Prevalence of and association between silent myocardial ischemia and new coronary events in older men and women with and without cardiovascular disease

OBJECTIVES: To investigate the prevalence of silent ischemia (SI) in older men and women detected by 24-hour ambulatory electrocardiograms (AECGs) and the association between SI and new coronary events.DESIGN: In a prospective study, the prevalence of SI detected by 24-hour AECGs and the incidence of new coronary events in 915 older men and 1,874 older women with coronary artery disease (CAD); with hypertension, valvular disease, or cardiomyopathy without CAD; and with no cardiovascular disease were investigated. SETTING: Large long-term healthcare facility. PARTICIPANTS: Nine hundred fifteen men, mean age 80, and 1,874 women, mean age 81. MEASUREMENTS: The prevalence of SI and the incidence of new coronary events in older men and women. RESULTS: SI was present in 34% of men and 33% of women with CAD; 15% of men and 14% of women with hypertension, valvular disease, or cardiomyopathy without CAD; and 6% of men and 5% of women with no cardiovascular disease. At 45-month follow-up in men and 47-month follow-up in women, SI significantly increased the incidence of new coronary events by 2.0 times in men and women with CAD (P <.001); by 1.8 times in men and 1.7 times in women with hypertension, valvular disease, or cardiomyopathy without CAD (P <.001); and by 6.3 times in men (P =.018) and 4.4 times in women (P =.008) with no cardiovascular disease. CONCLUSIONS: SI increases the incidence of new coronary events in older men and women with CAD, with hypertension, valvular disease, or cardiomyopathy without CAD, and with no cardiovascular disease.     

Prevalence of coronary artery disease, complex ventricular arrhythmias, and silent myocardial ischemia and incidence of new coronary events in older persons with chronic renal insufficiency and with normal renal function

In a prospective study of 98 persons > or = 65 years of age with chronic renal insufficiency (serum creatinine > 3.0 mg/dl) for > 1 year and 98 age- and sex-matched persons with normal renal function (serum creatinine < or = 1.2 mg/dl), new coronary events developed at 23-month follow-up in 69 persons (70%) with chronic renal insufficiency and at 48-month follow-up in 24 persons (24%) with normal renal function (p < 0.0001). Significant independent risk factors for new coronary events were age (risk ratio 1.1), prior coronary artery disease (risk ratio 3.5), complex ventricular arrhythmias diagnosed by 24-hour ambulatory electrocardiography (risk ratio 2.5), silent myocardial ischemia diagnosed by 24-hour ambulatory electrocardiography (risk ratio 1.9), and chronic renal insufficiency (risk ratio 3.4).     

Association of diabetes mellitus using old and new diagnostic criteria with incidence of new coronary events in older men and women

A prospective study investigated in 952 men (mean age 79 years) and in 2,014 women (mean age 81 years), the association of diabetes mellitus using the old and new diagnostic criteria with the incidence of new coronary events. At 40-month follow-up for men and 44-month follow-up for women, whether the old or the new criteria for diagnosing diabetes mellitus were used, diabetes mellitus was significantly associated with the incidence of new coronary events (p <0.0001) in older men and women.     

Renal insufficiency and cardiovascular events in postmenopausal women with coronary heart disease

OBJECTIVES: This study sought to determine the independent association of renal insufficiency with cardiovascular risk among women with known coronary heart disease (CHD). BACKGROUND: Although patients with end-stage renal disease and proteinuria are at high risk for cardiovascular events, little is known about the cardiovascular risk associated with moderate renal insufficiency. METHODS: The Heart and Estrogen/progestin Replacement Study (HERS) was a clinical trial among 2,763 women with coronary disease who were randomized to conjugated estrogen plus progestins or identical placebo and followed for a mean of 4.1 years. Women were categorized as having normal renal function (creatinine < 1.2 mg/dl; n = 2,012), mild renal insufficiency (1.2 mg/dl to 1.4 mg/dl; n = 567) and moderate renal insufficiency (>1.4 mg/dl; n = 182). We examined the independent association of renal function with incident cardiovascular events including CHD death, nonfatal myocardial infarction, hospitalization for unstable angina, stroke and transient ischemic attacks. RESULTS: Compared with women with normal renal function, those with mild and moderate renal insufficiency were older, more likely to be black, have a history of hypertension and diabetes and have higher serum levels of triglycerides and lipoprotein(a). After multivariate adjustment, both mild (relative hazards [RH] = 1.24; 95% confidence interval [CI]: 1.0 to 1.5) and moderate renal insufficiency (RH = 1.57; 95% CI: 1.2 to 2.1) were independently associated with increased risk for cardiovascular events compared with women with normal renal function. CONCLUSIONS: Renal insufficiency is an independent risk factor for cardiovascular events in postmenopausal women with known coronary artery disease. Renal function may add helpful information to CHD risk stratification.     

Pulse pressure and cardiovascular events in postmenopausal women with coronary heart disease

BACKGROUND: Pulse pressure (PP) has been shown to predict risk for cardiovascular events in men; however, this association has not been well established in women. Hormone replacement therapy may improve arterial compliance, but findings from cross-sectional and prospective studies report inconsistent results. We sought to examine the relationship between PP and risk for cardiovascular events, and to determine the effect of hormone therapy on PP in postmenopausal women with coronary heart disease (CHD). METHODS AND RESULTS: A total of 2,763 postmenopausal women (mean age, 66 +/- 7 years [+/- SD]) with CHD in the Heart and Estrogen/Progestin Replacement Study, a randomized, placebo-controlled, secondary CHD prevention trial of estrogen plus progestin, were followed up on average for 4.1 years. BP was measured at baseline and annually. Mean baseline PP was 62 +/- 16 mm Hg. There were 361 myocardial infarctions (MIs) or CHD deaths, 265 hospitalizations for congestive heart failure (CHF), and 215 strokes or transient ischemic attacks (TIAs). Women in the highest quartile of PP at baseline had a 47% increase in risk for MI or CHD death and more than a twofold increase in risk for stroke and TIA events or hospitalization for CHF (p < 0.01 for each outcome). After adjustment for other cardiovascular risk factors and mean arterial pressure, PP remained significantly associated with incident stroke or TIA events (odds ratio, 1.25; p = 0.02) and hospitalizations for CHF (odds ratio, 1.31; p < 0.01) but not with MI or CHD death. After adjustment for diastolic BP, systolic BP was similarly associated with stroke or TIA (odds ratio, 1.30; p < 0.01) and hospitalized CHF (odds ratio, 1.30; p < 0.01) and was also weakly associated with risk for MI and CHD death (odds ratio, 1.18; p = 0.02). Mean PP was 1- to 2-mm Hg higher in women randomized to hormone replacement therapy vs those receiving placebo (p < 0.01). CONCLUSIONS: PP had predictive value for CHF and stroke or TIA, but not MI or CHD death in this cohort of postmenopausal women with CHD. Use of hormone replacement therapy produced a small, statistically significant increase in PP. Further research is necessary to determine the clinical utility of PP as a potential therapeutic target.     

Prevalence and incidence of cardiovascular disease in 1160 older men and 2464 older women in a long-term health care facility.

BACKGROUND: We report the prevalence and incidence of cardiovascular disease in older men and women in a long-term health care facility. METHODS: The prevalence of hypertension, chronic atrial fibrillation, pacemaker rhythm, coronary artery disease (CAD), thromboembolic stroke, and symptomatic peripheral arterial disease (PAD) and the incidence of new coronary events, thromboembolic stroke, and congestive heart failure (CHF) were investigated in 1160 men, mean age 80 +/- 8 years, and in 2464 women, mean age 81 +/- 8 years, in a long-term health care facility. Mean follow-up was 46 +/- 30 months. RESULTS: The prevalences of hypertension, pacemaker rhythm, CAD, and thromboembolic stroke were similar in men and women. The prevalence of atrial fibrillation was higher in men (16%) than in women (13%; p =.019). The prevalence of PAD was higher in men (32%) than in women (26%; p =.0001). At the 46-month follow-up, the incidences of new coronary events, thromboembolic stroke, and CHF were similar in men and women. CONCLUSIONS: Older men and women in a long-term health care facility have a high prevalence and incidence of cardiovascular disease. The prevalences of hypertension, pacemaker rhythm, CAD, and thromboembolic stroke and the incidences of new coronary events, thromboembolic stroke, and CHF were similar in men and women. However, the prevalences of atrial fibrillation and of PAD were higher in men than in women.     

Proximal left anterior descending coronary heart disease and complex ventricular arrhythmias

In this study, 87 consecutive patients with angiographically proven coronary artery disease (CAD, stenosis >75%) underwent 24-h Holter monitoring, 76 of them having had transmural myocardial infarction, a mean of five months before evaluation. Of the total, 51 patients showed single-vessel disease, in 31 (61%) of them with involvement of the left anterior descending (LAD) artery. In 26 patients with proximal LAD stenosis or occlusion and usually large aneurysms and subsequently impaired left ventricular function relatively low prevalence of significant ventricular premature contraction (VPC, Lown (III) was seen. On the contrary in 19 patients with multivessel disease and proximal LAD stenosis advanced forms of VPCs were present in 63% (p<0.01). Further both groups differed significantly in the frequency of postinfarction angina (30% vs. 100%; p<0.001) and their incidence in positive exercise stress tests (15% vs. 84%; p<0.001). Ejection fractions were comparable in both groups (mean 45% vs. 52%). Finally 17 patients with multivessel disease but without proximal LAD lesion did not differ in any of the above mentioned parameters, when compared to the patients with single-vessel disease and proximal LAD stenosis. We conclude that impaired left ventricular function does not sufficiently explain the high risk of sudden death in postmyocardial infarction patients. The coronary and functional status of the surviving myocardium has to be taken into consideration as well.     

Prevalence of coronary artery disease, ischemic stroke, and symptomatic peripheral arterial disease and of associated risk factors in older men and women with and without diabetes mellitus

The authors performed a retrospective analysis of the prevalence of coronary artery disease, ischemic stroke, and symptomatic peripheral arterial disease and of associated risk factors in 99 men (mean age 79±8 years) with diabetes mellitus vs. 368 men (mean age 81±8 years) without diabetes mellitus, and in 260 women (mean age 80±8 years) with diabetes mellitus vs. 1184 women (mean age 81±8 years) without diabetes mellitus. All patients were seen in an academic outpatient geriatrics practice. Diabetic men had a higher prevalence of coronary artery disease, ischemic stroke, and symptomatic peripheral arterial disease (p<0.0001); a higher prevalence of smoking (p=0.023), hypertension (p<0.0001), and obesity (p=0.0007); higher levels of serum total and low density lipoprotein cholesterol (p<0.0001) and triglycerides (p=0.003); and lower levels of serum high density lipoprotein cholesterol (p=0.0001) than men without diabetes mellitus. Diabetic women had a higher prevalence of coronary artery disease, ischemic stroke, and symptomatic peripheral arterial disease (p<0.0001); a higher prevalence of hypertension and obesity (p<0.0001); higher levels of serum total and low density lipoprotein cholesterol (p=0.0001) and triglycerides (p=0.005); and lower levels of serum high density lipoprotein cholesterol (p=0.0001) than women without diabetes mellitus.     

Adiponectin and risk of coronary heart disease in older men and women

Context: Despite established insulin-sensitizing and antiatherogenic preclinical effects, epidemiological investigations of adiponectin have yielded conflicting findings, and its relationship with coronary heart disease (CHD) remains uncertain. Objective: Our objective was to investigate the relationship between adiponectin and CHD in older adults. Design, Setting, and Participants: This was a case-control study (n = 1386) nested within the population-based Cardiovascular Health Study from 1992-2001. Controls were frequency-matched to cases by age, sex, race, subclinical cardiovascular disease, and center. Main Outcome Measures: Incident CHD was defined as angina pectoris, percutaneous or surgical revascularization, nonfatal myocardial infarction (MI), or CHD death. A more restrictive CHD endpoint was limited to nonfatal MI and CHD death. Results: Adiponectin exhibited significant negative correlations with baseline adiposity, insulin resistance, dyslipidemia, inflammatory markers, and leptin. After controlling for matching factors, adjustment for waist to hip ratio, hypertension, smoking, alcohol, low-density lipoprotein cholesterol, creatinine, and leptin revealed a modestly increased risk of incident CHD with adiponectin concentrations at the upper end [odds ratio = 1.37 (quintile 5 vs. 1-4), 95% confidence interval 1.02-1.84]. This association was stronger when the outcome was limited to nonfatal MI and fatal CHD (odds ratio = 1.69, 95% confidence interval 1.23-2.32). The findings were not influenced by additional adjustment for weight change, health status, or cystatin C, nor were they abolished by adjustment for potential mediators. Conclusions: This study shows an association between adiponectin and increased risk of first-ever CHD in older adults. Further research is needed to elucidate the basis for the concurrent beneficial and detrimental aspects of this relationship, and under what circumstances one or the other may predominate.     

Cardiac arrhythmias on 24-h ambulatory electrocardiography in older women and men: The cardiovascular health study

Objective. This study describes the prevalence and correlates of cardiac arrhythmias in older persons.Background. Cardiac arrhythmias are frequent in selected samples of elderly persons, but their prevalence and association with cardiovascular disease and its risk factors not been examined in a large population-based sample.Methods. In 1,372 participants in the Cardiovascular Health Study, a population-based study of cardiovascular disease risk factors, 24-h ambulatory electrocardiography was performed.Results. Serious arrhythmias, such as sustained ventricular tachycardia and complete atrioventricular block, were uncommom, but brief episodes of ventricular tachycardia (≥3 consecutive ventricular depolarizations) were detected in 4.3% of women and 10.3% of men. Ventricular arrhythmias as a group (excluding ectopic beats < 15/h) were more common in men in women but were not significantly associated with age. The same patterns were true for bradycardia/conduction blocks. Supraventricular arrhythmias as a group (excluding ectopic beats < 15/h), in contrast, did not differ by gender but were strongly associated with increased age. Multivariate analyses showed associations with arrhythmias to differ by gender, with only one association (increased age and supraventricular arrhythmias) present in both women and men. Ventricular arrhythmias, particularly in men, were associated with a higher prevalence of cardiovascular disease and its risk factors and with subclinical disease, as measured by increased left ventricular mass and impaired left ventricular function.Conclusion. Arrhythmias are common in the elderly, and their association with cardiovascular disease differs by gender, Although risk related to arrhythmias can only be determined by prospective study, such studies should have adequate power to examine potential gender differences in associations.     

Comparison of remnant-like lipoprotein particles in postmenopausal women with and without coronary artery disease and in men with coronary artery disease

It is known that hypertriglyceridemia is a risk factor of coronary artery disease (CAD) in postmenopausal women. This study prospectively examined whether remnant lipoprotein, an atherogenic triglyceride-rich lipoprotein, may have a significant risk and prognostic values in postmenopausal women with angiographically verified CAD. Remnant-like lipoprotein particles cholesterol (RLP cholesterol) levels in fasting serum were measured in 134 consecutive postmenopausal women with (n = 56) or without (n = 78) CAD by an immunoseparation method. The women with CAD were followed for ≤24 months until occurrence of the following clinical coronary events: readmission or coronary revascularization due to recurrent or refractory angina pectoris, nonfatal myocardial infarction, and cardiac death. Multivariate logistic regression analysis showed that high RLP cholesterol levels (>5.7 mg/dl cholesterol; 90th percentile of the distribution of RLP cholesterol levels in controls) were a significant risk factor for the presence of CAD independent of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, and other traditional risk factors. Kaplan-Meier analysis demonstrated that women with CAD and higher RLP cholesterol levels had a significantly higher probability of developing coronary events (p <0.001). In multivariate Cox hazard analysis, high RLP cholesterol levels as well as diabetes and hypercholesterolemia were a significant predictor of future coronary events independent of other risk factors in women with CAD (odds ratio 9.7, 95% confidence intervals 1.3 to 20.3, P = 0.02). In conclusion, increased levels of RLP cholesterol are a significant and independent risk factor of CAD and predict future coronary events in postmenopausal women with CAD.     

Comparison of frequency of new coronary events in older subjects with and without valvular aortic sclerosis

In a prospective study of 1,980 subjects (mean age 81 +/- 8 years) without valvular aortic stenosis, 981 (50%) had valvular aortic sclerosis diagnosed by 2-dimensional and continuous-wave Doppler echocardiography. Independent risk factors for new coronary events were prior coronary artery disease (p = 0.0001, risk ratio 2.8), male gender (p = 0.002, risk ratio 1.3), and valvular aortic sclerosis (p = 0.0001, risk ratio 1.8).