Racial differences in the outcomes of patients with diastolic heart failure

Background

More than half of all patients with congestive heart failure have preserved left ventricular systolic function. This is particularly common in African American patients, yet there have been few studies examining the long-term natural history of this disorder in African-American and white patients.

Methods

We studied 2740 white and 563 African American patients with class II to IV symptoms and preserved systolic function (ejection fraction >40) identified in the Duke Cardiovascular Databank from 1984 to1996. Unadjusted and adjusted 5-year survival rate comparisons were performed with Kaplan-Meier and Cox proportional hazards models, respectively.

Results

The 5-year survival rates were 68% for African American patients and 70% for white patients (P = .55). However, after adjusting for known risk factors, African American patients had a significantly higher mortality risk than white patients (hazard ratio [HR], 1.34; 95% CI, 1.13-1.60). This racial difference in survival rate was most prominent in patients with a non-ischemic etiology (HR, 1.6; 95% CI, 1.2-2.0) as compared with patients with ischemic heart failure (HR, 1.1; 95% CI, 0.9-1.4).

Conclusion

Among patients with heart failure and preserved left ventricular systolic function, African American patients have a worse long-term prognosis than white patients. These results are important because of the prevalence of this condition in African American patients and their potential heterogeneous response to many heart failure therapies.     

Differences in the clinical features and outcomes in African Americans and whites with myocardial infarction

Purpose

Less is known about the differences in clinical and angiographic features and the outcomes of African Americans with ST-elevation myocardial infarction compared with whites with ST-elevation myocardial infarction. Accordingly, the current study examines the relationship of African American race to patient-related clinical factors, angiographic findings, and clinical events.

Methods

We evaluated data from 32 419 patients with ST-elevation myocardial infarction who received fibrinolysis. The primary outcomes of interest were 30-day and 5-year mortality.

Results

African Americans comprised 5.1% of the study population (1664/32 419). Compared with white patients, black patients were younger, were more likely female, had a higher prevalence of coronary risk factors, and were more likely to have higher presenting heart rate, blood pressure, and Killip Class. Coronary angiography rates were similar in the two groups, but blacks were less likely to undergo coronary revascularization. The patency of the infarct-related artery after thrombolysis or mechanical reperfusion was higher in blacks, who were more likely to have no significant coronary artery disease and less likely to have disease in two or more vessels. In-hospital stroke (adjusted odds ratio 1.75, 95% confidence interval [CI] 1.19-2.59) and major bleeding (adjusted odds ratio 1.32, 95% CI 1.13-1.55) were higher among African Americans. Although no differences were observed in the 30-day mortality between the two groups, African Americans who survived to 30 days had higher 5-year mortality than whites (17% vs 12.5%, adjusted hazard ratio 1.63, 95% CI 1.41-1.90).

Conclusions

Although 30-day survival was similar between African Americans and whites with ST-elevation myocardial infarction, in-hospital stroke and bleeding and 5-year mortality among 30-day survivors were significantly higher among blacks despite their younger age.     

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.     

Do Income Level and Race Influence Survival in Patients Receiving Hemodialysis?

Background

Residence in a lower-income area has been associated with higher mortality among patients receiving dialysis. We sought to determine whether these differences persist and whether the effect of income-area on mortality is different for African Americans versus patients of other races.

Methods

We evaluated relationships between lower- and higher-income versus middle-income area residence and mortality to 5 years after adjusting for differences in baseline clinical, dialysis facility, and socioeconomic characteristics in 186,424 adult patients with end-stage renal disease initiating hemodialysis at stand-alone facilities between 1996 and 1999. We also compared mortality differences between race and income level groups using non-African Americans residing in middle-income areas as the reference group.

Results

Patients with end-stage renal disease who reside in lower-income areas were younger and more frequently African American. After adjustment, there were no mortality differences among income level groups. However, African Americans in all income level groups had lower adjusted mortality compared with the reference group (lower-income hazard ratio [HR] = 0.771, 95% confidence interval [CI], 0.736-0.808; middle-income HR = 0.755, 95% CI, 0.730-0.781; higher-income HR = 0.809, 95% CI, 0.764-0.857), whereas adjusted mortality was similar among non-African-American income level groups (lower-income HR = 1.019, 95% CI, 0.976-1.064; higher-income HR = 1.003, 95% CI, 0.968-1.039).

Conclusion

Adjusted survival for patients receiving hemodialysis in all income areas was similar. However, this result masks the paradoxically higher survival for African American versus patients of other race and demonstrates the need to adjust for differences in demographic, clinical, provider, and socioeconomic status characteristics.     

Survival rates are similar between African American and white patients with heart failure

Background

The clinical characteristics of heart failure differ significantly between African American patients and white patients, apparently as a result of differences in the pathobiology of the condition in the races. We investigated the hypothesis that race also influences the survival of patients with heart failure.

Methods

Data from the University of North Carolina Heart Failure Database were analyzed for 853 patients (44% African American, 32% women) who had symptomatic heart failure (New York Heart Association class 2.8 ± 0.02 [mean ± SEM]) with a reduced left ventricular ejection fraction of 26% ± 0.5% and a body mass index of 27 ± 0.2. Data on vital status were available in 96.4% of these patients, with a mean length of follow-up of 3.8 ± 0.1 years.

Results

An unadjusted univariate proportional-hazards analysis suggested similar survival rates between African American patients and white patients in the study population (relative risk, 0.90; 95% CI, 0.73-1.10; P = .293). Adjusted analysis, taking into account the characteristics shown to be of prognostic importance, demonstrated no difference in survival rate between African American patients and white patients (relative risk,1.12; 95% CI, 0.89-1.42; P = .336). The adjusted relative risk of all-cause mortality in the respective races among patients with heart failure caused by ischemic heart disease was 1.21 (95% CI, 0.80-1.84; P = .367).

Conclusion

African American and white patients with symptomatic heart failure had similar survival rates in our database.     

Left ventricular hypertrophy and cardiovascular mortality by race and ethnicity

Background

Left ventricular hypertrophy is a major independent risk factor for cardiovascular mortality. The contribution of left ventricular hypertrophy to racial and ethnic differences in cardiovascular mortality is poorly understood.

Methods

We used data from the Third National Health and Nutrition Examination Survey and from the National Death Index to compare mortality for those with an electrocardiographic (ECG) diagnosis of left ventricular hypertrophy to those without left ventricular hypertrophy separately for whites, African Americans, and Latinos. We used Cox proportional hazards regression to control for other known prognostic factors.

Results

ECG left ventricular hypertrophy was significantly associated with 10-year cardiovascular mortality in all 3 racial/ethnic groups, both unadjusted and adjusted for other known prognostic factors. The hazard ratio for this association was significantly greater for African Americans (2.31; 95% confidence interval [CI], 1.55-3.42) than for whites and Latinos (1.32; 95% CI, 1.14-1.76 and 2.11; 95% CI, 1.35-3.30, respectively), independent of systolic blood pressure.

Conclusions

ECG left ventricular hypertrophy contributes more to the risk of cardiovascular mortality in African Americans than it does in whites. Using regression of ECG left ventricular hypertrophy as a goal of therapy might be a means to reduce racial differences in cardiovascular mortality; prospective validation is required.     

Antecedent hypertension and the effect of captopril on the risk of adverse cardiovascular outcomes after acute myocardial infarction with left ventricular systolic dysfunction: Insights from the Survival and Ventricular Enlargement Trial

Background

Hypertension is a well-established risk factor for myocardial infarction (MI), but its prognostic importance in survivors of an acute MI is less clear.

Methods

We used Cox proportional hazards models to examine the risk of any major cardiovascular event (cardiovascular death, heart failure, recurrent MI, or stroke)—combined or individual components—and all-cause death and evaluate the efficacy of captopril in 906 patients with hypertension and 1325 patients without hypertension in the Survival and Ventricular Enlargement (SAVE) clinical trial. All patients had survived an acute MI with resultant left ventricular (LV) systolic dysfunction, but without overt heart failure, and were randomized within 3 to 16 days after the index MI to receive either captopril or placebo. The mean (± SD) follow-up period was 42 ± 10 months.

Results

After adjustment for known risk factors, medication use at enrollment, and baseline systolic blood pressure, patients with hypertension had a significant increase in the risk of experiencing a combined cardiovascular event (47.7% vs 31.3%; hazard ratio [HR], 1.49; 95% CI, 1.28-1.74), cardiovascular death (23.4% vs 15.9%; HR, 1.40; 95% CI, 1.12-1.74), heart failure (27.7% vs 15.5%; HR, 1.64; 95% CI, 1.34-2.02), and all-cause death (27.4 vs 19.3%; HR, 1.25; 95% CI, 1.02-1.53), and a similar but statistically non-significant increase in the risk of non-fatal or fatal recurrent MI (17.4% vs 10.9%; HR, 1.27; 95% CI, 0.98-1.65), and non-fatal or fatal stroke (5.0% vs 3.6%; HR, 1.31; 95% CI, 0.81-2.09). Captopril resulted in similar benefits for both patients with and patients without hypertension. The number of combined cardiovascular events prevented for every 100 patients treated with captopril was 7.0 (95% CI, 0.5-13.5) in patients with hypertension and 7.5 (95% CI, 2.6-12.5) in patients without hypertension.

Conclusions

In survivors of an acute MI with LV systolic dysfunction, antecedent hypertension was associated with a greater risk of subsequent adverse cardiovascular events, not directly explained by elevated blood pressure levels. Captopril use was beneficial in both patients with and patients without hypertenson.     

Does the content of primary care visits differ by the racial composition of physicians' practices?

Purpose

The study compared the content of primary care visits between physicians with larger and smaller African American practices.

Methods

We compared the content of primary care adult visits between physicians with larger and smaller African American practices using data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey 1997 to 2002. Larger African American practice (>14% of primary care visits by African Americans) was empirically defined to conform with previous studies.

Results

Larger African American practices comprised 24% of all practices but accounted for 80% of all visits by African American patients. In adjusted analyses, physicians with larger African American practices were less likely to refer patients to specialists (adjusted odds ratio 0.77; 95% confidence internal 0.61-0.98) and marginally less likely to perform rectal examinations (adjusted odds ratio 0.84; 95% confidence interval 0.56-1.00) but were more likely to schedule a return appointment (adjusted odds ratio 1.25; 95% confidence interval, 1.02-1.52). However, there were no other significant differences in the reported content of the office visits. Results were not altered when different cutoffs for larger African American practices were used or when obstetricians-gynecologists were excluded from the analyses.

Conclusion

There are few differences in the content of office visits between physicians with larger and smaller African American practices.     

Relationship of Ethnic Origin, Gender, and Age to Blood Creatine Kinase Levels

Background

Creatine kinase is expressed at high levels in muscle, where it plays a central role in energy metabolism. Highly elevated creatine kinase levels in blood may indicate muscle trauma or disease. However, it is known that baseline creatine kinase levels are higher in African Americans than in whites and that they are higher in men than in women. This analysis explores the relationship of ethnic origin, gender, and age to baseline blood creatine kinase levels in a large group of adults with hypercholesterolemia.

Methods

Data from the screening phases of 4 North American trials of statins, which included large numbers of specific racial/ethnic populations, were combined for analysis. The pooled population (N = 11,346) included 2760 African Americans, 3301 whites, 2930 Hispanics, and 2355 South Asians.

Results

Creatine kinase levels varied according to ethnic origin, gender, and age. African American participants had higher median creatine kinase levels than did individuals of the 3 other ethnicities. Within each ethnic group, men had higher median creatine kinase levels than women: African Americans, 135 versus 73 U/L; whites, 64 versus 42 U/L; Hispanics, 69 versus 48 U/L; and South Asians, 74 versus 50 U/L. An age-dependent decrease in creatine kinase levels was noted among men, but no such trend was seen among women. The median creatine kinase levels for younger African American men exceeded the standard upper limit of normal.

Conclusion

Physicians should use caution when interpreting creatine kinase levels that seem elevated, particularly when treating African American patients and younger men.     

Metoprolol CR/XL in postmyocardial infarction patients with chronic heart failure: experiences from MERIT-HF

Background

The benefit of β-blockers post-myocardial infarction (MI) was established in the late 1970s. Major advances in the treatment of MI have since occurred. However, patients with chronic heart failure (CHF) were excluded from those trials. The purpose of this study was to assess the effect of β-blockers in post-MI patients with CHF receiving contemporary management.

Methods

This was a prespecified subgroup analysis of a double-blind, randomized trial: the Metoprolol CR/XL Randomized Intervention Trial in Heart Failure (MERIT-HF). Patients with CHF in New York Heart Association class II to IV with an ejection fraction (EF) ≤0.40 and a history of being hospitalized for an acute MI (n = 1926) were randomized to metoprolol succinate controlled release/extended release (CR/XL) versus placebo. Mean EF was 0.28, and the mean follow-up was 1 year.

Results

Metoprolol CR/XL reduced total mortality by 40% (95% CI 0.20-0.55, P = .0004), and sudden death by 50% (95% CI 0.26-0.66, P = .0004). The combined end point of all-cause mortality/hospitalization for worsening CHF was reduced by 31% (95% CI 0.16-0.44, P < .0001), and cardiac death/nonfatal acute MI by 45% (95% CI 0.26-0.58, P < .0001). A post-hoc analysis showed that the outcome in patients with earlier revascularization (44%) and outcome in those with more severe CHF (20%) was similar to the entire post-MI population.

Conclusions

In post-MI patients with symptomatic CHF, β-blockade continues to exert a profound reduction in mortality and morbidity in the presence of contemporary management that includes early and late revascularization, angiotensin-converting enzyme inhibitors, aspirin, and statins.     

Racial differences in blood pressure control: potential explanatory factors

Purpose

Poor blood pressure control remains a common problem that contributes to significant cardiovascular morbidity and mortality, particularly among African Americans. We explored antihypertensive medication adherence and other factors that may explain racial differences in blood pressure control.

Methods

Baseline data were obtained from the Veteran’s Study to Improve The Control of Hypertension, a randomized controlled trial designed to improve blood pressure control. Clinical, demographic, and psychosocial factors relating to blood pressure control were examined.

Results

A total of 569 patients who were African American (41%) or white (59%) were enrolled in the study. African Americans were more likely to have inadequate baseline blood pressure control than whites (63% vs 50%; odds ratio = 1.70; 95% confidence interval [CI] 1.20-2.41). Among 20 factors related to blood pressure control, African Americans also had a higher odds ratio of being nonadherent to their medication, being more functionally illiterate, and having a family member with hypertension compared with whites. Compared with whites, African Americans also were more likely to perceive high blood pressure as serious and to experience the side effect of increased urination compared with whites. Adjusting for these differences reduced the odds ratio of African Americans having adequate blood pressure control to 1.59 (95% confidence interval 1.09-2.29).

Conclusions

In this sample of hypertensive patients who have good access to health care and medication benefits, African Americans continued to have lower levels of blood pressure control despite considering more than 20 factors related to blood pressure control. Interventions designed to improve medication adherence need to take race into account. Patients’ self-reports of failure to take medications provide an opportunity for clinicians to explore reasons for medication nonadherence, thereby improving adherence and potentially blood pressure control.     

Thyroid hormone use, hyperthyroidism and mortality in older women

Purpose

Thyroid dysfunction is common, particularly among older women. The safety of thyroid hormone use and long-term prognosis of hyperthyroidism remain controversial. We performed a prospective cohort study to examine the relationship among thyroid hormone use, previous hyperthyroidism, abnormal thyroid function, and mortality.

Methods

We studied 9449 community-dwelling white women aged ≥65 years followed for 12 years. For analyses of thyroid function, we performed a nested case-cohort in 487 women using a third-generation thyroid-stimulating hormone assay. Causes of death were adjudicated based on death certificates and hospital records.

Results

Twelve percent of the 9449 women took thyroid hormone at baseline, and the mean duration of thyroid hormone use was 15.8 years; 9.4% of participants reported a history of hyperthyroidism. During 12 years of follow-up, 3159 women died (33%). In multivariate analysis, mortality among users of thyroid hormone was similar to that observed for nonusers (relative hazard [RH] 1.11, 95% confidence interval [CI], 0.98-1.24, P = .09). Previous hyperthyroidism was associated with a higher risk of all-cause mortality (RH 1.20, 95% CI, 1.06-1.36), particularly cardiovascular mortality (RH 1.46, 95% CI, 1.20-1.77). Low (≤0.5 mU/L) or high (>5 mU/L) thyroid-stimulating hormone levels were not associated with excess total or cause-specific mortality, but the power to detect these relationships was limited.

Conclusions

Among older women, thyroid hormone use is not associated significantly with excess mortality, but previous hyperthyroidism may be associated with a small increase in all-cause and cardiovascular mortality. Additional long-term studies of hyperthyroidism and its treatment should further explore these findings.     

White/Black Racial Differences in Risk of End-stage Renal Disease and Death

Background

End-stage renal disease disproportionately affects black persons, but it is unknown when in the course of chronic kidney disease racial differences arise. Understanding the natural history of racial differences in kidney disease may help guide efforts to reduce disparities.

Methods

We compared white/black differences in the risk of end-stage renal disease and death by level of estimated glomerular filtration rate (eGFR) at baseline in a national sample of 2,015,891 veterans between 2001 and 2005.

Results

Rates of end-stage renal disease among black patients exceeded those among white patients at all levels of baseline eGFR. The adjusted hazard ratios for end-stage renal disease associated with black versus white race for patients with an eGFR ≥90, 60-89, 45-59, 30-44, 15-29, and <15 mL/min/1.73m², respectively, were 2.14 (95% confidence interval [CI], 1.72-2.65), 2.30 (95% CI, 2.02-2.61), 3.08 (95% CI, 2.74-3.46), 2.47 (95% CI, 2.26-2.70), 1.86 (95% CI, 1.75-1.98), and 1.23 (95% CI, 1.12-1.34). We observed a similar pattern for mortality, with equal or higher rates of death among black persons at all levels of eGFR. The highest risk of mortality associated with black race also was observed among those with an eGFR 45-59 mL/min/1.73m² (hazard ratio 1.32, 95% CI, 1.27-1.36).

Conclusion

Racial differences in the risk of end-stage renal disease appear early in the course of kidney disease and are not explained by a survival advantage among blacks. Efforts to identify and slow progression of chronic kidney disease at earlier stages may be needed to reduce racial disparities.     

Prognostic implications of ejection fraction from linear echocardiographic dimensions: the Strong Heart Study

Background

Although echocardiography is commonly used to assess left ventricular (LV) systolic function, few data are available concerning the prognostic significance of LV ejection fraction (EF) calculated from linear echocardiographic measurements or 2-dimensional (2-D) wall motion scores in population-based samples.

Methods

Echocardiography was used in the second Strong Heart Study (SHS) examination to calculate LV EF in 2948 American Indians without prevalent coronary heart disease; 2923 had 2-D wall motion scores.

Results

Mildly and severely reduced LV EF occurred in 10% and 2% of participants, was associated with older age, male sex, higher systolic pressure, heart rate and markers of renal disease and inflammation. During 37 ± 9 months follow-up, cardiovascular death occurred in 2%, 5% and 12% of participants with normal, mildly reduced and severely reduced EF; all cause mortality rates were 6%, 10% and 32% (both P < .001). In Cox proportional hazards analyses, adjusting for covariates, cardiovascular death was higher with mildly reduced EF (risk ratio [RR] 2.9, 95% CI 1.6-5.4, P = .0007) and especially with severely reduced EF (RR 6.9, 95% CI 3.0-15.9, P < .0001); all-cause mortality was increased with severe LV dysfunction (RR 4.8, 95% CI 2.8-8.1, P < .001) and marginally with mildly reduced EF (odds ratio 1.4, 95% CI 0.95-2.15, P = .08). Segmental LV dysfunction and mildly and severely reduced EF from 2-D wall motion scores were associated with 3.3-fold (95% CI 1.1-9.4, P = .02), 3.5-fold (95% CI 2.1-5.8) and 3.8-fold (95% CI 1.9-7.6) (all P < .001) increased rates of cardiovascular death.

Conclusions

LV EF from linear echocardiographic measurements as well as segmental LV dysfunction and EF from 2-D wall motion scores strongly and independently predict cardiovascular mortality. Reduced EF by simple echocardiographic method has estimated population-attributable risks of about 35% for cardiovascular death and 12% for all-cause mortality in a population-based sample of middle-aged to elderly adults.     

Early sustained ventricular arrhythmias complicating acute myocardial infarction

Objective

Sustained ventricular arrhythmias complicate 2% to 20% of acute myocardial infarctions (MIs) and are associated with increased in-hospital mortality. However, it remains unclear whether successful mechanical revascularization improves outcomes in these patients. The objective of this analysis was to identify predictors of sustained ventricular arrhythmias after acute MI and to determine the influence of successful revascularization on in-hospital mortality.

Methods

We conducted a retrospective cohort study of all patients who underwent percutaneous coronary intervention for acute MI in New York State between 1997 and 1999.

Results

Of the 9015 patients who underwent percutaneous coronary intervention for acute MI, 472 (5.2%) developed sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) before revascularization. After multivariable adjustment, independent predictors of sustained VT/VF included cardiogenic shock (odds ratio [OR], 4.10; 95% confidence interval [CI], 3.20-5.58; P <.001), heart failure (OR, 2.86; 95% CI, 2.24-3.67: P <.001), chronic kidney disease (OR, 2.58; 95% CI, 1.27-5.23; P = .009), and presentation within 6 hours of symptom onset (OR, 1.46; 95% CI, 1.18-1.81; P = .001). Patients with sustained VT/VF had greater in-hospital mortality (16.3% vs 3.7%, P <.001). Although successful percutaneous coronary intervention was associated with decreased in-hospital mortality in patients with VT/VF (P <.001), patients with sustained VT/VF and successful revascularization experienced increased mortality compared with patients without sustained ventricular arrhythmias (P <.001).

Conclusion

Among patients undergoing percutaneous coronary intervention for acute MI, sustained VT/VF remains a significant complication associated with a 4-fold increased risk of in-hospital mortality. Early mortality is reduced after successful percutaneous coronary intervention, but remains elevated in this high-risk group.     

Short alleles of P-selectin glycoprotein ligand-1 protect against premature myocardial infarction

Background

Atherosclerosis is an inflammatory disease resulting from an injury that leads to an increase in the adhesiveness and permeability of the endothelium to leukocytes or platelets. The selectin family plays a key role initiating the cascade of events. Recently, we have demonstrated the functional relevance of a variable number of tandem repeats polymorphism affecting the P-selectin glycoprotein ligand (PSGL-1). Neutrophils carrying short alleles exhibit a significantly lower capacity to bind activated platelets. These alleles consistently protect against transient ischemic attack. We sought to evaluate the role of this polymorphism in premature myocardial infarction because genetic risk factors have more relevance in the development of disease in young patients.

Methods

We genotyped 219 Caucasian patients who had suffered a premature myocardial infarction (MI) (aged ≤45 years) and 594 control subjects from our Mediterranean area. The role of the PSGL-1 polymorphism was also evaluated according to the additional risk factors of age, sex, smoking history, hypertension, hypercholesterolemia, and diabetes.

Results

The frequency of the short alleles (B and C) was significantly lower in patients than in controls (P = .012, odds ratio 0.62; 95% CI 0.42-0.92). Multiple regression analysis revealed that B and C alleles had an independent protective effect on the development of premature MI (P = .034, odds ratio 0.62 95%CI: 0.40-0.96).

Conclusions

We found an interesting association between a functional polymorphism and the risk of MI at a younger age. According to our results, the short B and C PSGL-1 alleles might protect against premature MI, probably because of their lesser adhesive capacity.     

Impact of anemia on mortality, cognition, and function in community-dwelling elderly

Purpose

To explore the impact of varying hemoglobin levels on mortality, function, and cognition in a representative population of older persons.

Methods

Participants in this prospective cohort study included 1 744 men and women, aged 71 years or older, from a random household sample living in Durham and surrounding counties in North Carolina. Hemoglobin levels were obtained from participants at baseline in 1992. Functional status was measured at the 4-year follow-up interview using Katz and instrumental activities of daily living. Cognition was measured using the Short Portable Mental Status Questionnaire (SPMSQ). Death was determined by search of the National Death Index, and all deaths through 2000 are included.

Results

Using World Health Organization (WHO) criteria, the prevalence of anemia was 24%. There was a strong racial difference with an odds ratio, adjusted for age, education, estimated glomerular filtration rate and comorbidity of 3.0 (95% CI, 2.3-3.9) in African Americans compared with Caucasians. The risk ratio for 8-year mortality was 1.7 (95% CI, 1.5-2.0) for anemic subjects (P = .0001) and did not differ by sex or race. Anemia was strongly associated with poorer physical function (P = .0001) and cognitive function (P = .0001), and predicted decreases in both over a 4-year period.

Conclusions

In an elderly community-based population, anemia is more prevalent in African Americans and is independently associated with increased mortality over 8 years for both races and sexs. Anemia also is a risk factor for functional and cognitive decrease.     

Impact of female sex on outcome after percutaneous coronary intervention

Background

Prior reports have suggested that women have increased mortality compared to men following percutaneous coronary intervention (PCI). It remains unclear if this difference is secondary to sex or other confounding variables.

Methods

We sought to examine the characteristics and outcomes of 18039 consecutive women and men undergoing PCI at The Cleveland Clinic Foundation from 1992-2002.

Results

Procedural success rates were similar in both sexes, but the female cohort had a greater incidence of access site hematoma (5% vs. 2%, P < .0001) and blood product transfusion (12% vs. 4%, P < .0001) following PCI. The rate of myocardial infarction (MI) at 1 year was slightly higher among females (10% vs. 9%, P = .004), but revascularization rates were not significantly different between sexes. One-year mortality was also higher in the female cohort (7% vs. 5%, P < .0001). After adjustment in a multivariate model, the Cox proportional hazard ratio for mortality in females was 1.01 (95% CI 0.93-1.11, P = .78). The hazard ratio for the combined endpoint of death or MI was 1.05 (95% CI 0.97-1.13, P = .23).

Conclusions

After adjustment for differences in comorbidities, the risk for long-term mortality is not significantly different between sexes following PCI. However, there is a greater incidence of post-procedural bleeding complications among women.     

Long-Acting Calcium Antagonists in Patients with Coronary Artery Disease: A Meta-Analysis

Background

The use of calcium channel blockers (CCBs) in patients with coronary artery disease remains controversial, with reports of increased risk of myocardial infarction and all-cause mortality. Short-acting CCBs have an unfavorable hemodynamic profile. The role of long-acting CCBs in patients with coronary artery disease is unknown.

Methods

MEDLINE/CENTRAL/EMBASE database were searched from 1966 to August 2008 for randomized controlled trials of long-acting CCBs in patients with coronary artery disease with follow-up for at least 1 year. We extracted from the studies the baseline characteristics and 6 outcomes: all-cause mortality, cardiovascular mortality, nonfatal myocardial infarction, stroke, angina pectoris, and heart failure.

Results

Of the 100 randomized controlled trials of CCBs in patients with coronary artery disease, 15 studies evaluating 47,694 patients fulfilled our inclusion criteria. When compared with the comparison group (including placebo), CCBs were not associated with an increased risk of all-cause mortality (relative risk [RR] 0.99; 95% confidence interval [CI], 0.94-1.05), cardiovascular mortality (RR 1.03; 95% CI, 0.95-1.11), nonfatal myocardial infarction (RR 0.96; 95% CI, 0.87-1.06), or heart failure (RR 0.86; 95% CI, 0.71-1.05), and with a 21% reduction in the risk of stroke (95% CI, 0.70-0.89) and 18% reduction in the risk of angina pectoris (95% CI, 0.72-0.94). When compared with placebo, CCBs resulted in a 28% reduction in the risk of heart failure (95% CI, 0.73-0.92). The results were similar for both dihydropyridines and nondihydropyridine CCBs.

Conclusions

In patients with coronary artery disease, long-acting CCBs (either dihydropyridines or nondihydropyridines), were associated with a reduction in the risk of stroke, angina pectoris, and heart failure, with similar outcomes for other cardiovascular events as the comparison group.     

The clinical profile and outcomes associated with coronary collaterals in patients with coronary artery disease

Background

The clinical correlates of coronary collaterals and the effects of coronary collaterals on prognosis are incompletely understood.

Methods

We performed a study of 55,751 patients undergoing coronary angiography to evaluate the correlates of angiographically apparent coronary collaterals, and to evaluate their association with survival.

Results

The characteristic most strongly associated with the presence of collaterals was a coronary occlusion (odds ratio [OR], 28.9; 95% confidence interval [CI], 27.1-30.6). Collaterals were associated with improved adjusted survival overall (hazard ratio [HR] 0.89; 95% CI, 0.85-0.95), and in both acute coronary syndrome (ACS) (HR 0.90; 95% CI, 0.84-0.96) and non-ACS (HR 0.84; 95% CI, 0.77-0.92) patients. Collaterals were associated with improved survival in those receiving angioplasty (HR 0.78; 95% CI, 0.71-0.85) and those with low risk anatomy treated medically (HR 0.84; 95% CI, 0.72-0.98), but not for those treated with coronary bypass graft surgery or those with high-risk anatomy treated without revascularization.

Conclusions

The major correlate of coronary collaterals is the presence/extent of obstructive coronary artery disease. Collaterals are associated with better survival overall and in both ACS and non-ACS presentations, but not for those treated with coronary artery bypass graft (CABG) or those with high-risk anatomy who are not revascularized.