the context of another exposure. Accordingly, the disease has not been well characterized in these “never smokers.”

Methods

We evaluated airway obstruction (defined as forced expiratory volume in 1 second/forced vital capacity <0.70) in US adults aged 30 to 80 years interviewed in the Third National Health and Nutrition Examination Survey with valid spirometry who had never smoked. Previously described risk factors were examined for their association with obstruction in bivariate and multivariate analyses.

Results

Never smokers represented 42% of the Third National Health and Nutrition Examination Survey population aged 30 to 80 years, with obstruction prevalence of 91 per 1000. Never smokers accounted for 4.56 million cases of obstruction, or 23% of the total burden. Among these obstructed never smokers, 19% reported a prior diagnosis of asthma alone, and 12.5% reported COPD (alone or with asthma), leaving 68.5% with no prior respiratory diagnosis. After adjustment for other factors, higher rates of obstruction were significantly associated with increasing age, male sex, lower body mass index, and a history of allergies.

Conclusions

Never smokers represent a significant proportion of airway obstruction in US adults. Only one fifth of obstruction in this group is explained by asthma. COPD may explain much of the remainder, although known risk factors were not explanatory in this dataset. Recommendations that lung health screening programs be limited to smokers should be reconsidered.     

Preoperative Cardiac Risk Index Predicts Long-term Mortality and Health Status

Objectives

Peripheral arterial disease patients undergoing vascular surgery are known to be at risk for the occurrence of (late) cardiovascular events. Before surgery, the perioperative cardiac risk is commonly assessed using the Lee Risk Index score, a combination of 6 cardiac risk factors. This study assessed the predictive value of the Lee Risk Index for late mortality and long-term health status in patients after vascular surgery.

Methods

Between May and December 2004, data on 711 consecutive peripheral arterial disease patients undergoing vascular surgery were collected from 11 hospitals in the Netherlands. Before surgery, the Lee Risk Index was assessed in all patients. At 3-year follow-up, 149 patients died (21%) and the disease-specific Peripheral Artery Questionnaire (PAQ) was completed in 84% (n = 465) of the survivors. Impaired health status according to the PAQ was defined by the lowest tertile of the PAQ summary score. Multivariable regression analyses were performed to investigate the prognostic ability of the Lee Index for mortality and impaired health status at 3-year follow-up.

Results

The Lee Risk Index proved to be an independent prognostic factor for both late mortality (1 risk factor hazard ratio (HR) = 2.1; 95% confidence interval [CI], 1.2-3.6; 2 risk factors HR = 2.4; 95% CI, 1.4-4.0 and ≥3 risk factors HR = 3.2; 95% CI, 1.7-6.2) and impaired health status at 3-year follow-up (1 risk factor odds ratio [OR] = 2.0; 95% CI, 1.1-3.5; 2 risk factors OR = 2.9; 95% CI, 1.6-5.2 and ≥3 risk factors OR = 3.2; 95% CI, 1.3-7.5). The predominant contributing factors associated with late mortality were cerebrovascular disease, insulin-dependent diabetes, and renal insufficiency. For impaired health status, ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, and renal insufficiency were the prognostic factors.

Conclusions

The preoperative Lee Risk Index is not only an important prognostic factor for in-hospital outcome but also for late mortality and impaired health status in patients with peripheral arterial disease.     

Comparative study of ambient air particles in patients hospitalized for heart failure and acute coronary syndrome

Introduction and objectives

Currently air pollution is considered as an emerging risk factor for cardiovascular disease. Our objective was to study the concentrations of particulate matter in ambient air and analyze their relationship with cardiovascular risk factors in patients admitted to a cardiology department of a tertiary hospital with the diagnosis of heart failure or acute coronary syndrome (ACS).

Methods

We analyzed 3950 consecutive patients admitted with the diagnosis of heart failure or ACS. We determined the average concentrations of different sizes of particulate matter (<10, <2.5, and <1 μm and ultrafine particles) from 1 day or up to 7 days prior to admission (1 to 7 days lag time).

Results

There were no statistically significant differences in mean concentrations of particulate matter <10, <2.5 and <1 μm in size in both populations. When comparing the concentrations of ultrafine particles of patients admitted due to heart failure and acute coronary syndrome, it was observed that the former had a tendency to have higher values (19 845.35 ± 8 806.49 vs 16 854.97 ± 8005.54 cm⁻³, P <.001). The multivariate analysis showed that ultrafine particles are a risk factor for admission for heart failure, after controlling for other cardiovascular risk factors (odds ratio = 1.4; confidence interval 95%, from 1.15 to 1.66 P = .02).

Conclusions

In our study population, compared with patients with ACS, exposure to ultrafine particles is a precipitating factor for admission for heart failure.Full English text available from: www.revespcardiol.org     

Glomerular filtration rate, albuminuria and risk of cardiovascular and all-cause mortality in type 2 diabetic individuals

Background and aims

To assess all-cause and cardiovascular mortality in type 2 diabetic individuals according to estimated glomerular filtration rate (eGFR) and albuminuria.

Methods and results

We followed 2823 type 2 diabetic outpatients for a median period of 6 years for the occurrence of all-cause and cardiovascular mortality. eGFR was estimated using the abbreviated Modification of Diet in Renal Disease study equation. At baseline, an eGFR <60 ml/min/1.73 m² and abnormal albuminuria were present in 22.5% and 26.0% of participants, respectively. During follow-up, a total of 309 patients died, 53% of deaths were secondary to cardiovascular causes. Risks of all-cause and cardiovascular mortality increased progressively with decreasing eGFR and increasing albuminuria. After adjustment for age, sex, body mass index, smoking, hypertension, diabetes duration, hemoglobin A1c, plasma lipids, medications use (hypoglycemic, anti-hypertensive, anti-platelet or lipid-lowering drugs) and albuminuria, the hazard ratios of all-cause and cardiovascular mortality per 1-SD decrease in eGFR were 1.53 (95%CI 1.2-2.0; p < 0.0001) and 1.51 (95%CI 1.05-2.2; p = 0.023), respectively. A similar pattern in the risk of all-cause and cardiovascular mortality was seen for albuminuria (1.14, 1.01-1.3, p = 0.028 and 1.19, 1.01-1.4, p = 0.043 per 1-SD increase in albuminuria, respectively) after adjustment for eGFR and other potential confounders.

Conclusions

These findings suggest that both decreasing eGFR and rising albuminuria are associated with all-cause and cardiovascular mortality in type 2 diabetic individuals, independently of traditional risk factors and diabetes-related variables.     

Prediction of Incident Hypertension Risk in Women with Currently Normal Blood Pressure

Background

We examined whether a hypertension risk prediction model based on clinical characteristics and blood biomarkers might improve on risk prediction based on current blood pressure alone.

Methods

A prospective cohort of 14,822 normotensive women aged 45 years and older were followed over 8 years beginning in 1992 for the development of hypertension. Among a randomly selected two-thirds sample (N = 9427), hypertension prediction models were developed using 52 potential predictors and compared with a model based on blood pressure alone. Each prediction model was validated in the remaining one third (N = 5395).

Results

In the development cohort, the best prediction model for incident hypertension included age, blood pressure, ethnicity, body mass index, total grain intake, apolipoprotein B, lipoprotein(a), and C-reactive protein (Bayes Information Criteria [BIC] = 8788). Although this model was superior to a model based on blood pressure alone (BIC = 8957), it was only marginally better than a simplified model including age, blood pressure, ethnicity, and body mass index (BIC = 8820). In the validation cohort, the simplified model demonstrated adequate calibration, a c-index similar to that of the best model (0.703 vs 0.705), and when compared with the model based on blood pressure alone, reclassified 1499 participants to hypertension risk categories that proved to be closer to observed risk in all but one instance.

Conclusion

In this prospective cohort of initially normotensive women, a model based on readily available clinical information predicted incident hypertension better than a model based on blood pressure alone.     

Long-term prognostic value of elevated heart rate one year after heart transplantation

Background

Elevated heart rate (HR) is associated with adverse cardiovascular outcome in the general population and in patients with cardiovascular disease. Elevated HR due to graft denervation is often found in heart transplantation (HTx) patients; the effect on graft survival and vasculopathy is unclear. Thus, the aim of this study was to evaluate the role of elevated HR at 12 months post-HTx and its power to predict HTx long-term outcome.

Methods

We evaluated retrospectively a prospective database of 312 patients undergoing HTx at two centers. HR was registered at 12 months post-HTx. The median HR was used as a cutoff point. Cox regression analysis was performed with variables known to be clinically relevant to mortality and those selected from the univariate analysis.

Results

During a mean follow-up of 5.5 ± 2.8 years there were 58 deaths (19%). Patients with a HR ≥ 90 bpm (median HR) at 12 months had an increased risk for all-cause mortality (Hazard Ratio = 2.4, 95% CI 1.2 to 4.5, p = 0.009) and mortality related to coronary allograft vasculopathy (CAV) (Hazard Ratio = 3.0, 95% CI 1.25–7.14, p = 0.01). Multivariate analysis showed that a HR ≥ 90 bpm independently predicted mortality (HR 3.2, 95% CI 1.4–7.1, p = 0.004).

Conclusions

Elevated HR measured at 12 months after HTx is an independent predictor of all-cause mortality in HTx recipients. A HR ≥ 90 bpm identifies a group of patients at high risk of death and CAV-related mortality at mid- to long-term.     

Impact of malnutrition on long-term mortality in hospitalized patients with heart failure

Introduction and objectives

The prevalence of malnutrition among patients with heart failure and the role it might play in prognosis is not currently known. The aim of this study was to analyse the prevalence and risk of malnutrition as well as its possible influence on long-term mortality in patients with heart failure.

Methods

A prospective analysis was conducted on 208 patients discharged consecutively from our centre between January 2007 and March 2008 after being hospitalised with heart failure. Before discharge, a complete nutritional assessment was performed and diagnosis of malnutrition and risk of malnutrition was done with the Mini Nutritional Assessment. Its possible independent association with mortality was assessed by a Cox multivariate analysis.

Results

The mean age of the patients was 73 ± 10 years, with 46% women; the most common aetiology of heart failure was ischaemia (41%). In addition, 13% were classified as malnourished, 59.5% at risk of malnutrition and 27.5% were well-nourished. At a median follow-up of 25 months, mortality in the three groups was 76%, 35.9% and 18.9%, respectively (log-rank, P < .001). In the Cox multivariate analysis, the malnutrition state was an independent predictor of mortality (hazard ratio 3.75, 95% confidence interval, 1.75-8.02, P = .001).

Conclusions

Malnutrition and the risk of malnutrition are highly prevalent in patients hospitalised for heart failure. Furthermore, we found that the state of malnutrition as defined by the Mini Nutritional Assessment survey is an independent predictor of mortality in these patients.Full English text available from: www.revespcardiol.org     

Randomized clinical trial to assess the efficacy of a comprehensive programme of secondary prevention of cardiovascular disease in general practice: the PREseAP study

Introduction and objectives

To assess the efficacy of a comprehensive program of secondary prevention of cardiovascular disease in general practice.

Methods

A cluster randomized clinical trial was carried out in a regular general practice setting. Male and female patients aged under 86 years with a diagnosis of ischemic heart disease, stroke or peripheral artery disease were recruited between January 2004 and May 2005. Study participants were seen at 42 health centers throughout the whole of Spain. The primary endpoint was the combination of all-cause mortality and hospital cardiovascular readmission at 3-year follow-up.

Results

In total, 1224 patients were recruited: 624 in the intervention group and 600 in the control group. The primary endpoint was observed in 29.9% (95% confidence interval [CI], 25.5-34.8%) in the intervention group and 25.6% (22.3-29.2%) in the control group (P = .15). At the end of follow-up, 8.5% (6.3-11.3%) in the intervention group and 11% (7.4-16%) in the control group were smokers (P = .07). The mean waist circumference of patients in the intervention and control groups was 100.44 cm (95% CI, 98.97-101.91 cm) and 102.58 cm (95% CI, 100.96-104.21 cm), respectively (P = .07). Overall, 20.9% (15.6-27.7%) of patients in the intervention group and 29.6% (23.9-36.1%) in the control group suffered from anxiety (P = .05), and 29.6% (22.4-37.9%) in the intervention group and 41.4% (35.8-47.3%) in the control group had depression (P = .02).

Conclusions

A comprehensive program of secondary prevention of cardiovascular disease in general practice was not effective in reducing cardiovascular morbidity and mortality. However, some factors associated with a healthy lifestyle were improved and anxiety and depression were reduced.Full English text available from: www.revespcardiol.org     

One-week and 6-month cardiovascular magnetic resonance outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction

Introduction and objectives

Pharmacoinvasive strategy represents an attractive alternative to primary angioplasty. Using cardiovascular magnetic resonance imaging we compared the left ventricular outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction.

Methods

Cardiovascular magnetic resonance was performed 1 week and 6 months after infarction in two consecutive cohorts of patients included in a prospective university hospital ST-segment elevation myocardial infarction registry. During the period 2004-2006, 151 patients were treated with pharmacoinvasive strategy (thrombolysis followed by routine non-immediate angioplasty). During the period 2007-2008, 93 patients were treated with primary angioplasty. A propensity score matched population was also evaluated.

Results

At 1-week cardiovascular magnetic resonance, pharmacoinvasive strategy and primary angioplasty patients showed a similar extent of area at risk (29 ± 15 vs. 29 ± 17%, P = .9). Non-significant differences were detected by cardiovascular magnetic resonance at 1 week and at 6 months in infarct size, salvaged myocardium, microvascular obstruction, ejection fraction, end-diastolic volume index and end-systolic volume index (P > .2 in all cases). The same trend was observed in 1-to-1 propensity score matched patients. The rate of major adverse cardiac events (death and/or re-infarction) at 1 year was 6% in pharmacoinvasive strategy and 7% in primary angioplasty patients (P = .7).

Conclusions

A pharmacoinvasive strategy including thrombolysis and routine non-immediate angioplasty represents a widely available and logistically attractive approach that yields identical short-term and long-term cardiovascular magnetic resonance-derived left ventricular outcome compared to primary angioplasty.Full English text available from:www.revespcardiol.org