Biological risk factors for sudden death in patients with coronary artery disease and without heart failure.

In a study of biological risk factors for sudden death in patients with coronary artery disease, 320 patients were, prospectively, recruited and followed-up over two years. None of the patients had heart failure or recent myocardial infarction. The following variables were recorded: previous acute myocardial infarction, hypertension, smoking habits, ventricular arrhythmia; the angiographic variables included: left ventricular ejection fraction, Jenkins' and mean atherosclerotic scores; lipid profile: cholesterol, triglycerides, high density lipoprotein cholesterol, low density lipoprotein cholesterol, apolipoproteins Al and B; hemostatic profile: fibrinogen, fibrinopeptide A, antithrombin III, factor VIII antigen, factor VIII coagulant, protein C, plasminogen, alpha 2-antiplasmin, euglobulin clot lysis time and tissue plasminogen activator before and after venous occlusion, tissue plasminogen activator inhibitor, platelet factor 4, beta-thromboglobulin. During the follow-up period, 12 of the patients died suddenly. In these patients, ejection fraction was lower: 49 +/- 16% versus 61 +/- 14% for the other patients (P less than 0.02), fibrinogen higher: 3.9 +/- 0.8 g/l versus 3.5 +/- 0.8 for the living patients (P less than 0.05) and protein C lower: 89 +/- 39% versus 111 +/- 39% (P = 0.06) for the other patients. In multivariate analysis: lower ejection fraction (P less than 0.008), older age (P less than 0.03) and lower protein C (P less than 0.01) were correlated with sudden death. Among the patients with coronary artery disease, the raised fibrinogen and the decreased protein C appeared to be risk factors for sudden cardiac death. These alterations reflected a prothrombotic state which might increase the ischemic risk, due to an acute thrombosis, leading to the fatal ventricular arrhythmia. Determination of these hemostatic variables might be a useful adjunct for assessment of the vital prognosis of patients with coronary artery disease, especially the risk of sudden death in addition to other known clinical, electrocardiographic, hemodynamic risk factors. This would also guide both the instigation of complementary investigations and appropriate therapy in such high risk group of patients.     

Joint effect of heart failure and coronary artery disease on the risk of death during hospitalization for COVID-19

Aimsheart failure (HF) and coronary artery disease (CAD) are independent predictors of death in patients with COVID-19. The adverse prognostic impact of the combination of HF and CAD in these patients is unclear.Methods and resultswe analysed data from 954 consecutive patients hospitalized for SARS-CoV-2 in five Italian Hospitals from February 23 to May 22, 2020. The study was a systematic prospective data collection according to a pre-specified protocol. All-cause mortality during hospitalization was the outcome measure.Mean duration of hospitalization was 33 days. Mortality was 11% in the total population and 7.4% in the group without evidence of HF or CAD (reference group). Mortality was 11.6% in the group with CAD and without HF (odds ratio [OR]: 1.6, p = 0.120), 15.5% in the group with HF and without CAD (OR: 2.3, p = 0.032), and 35.6% in the group with CAD and HF (OR: 6.9, p<0.0001).The risk of mortality in patients with CAD and HF combined was consistently higher than the sum of risks related to either disorder, resulting in a significant synergistic effect (p<0.0001) of the two conditions. Age-adjusted attributable proportion due to interaction was 64%. Adjusting for the simultaneous effects of age, hypotension, and lymphocyte count did not significantly lower attributable proportion which persisted statistically significant (p = 0.0360).ConclusionThe combination of HF and CAD exerts a marked detrimental impact on the risk of mortality in hospitalized patients with COVID-19, which is independent on other adverse prognostic markers.     

Management issues for patients with coronary artery disease and heart failure

Despite recent favorable trends in survival, heart failure remains a highly fatal disease. Improvements in the prevention of early death from coronary artery disease, along with an aging population, have resulted in an increased prevalence for heart failure in the United States. In the management of patients with heart failure secondary to coronary artery disease, the relative efficacy of invasive therapies such as coronary revascularization, surgical left ventricle remodeling, internal cardiac defibrillator implantation, cardioverter resynchronization therapy, mechanical ventricular assist, and cardiac transplantation need to be considered. Clinical studies examining these important treatment options are reviewed in order to better define the optimal management strategy for this challenging population of patients.     

Congestive heart failure in coronary artery disease

Congestive heart failure (CHF) affects approximately 1% of the United States population and its incidence continues to increase. Next to hypertension, coronary artery disease (CAD) is the second most frequent cause of CHF. Important distinction should be made between systolic dysfunction and diastolic dysfunction in CAD. The diagnostic and therapeutic challenges posed by both have stimulated much investigation into the pathophysiologic mechanisms involved and have led to innovative pharmacologic interventions to forestall progression of the disease. The challenge in the 1990s is prevention. In the meantime, results of completed and ongoing randomized controlled trials will determine the most effective forms of therapy, which will not only improve symptoms but also hopefully extend survival.     

Sex differences in risk for coronary heart disease mortality associated with diabetes and established coronary heart disease

BACKGROUND: The sex-specific independent effect of diabetes mellitus and established coronary heart disease (CHD) on subsequent CHD mortality is not known. METHODS: This is an analysis of pooled data (n = 5243) from the Framingham Heart Study and the Framingham Offspring Study with follow-up of 20 years. At baseline (1971-1975), 134 men and 95 women had diabetes, while 222 men and 129 women had CHD. Risk for CHD death was analyzed by proportional hazards models, adjusting for age, hypertension, serum cholesterol levels, smoking, and body mass index. The comparative effect of established CHD vs diabetes on the risk of CHD mortality was tested by testing the difference in log hazards. RESULTS: The adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for death from CHD were 2.1 (95% CI, 1.3-3.3) in men with diabetes only, and 4.2 (95% CI, 3.2-5.6) in men with CHD only compared with men without diabetes or CHD. The HR for CHD death was 3.8 (95% CI, 2.2-6.6) in women with diabetes, and 1.9 (95% CI, 1.1-3.4) in women with CHD. The difference between the CHD and the diabetes log hazards was +0.73 (95% CI, 0.72-0.75) in men and -0.65 (95% CI, -0.68 to -0.63) in women. CONCLUSIONS: In men, established CHD signifies a higher risk for CHD mortality than diabetes. This is reversed in women, with diabetes being associated with greater risk for CHD mortality. Current treatment recommendations for women with diabetes may need to be more aggressive to match CHD mortality risk.     

Alcohol consumption and risk for coronary heart disease in men with healthy lifestyles

BACKGROUND: Although moderate alcohol intake is associated with lower risk for myocardial infarction (MI), guidelines generally suggest that adults seek other lifestyle measures to reduce cardiovascular risk. We studied whether alcohol consumption is inversely associated with risk for coronary heart disease in men who report consistently favorable lifestyle behaviors. METHODS: From 51 529 male participants of the Health Professionals Follow-up Study who have reported diet and other lifestyle factors in biennial questionnaires since 1986, we defined a cohort of 8867 men free of major illness to participate in a prospective study. All participants reported 4 healthy lifestyle behaviors, including a body mass index (calculated as weight in kilograms divided by height in meters squared) of less than 25, moderate to vigorous activity for 30 minutes or more per day, abstention from smoking, and a summary diet score in the top 50% for men. High dietary scores reflected a high intake of vegetables, fruits, cereal fiber, fish, chicken, nuts, soy, and polyunsaturated fat; low consumption of trans-fat, and red and processed meats; and multivitamin use. We ascertained the incidence of nonfatal MI and fatal coronary heart disease according to reported intake of beer, wine, and liquor every 4 years. RESULTS: During 16 years of follow-up, we documented 106 incident cases of MI. Compared with abstention, the hazard ratios for MI were 0.98 (95% confidence interval, 0.55-1.74) for alcohol intake of 0.1 to 4.9 g/d, 0.59 (95% confidence interval, 0.33-1.07) for alcohol intake of 5.0 to 14.9 g/d, 0.38 (95% confidence interval, 0.16-0.89) for alcohol intake of 15.0 to 29.9 g/d, and 0.86 (95% confidence interval, 0.36-2.05) for alcohol intake of 30.0 g/d or more. In men who met 3 criteria, the lower risk associated with alcohol intake of 5.0 to 29.9 g/d tended to be similar to the lower risk associated with the remaining healthy lifestyle behavior. CONCLUSION: Even in men already at low risk on the basis of body mass index, physical activity, smoking, and diet, moderate alcohol intake is associated with lower risk for MI.     

Comparative effects of ventricular resynchronization therapy in heart failure patients with or without coronary artery disease

In patients with advanced heart failure, intraventricular conduction delay (IVCD) and left ventricular systolic dysfunction (LVSD), multisite cardiac pacing can be proposed as an additive treatment. The aim of this study was to assess the clinical effectiveness of atrioventricular pacing according to the etiology of LVSD, by comparing the outcome of patients with and without coronary artery disease. Between August 1997 and November 1998, 103 patients were included in the InSync trial and received a biventricular pacemaker and a specifically designed left ventricular pacing lead. Baseline evaluation (12 lead ECG, New York Heart Association Class, quality of life (QOL) and distance walked during the 6 min walk test) was repeated in survival patients at 1, 3, 6 and 12 months after pacemaker implantation. Patients were split in two groups, ischemic (N = 48) and non-ischemic (N = 55), according the result of a recent coronary angiography, the existence of coronary angioplasty or coronary artery bypass or the history of a prior myocardial infarction. RESULTS: The mortality rate was similar in the two groups with a mean 12 months actuarial survival rate of 78%. Nevertheless, the delay between the death and the pacemaker implantation was significantly higher in the non-ischemic group. A significant reduction in QRS duration and a significant improvement in NYHA class (-1.5). QOL score (-50%) and 6 min walking test (+18%) were observed similarly in the two groups. CONCLUSION: This study shows that biventricular pacing improves significantly functional status of patients with LVSD, IVCD and advanced heart failure, regardless the etiology of the cardiomyopathy, ischemic or not, without over-mortality in ischemic patients.     

冠状动脉狭窄程度与冠心病危险因素的相关性分析

目的探讨冠状动脉狭窄程度与冠心病危险因素的相关性。方法连续性收集我科行冠状动脉造影的患者121例,根据造影结果,将患者分为冠心病组89例与对照组32例。收集2组患者临床、实验室和影像学资料,采用单因素和多因素logistic回归模型进行分析。结果冠心病组男性、糖尿病、吸烟比例和LDL-C水平均高于对照组,HDL-C水平低于对照组(P<0.05);多因素logistic回归分析示,糖尿病(OR=3.769,P=0.042)、LDL-C水平(OR=1.873,P=0.021)是冠心病的独立危险因素。中、重度冠状动脉狭窄患者吸烟比例均高于轻度狭窄者,中度狭窄患者男性比例、年龄与尿酸水平和重度狭窄患者高血压、糖尿病比例均高于轻度狭窄者,差异均有统计学意义(P<0.05);logistic回归分析示,年龄(OR=1.094,P=0.001)、高血压(OR=3.340,P=0.003)、糖尿病(OR=3.877,P=0.003)和吸烟(OR=4.536,P=0.003)与冠状动脉狭窄程度相关。结论冠心病的危险因素与冠状动脉狭窄程度存在显著相关性,其中糖尿病是两者共同的重要危险因素。     

Anaemia and coronary artery disease severity in patients with heart failure

BACKGROUND: Anaemia is common in heart failure (HF) and associated with higher mortality. Exacerbation of myocardial ischemia in patients with heart failure, coronary disease, and anaemia patients has been suggested as a potential mechanism underlying this association. AIMS: The aim of this study was to evaluate the hypothesis that greater CAD severity would exacerbate the adverse effects of anaemia in HF. METHODS: We examined data on patients with symptomatic heart failure (NYHA class > or = II) undergoing coronary angiography between 1995 and 2003 (n = 4951). Patients with primary valvular or congenital heart disease were excluded. Cox proportional hazards modeling was used to evaluate the relationship between coronary disease severity (as defined by no. of diseased vessels) and hemoglobin concentration. RESULTS AND CONCLUSIONS: In patients with symptomatic HF undergoing coronary angiography, we found an interaction between hemoglobin and CAD severity (p = 0.003 for interaction). Contrary to our hypothesis, the mortality hazard associated with anaemia was greatest in patients without CAD and progressively lower with increasing CAD severity. These data suggest that anaemia may exert its effect on HF outcomes through mechanisms beyond simply the exacerbation of myocardial ischemia.     

Employment status at time of first hospitalization for heart failure is associated with a higher risk of death and rehospitalization for heart failure

Aims

Employment status at time of first heart failure (HF) hospitalization may be an indicator of both self‐perceived and objective health status. In this study, we examined the association between employment status and the risk of all‐cause mortality and recurrent HF hospitalization in a nationwide cohort of patients with HF.

Methods and results

We identified all patients of working age (18–60 years) with a first HF hospitalization in the period 1997–2015 in Denmark, categorized according to whether or not they were part of the workforce at time of the index admission. The primary outcome was death from any cause and the secondary outcome was readmission for HF. Cumulative incidence curves, binomial regression and Cox regression models were used to assess outcomes. Of 25 571 patients with a first hospitalization for HF, 15 428 (60%) were part of the workforce at baseline. Patients in the workforce were significantly younger (53 vs. 55 years) more likely to be male (75% vs 64%) and less likely to have diabetes (13% vs 22%) and chronic obstructive pulmonary disease (5% vs 10%) (all P < 0.0001). Not being part of the workforce was associated with a significantly higher risk of death [hazard ratio (HR) 1.59; 95% confidence interval (CI) 1.50–1.68] and rehospitalization for HF (HR 1.09; 95% CI 1.05–1.14), in analyses adjusted for age, sex, co‐morbidities, education level, calendar time, and duration of first HF hospitalization.

Conclusion

Not being part of the workforce at time of first HF hospitalization was independently associated with increased mortality and recurrent HF hospitalization.

     

Alcohol and coronary heart disease

The consumption of alcohol and its impact on health have been of great interest to researchers for many years, but remains complex for several reasons. First, with the exception of violent deaths attributable to intoxication, risks and benefits of alcohol consumption are likely to accrue over years or even decades. Second, quantitative assessment of drinking is generally based on self-report, and this may lead to some degree of misclassification. Third, drinking habits change over time, and thus, it may be important to update drinking habits periodically during any prospective study. Fourth, consumption of alcoholic beverages tends to be imbedded in cultural practices and associated with a number of lifestyle factors. For example, age, sex, race, smoking, ethnic background, and education are related to alcohol intake and may confound relationships with disease. Fifth, alcohol is derived from a number of different beverages whose other components may increase or decrease risk of disease aside from, or in addition to, the specific effect of ethanol. In addition, most studies tend to take into account average daily intake, disregarding issues of how or when the alcoholic beverage was consumed. For example, southern Europeans tend to drink wine with meals, while northern Europeans tend to drink distilled spirits, often at times other than mealtime. The risks and benefits of alcohol consumption certainly seem to be quite different for an individual who consumes seven beers on a Saturday night compared with an individual who consumes a half of a glass of wine with lunch and dinner every day, despite the obvious similarities in average weekly consumption. Finally, the precise mechanisms by which alcohol raises or lowers risks of various disease are only now beginning to be understood. (Trends Cardiovasc Med 1996;6:175-178).     

青年女性冠心病患者住院变化趋势及主要危险因素的分析

目的:分析安贞医院11年青年女性冠心病的住院趋势及危险因素的特征。方法:收集2007年1月至2017年12月,首都医科大学附属北京安贞医院首次住院、临床病例资料完整,且出院第一诊断为冠心病的病例150 846例,其中男性109 277例(72.4%),女性41 569例(27.6%);根据年龄分为青年冠心病(年龄<45岁)、中年冠心病(45～64岁)、老年冠心病(≥65岁)。青年冠心病患者10 232例(6.8%),其中男性9 456例(92.4%),女性776例(7.6%)。收集患者的一般资料(性别、年龄、SBP、DBP、HR)、实验室检查结果(TG、TC、HDL-C、HDL-C、UA、HCY和HbA1C)。结果:2007年至2017年,青年冠心病患者的比例呈降低的趋势(8.6%降至6.2%,P=0.000),青年女性冠心病比例亦呈降低趋势(10.4%降至7.5%,P=0.000)。中老年女性冠心病患者比例没有变化(趋势P=0.158)。中老年女性冠心病患者TG[1.66(1.23,2.26)]降至[1.42(1.03,1.97)]mmol/L、 TC(4.78±1.12)降至(4.44±1.09)mmol/L、LDL-C(3.00±0.99)降至(2.56±0.90)mmol/L、HCY(16.8±4.4)降至(12.2±6.2)μmol/L水平,均呈逐渐降低的趋势(P=0.000);而青年女性没有变化。与青年男性冠心病比较,青年女性冠心病患者TG(t′=7.66,P=0.000)、UA(t′=28.790,P=0.000)、HCY(t′=17.732,P=0.000)水平低,HDL-C(t′=15.676,P=0.000)水平高,差异均有统计学意义。与中老年女性比较,青年女性冠心病患者SBP最低(F=48.458,P=0.000)、TC、HDL-C、LDL-C、HbA1c、UA、HCY(F=17.174,F=9.776,F=5.481,F=1.758,F=230.951,F=323.408,P<0.01)水平最低。青年女性冠心病患者TG水平高于老年女性,低于中年女性,差异均有统计学意义(F=88.536,P=0.000)。结论:从2007至2017年,青年女性冠心病患者TG、 TC、LDL-C、HCY水平没有变化。与青年男性和中老年女性冠心病患者比较,青年女性冠心病患者TC、HDL-C、LDL-C、HbA1c、UA、HCY水平最低。