Abdominal aortic calcification on vertebral morphometry images predicts incident myocardial infarction

Abdominal aortic calcification (AAC) measured on spine X‐rays is an established risk factor for cardiovascular disease. We investigated whether AAC assessed using vertebral morphometry and a recently developed scoring system (AAC‐8) is reliable and associated with cardiovascular risk factors or events. A total of 1471 healthy postmenopausal women and 323 healthy middle‐aged and older men participated in 5 and 2 year trials of calcium supplements, respectively. AAC‐8 was assessed on vertebral morphometry images at baseline and follow‐up. In addition, 163 men also had coronary artery calcification measured using computed tomography. Cardiovascular events during the trials were independently adjudicated. We found strong inter‐ and intrameasurer agreement for AAC‐8 (κ > 0.87). The prevalence of AAC increased with age (p < .01) in women and in men. AAC was associated with many established cardiovascular risk factors, with serum calcium in women (p = .002) and with higher coronary calcium scores in men (p = .03). Estimated 5 year cardiovascular risk increased with increasing AAC‐8 score (p < .001) in women and in men. The presence of AAC independently predicted myocardial infarction (MI) in women [hazards ratio (HR) = 2.30, p = .007] and men (HR = 5.32, p = .04), even after adjustment for estimated cardiovascular risk in women. In women, AAC independently predicted cardiovascular events (MI, stroke, or sudden death) (HR = 1.74, p = .007), and changes in AAC‐8 score over time were associated with MI and cardiovascular events, even after adjustment for estimated cardiovascular risk. In summary, scoring AAC on vertebral morphometric scans is a reproducible method of assessing cardiovascular risk that independently predicts incident MI and cardiovascular events, even after taking into account traditional cardiovascular risk factors. © 2010 American Society for Bone and Mineral Research     

Abdominal Aortic Calcification Detected on Lateral Spine Images From a Bone Densitometer Predicts Incident Myocardial Infarction or Stroke in Older Women

Among a cohort of elderly women, abdominal aortic calcification scored on baseline lateral spine densitometric images intended for vertebral fracture assessment was associated with subsequent myocardial infarction or stroke over a median 4‐yr period, independent of clinical cardiovascular disease risk factors. Introduction: Cardiovascular disease (CVD) risk among older women is not adequately captured by traditional CVD risk factors. Lateral spine images obtained on bone densitometers for vertebral fracture assessment (VFA) can detect abdominal aortic calcification (AAC), an important marker of subclinical CVD. Our objective was to estimate the association between AAC scored on VFA images and subsequent myocardial infarction (MI) or stroke in elderly women. Materials and Methods: Among participants in a randomized controlled trial (women; age >75 yr) of clodronate versus placebo, those who sustained an MI or stroke during the median 4‐yr follow‐up study period were selected as cases (n = 408), and 408 controls were randomly selected from the remainder of the parent study population. Baseline VFA images were scored for AAC with a previously validated 24‐point scale and a newer, simpler 8‐point scale. Results: The OR of incident MI or stroke for those in the middle and top tertiles, respectively, compared with the bottom tertile of AAC score were 1.14 (95% CI, 0.79–1.66) and 1.74 (95% CI, 1.19–2.56) for the 24‐point scale and 1.42 (95% CI, 0.98–2.05) and 1.77 (95% CI, 1.22–2.55) for the 8‐point scale, adjusted for age, high‐density lipoprotein and low‐density lipoprotein cholesterol, triglycerides, blood pressure, smoking, renal function, health status, and baseline diagnoses of diabetes mellitus, hypertension, angina, and prior stroke. Conclusions: AAC scored on VFA images is independently associated with incident MI or stroke. Because bone densitometry is indicated for all women ≥65 yr of age, VFA imaging offers an opportunity to capture this CVD risk factor in postmenopausal women undergoing bone densitometry at very little additional cost.     

Influence of preoperative cardiovascular risk factor clusters on complications of total joint arthroplasty

Identification of preexisting cardiovascular risk factors is important in projecting postoperative outcomes. Using claims data for 16,317 patients who underwent total hip arthroplasty and/or total knee arthroplasty, we performed logistic regression and survival analysis to determine the effects of hypertension, diabetes, dyslipidemia,and obesity (both independently and in clusters) on incidence of myocardial infarction (MI), venous thromboembolism (VTE), and revision arthroplasty. Our results indicated that diabetes (odds ratio [OR],1.55; P<.05) and hypertension (OR, 1.56; P<.05) were independent risk factors for postoperative MI. Risk for MI increased significantly with the addition of each risk factor; there was a 128% increase in risk when all 4 cardiovascular risk factors were present (OR, 2.28; P<.0001). Risk for VTE did not change significantly with 1, 2, or 3 risk factors but reached statistical significance when all 4 risk factors were present (hazard ratio, 3.20; P = .05). There was no association between cardiovascular risk factors and incidence of revision arthroplasty. Our analysis confirmed that diabetes and hypertension are risk factors for postoperative MI, but the respective significant and near significant increased risks for MI and VTE seen with cardiovascular risk factor clustering merit further evaluation of the role of metabolic syndrome in patients who undergo arthroplasty.     

Ischaemic cardiac events and use of strontium ranelate in postmenopausal osteoporosis: a nested case–control study in the CPRD

Summary

We explored the cardiac safety of the osteoporosis treatment strontium ranelate in the UK Clinical Practice Research Datalink. While known cardiovascular risk factors like obesity and smoking were associated with increased cardiac risk, use of strontium ranelate was not associated with any increase in myocardial infarction or cardiovascular death.

Introduction

It has been suggested that strontium ranelate may increase risk for cardiac events in postmenopausal osteoporosis. We set out to explore the cardiac safety of strontium ranelate in the Clinical Practice Research Datalink (CPRD) and linked datasets.

Methods

We performed a nested case–control study. Primary outcomes were first definite myocardial infarction, hospitalisation with myocardial infarction, and cardiovascular death. Cases and matched controls were nested in a cohort of women treated for osteoporosis. The association with exposure to strontium ranelate was analysed by multivariate conditional logistic regression.

Results

Of the 112,445 women with treated postmenopausal osteoporosis, 6,487 received strontium ranelate. Annual incidence rates for first definite myocardial infarction (1,352 cases), myocardial infarction with hospitalisation (1,465 cases), and cardiovascular death (3,619 cases) were 3.24, 6.13, and 14.66 per 1,000 patient-years, respectively. Obesity, smoking, and cardiovascular treatments were associated with significant increases in risk for cardiac events. Current or past use of strontium ranelate was not associated with increased risk for first definite myocardial infarction (odds ratio [OR] 1.05, 95 % confidence interval [CI] 0.68–1.61 and OR 1.12, 95 % CI 0.79–1.58, respectively), hospitalisation with myocardial infarction (OR 0.84, 95 % CI 0.54–1.30 and OR 1.17, 95 % CI 0.83–1.66), or cardiovascular death (OR 0.96, 95 % CI 0.76–1.21 and OR 1.16, 95 % CI 0.94–1.43) versus patients who had never used strontium ranelate.

Conclusions

Analysis in the CPRD did not find evidence for a higher risk for cardiac events associated with the use of strontium ranelate in postmenopausal osteoporosis.     

Androgen-deprivation Therapy in Treatment of Prostate Cancer and Risk of Myocardial Infarction and Stroke: A Nationwide Danish Population-based Cohort Study

BackgroundAndrogen-deprivation therapy (ADT) has been suggested to increase the risk for cardiovascular diseases, including myocardial infarction (MI) and stroke, but data are inconsistent.ObjectivesTo investigate the association between ADT and risk for MI and stroke in Danish men with prostate cancer.Design, setting, and participantsA national cohort study of all patients with incident prostate cancer registered in the Danish Cancer Registry from January 1, 2002, through 2010 was conducted.Outcome measurements and statistical analysisWe used Cox regression analysis to estimate hazard ratios (HR) of MI and stroke for ADT users versus nonusers, adjusting for age, prostate cancer stage, comorbidity, and calendar period. Additionally, we stratified the analysis on preexisting MI/stroke status.Results and limitationsOf 31 571 prostate cancer patients, 9204 (29%) received medical endocrine therapy and 2060 (7%) were orchidectomized. Patients treated with medical endocrine therapy had an increased risk for MI and stroke with adjusted HRs of 1.31 (95% confidence interval [CI], 1.16–1.49) and 1.19 (95% CI, 1.06–1.35), respectively, compared with nonusers of ADT. We found no increased risk for MI (HR: 0.90; 95% CI, 0.83–1.29) or stroke (HR: 1.11; 95% CI, 0.90–1.36) after orchiectomy. One limitation of the study is that information on prognostic lifestyle factors was not included and might have further informed our estimates.ConclusionsIn this nationwide cohort study of >30 000 prostate cancer patients, we found that endocrine hormonal therapy was associated with increased risk for MI and stroke. In contrast, we did not find this association after orchiectomy.     

Relationship between bone mineral density and myocardial infarction in US adults

Cardiovascular disease and osteoporosis have several common risk factors, and quite a few studies suggest a relationship between them. The objective of the present study was to explore the relationship between cardiovascular disease risk factors and bone mineral density in association with having had a previous myocardial infarction in a general population. This cross-sectional study was conducted using data for 5,050 women and men aged 50–79 years who participated in the Third National Health and Nutrition Examination Survey (NHANES III). Race/ethnic and gender-specific mean BMD values for young adults were used to determine race/ethnic and gender-specific T -scores to define osteoporosis and low BMD. Multiple logistic regression analysis revealed that subjects self-reporting a previous myocardial infarction had significantly higher odds (odds ratio 1.28, [95% confidence interval (CI), 1.01 to 1.63] p =0.04) of having low bone mineral density, when adjusting for cardiovascular disease and osteoporosis risk factors. Self-reported myocardial infarction was not significantly associated with low bone mineral density in women, (odds ratio 1.22, [95% CI, 0.80 to 1.86] p =0.37), but was significant in men, (odds ratio 1.39, [95% CI, 1.03 to 1.87] p =0.03). These findings demonstrate that male survivors of myocardial infarction have low bone mineral density. The pathophysiologic connection between the atherosclerotic and the osteoporotic processes needs further elucidation. It is also of importance to study the processes in both men and women.     

Circulating endostatin and the incidence of heart failure

Abstract

Objective. Circulating levels of endostatin are elevated in many underlying conditions leading to heart failure such as hypertension, diabetes, chronic kidney disease and ischemic heart disease. Yet, the association between endostatin and the incidence of heart failure has not been reported previously in the community. Design. We investigated the longitudinal association between serum endostatin levels and incident heart failure in two community-based cohorts of elderly: Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS, n?=?966; mean age 70 years, 51% women, 81 events, mean follow-up 10 years) and Uppsala Longitudinal Study of Adult Men (ULSAM, n?=?747 men; mean age 78 years, 98 heart failure events, mean follow-up 8 years). We also investigated the cross-sectional association between endostatin and echocardiographic left ventricular systolic function and diastolic function (ejection fraction and E/A-ratio, respectively). Results. Higher serum endostatin was associated with an increased risk for heart failure in both cohorts after adjustment for established heart failure risk factors, glomerular filtration rate and N-terminal pro-brain natriuretic peptide (NT-proBNP) (PIVUS: multivariable hazard ratio (HR) per 1-standard deviation (SD) increase, HR 1.46 (95%CI, 1.17-1.82, p?<?.001); ULSAM: HR 1.29 (95%CI, 1.00-1.68, p?<?.05). In cross-sectional analyses at baseline, higher endostatin was significantly associated with both worsened left ventricular systolic and diastolic function in both cohorts. Conclusion Higher serum endostatin was associated with left ventricular dysfunction and an increased heart failure risk in two community-based cohorts of elderly. Our findings encourage further experimental studies that investigate the role of endostatin in the development of heart failure.     

Cardiovascular profile in osteoarthritis: a meta-analysis of cardiovascular events and risk factors

IntroductionHigher cardiovascular risk found in rheumatoid arthritis or psoriatic arthritis is largely due to systemic inflammation. In osteoarthritis (OA), occurrence of systemic inflammation has already been sometimes reported, but the possible association between OA and increased cardiovascular risk remains unclear. In this meta-analysis, we aimed to assess the incidences of myocardial infarction (MI) and stroke, and the cardiovascular risk factors in OA patients.MethodsWe searched PubMed, EMBase, and the Cochrane Library to find references of interest up to June 2018. MI and stroke incidence were calculated using meta-proportion analysis. Differences in cardiovascular risk factors between OA patients and controls were expressed as standardized mean differences using the inverse of variance method.ResultsThe reviewed studies reported 227 MIs in 3550 OA patients (incidence, 7.5%; 95% CI: 3.0–13.8%) and 616 MIs among 12,444 control subjects (incidence, 6.0%; 95% CI: 2.8–10.3%). Meta-analysis of the three longitudinal studies revealed a significantly increased MI risk among OA patients (RR = 1.22; 95% CI: 1.02–1.45). We also found a significantly increased stroke risk in OA patients (RR = 1.43; 95% CI: 1.38–1.48). Concerning cardiovascular risk factors, OA patients exhibited a pro-atherogenic lipid and glycemic profile including high levels of fasting glucose, total cholesterol, and LDL cholesterol and a high body mass index. Concerning atherosclerosis markers, OA patients exhibited a higher risk of metabolic syndrome, and increased pulse wave velocity.ConclusionOur meta-analysis results revealed higher cardiovascular risk in OA patients. This highlights the importance of cardiovascular risk factor management in OA.     

Five‐year cardiovascular and all‐cause mortality,and myocardial infarction in all subjects referred for exercise testing in two Danish counties

Objective—To examine the association between exercise test results and the 5‐year cardiovascular and all‐cause mortality, and myocardial infarction, in patients referred for exercise testing because of known or suspected coronary heart disease.

Design—A study of all patients (N?=?2763) who in 1996 had an exercise test in two Danish counties (900?000 inhabitants). Data and follow‐up were based on medical records and general administrative healthcare and population registries.

Results—Abnormal tests, compared with normal ones, were associated with an increased adjusted cardiovascular mortality ratio of 1.77 (95% confidence interval (CI): 1.19–2.63), all‐cause mortality ratio of 1.46 (95% CI: 1.11–1.93), and myocardial infarction ratio of 1.71 (95% CI: 1.28–2.28). Inconclusive tests, compared with normal ones, were associated with an increased adjusted all‐cause mortality ratio of 1.52 (95% CI: 1.05–2.20) and myocardial infarction ratio of 1.67 (95% CI: 1.12–2.56). A history of myocardial infarction increased the cardiovascular death ratio by 1.51 (95% CI: 1.05–2.16) and the myocardial infarction ratio by 2.39 (95% CI: 1.84–3.10).

Conclusion—Over a 5‐year period, the result of the bicycle exercise test was clearly associated with both mortality and risk of myocardial infarction. An inconclusive test may deserve special attention.     

Calcium and Vitamin D Supplementation Are Not Associated With Risk of Incident Ischemic Cardiac Events or Death: Findings From the UK Biobank Cohort

We investigated associations between calcium/vitamin D supplementation and incident cardiovascular events/deaths in a UK population‐based cohort. UK Biobank is a large prospective cohort comprising 502,637 men and women aged 40 to 69 years at recruitment. Supplementation with calcium/vitamin D was self‐reported, and information on incident hospital admission (ICD‐10) for ischemic heart disease (IHD), myocardial infarction (MI), and subsequent death was obtained from linkage to national registers. Cox proportional hazards models were used to investigate longitudinal relationships between calcium/vitamin D supplementation and hospital admission for men/women, controlling for covariates. A total of 475,255 participants (median age 58 years, 55.8% women) had complete data on calcium/vitamin D supplementation. Of that number, 33,437 participants reported taking calcium supplements; 19,089 vitamin D; and 10,007 both. In crude and adjusted analyses, there were no associations between use of calcium supplements and risk of incident hospital admission with either IHD, or subsequent death. Thus, for example, in unadjusted models, the hazard ratio (HR) for admission with myocardial infarction was 0.97 (95% confidence interval [CI] 0.79–1.20, p = 0.79) among women taking calcium supplementation. Corresponding HR for men is 1.16 (95% CI 0.92–1.46, p = 0.22). After full adjustment, HR (95% CI) were 0.82 (0.62–1.07), p = 0.14 among women and 1.12 (0.85–1.48), p = 0.41 among men. Adjusted HR (95% CI) for admission with IHD were 1.05 (0.92–1.19), p = 0.50 among women and 0.97 (0.82–1.15), p = 0.77 among men. Results were similar for vitamin D and combination supplementation. There were no associations with death, and in women, further adjustment for hormone‐replacement therapy use did not alter the associations. In this very large prospective cohort, there was no evidence that use of calcium/vitamin D supplementation was associated with increased risk of hospital admission or death after ischemic cardiovascular events. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals, Inc.     

Prognosis of Atrial Fibrillation in Patients with Symptomatic Peripheral Arterial Disease: Data from the REduction of Atherothrombosis for Continued Health (REACH) Registry

BackgroundAtrial fibrillation (AF) is a significant risk factor for cardiovascular (CV) mortality. This study aims to evaluate the prognostic implication of AF in patients with peripheral arterial disease (PAD).MethodsThe International Reduction of Atherothrombosis for Continued Health (REACH) Registry included 23,542 outpatients in Europe with established coronary artery disease, cerebrovascular disease (CVD), PAD and/or ≥3 risk factors. Of these, 3753 patients had symptomatic PAD. CV risk factors were determined at baseline. Study end point was a combination of cardiac death, non-fatal myocardial infarction (MI) and stroke (CV events) during 2 years of follow-up. Cox regression analysis adjusted for age, gender and other risk factors (i.e., congestive heart failure, coronary artery re-vascularisation, coronary artery bypass grafting (CABG), MI, hypertension, stroke, current smoking and diabetes) was used.ResultsOf 3753 PAD patients, 392 (10%) were known to have AF. Patients with AF were older and had a higher prevalence of CVD, diabetes and hypertension. Long-term CV mortality occurred in 5.6% of patients with AF and in 1.6% of those without AF (p < 0.001). Multivariable analyses showed that AF was an independent predictor of late CV events (hazard ratio (HR): 1.5; 95% confidence interval (CI): 1.09–2.0).ConclusionAF is common in European patients with symptomatic PAD and is independently associated with a worse 2-year CV outcome.     

Development of a bariatric surgery specific risk assessment tool for perioperative myocardial infarction

BackgroundPerioperative myocardial infarction (PMI) is a feared complication after surgery. Bariatric surgery, due to its intraabdominal nature, is traditionally considered an intermediate risk procedure. However, there are limited data on MI rates and its predictors in patients undergoing bariatric surgery.ObjectivesTo enumerate the prevalence of PMI after bariatric surgery and develop a risk assessment tool.SettingBariatric surgery centers, United States.MethodsPatients undergoing bariatric surgery were identified from the MBSAQIP participant use file (PUF) 2016. Preoperative characteristics, which correlated with PMI were identified by multivariable regression analysis. PUF 2015 was used to validate the scoring tool developed from PUF 2016.ResultsWe identified 172,017 patients from PUF 2016. Event rate for MI within 30 days of the operation was .03%; with a mortality rate of 17.3% in patients with a PMI. Four variables correlated with PMI on regression, including history of a previous MI (odds ratio [OR] = 8.57, confidence interval [CI] = 3.4–21.0), preoperative renal insufficiency (OR = 3.83, CI = 1.2–11.4), hyperlipidemia (OR = 2.60, CI = 1.3–5.1), and age >50 (OR = 2.15, CI = 1.1–4.2). Each predicting variable was assigned a score and event rate for MI was assessed with increasing risk score in PUF 2015; the rate increased from 9.5 per 100,000 operations with a score of 0 to 3.2 per 100 with a score of 5.ConclusionThe prevalence of MI after bariatric surgery is lower than other intraabdominal surgeries. However, mortality with PMI is high. This scoring tool can be used by bariatric surgeons to identify patients who will benefit from focused perioperative cardiac workup.     

High on-clopidogrel platelet reactivity and chronic kidney disease: a meta-analysis of literature studies

Background. The efficacy of clopidogrel is often attenuated in the setting of renal impairment. High on-treatment platelet reactivity (HPR) is an independent correlate of adverse event. Here we performed a quantitative evaluation of the prevalence and impact of HPR in patients with chronic kidney disease (CKD). Methods. We systematically searched PubMed, EMBASE and the Cochrane Library from their inception to 1 March 2018 for cohort studies assessing the risk ratio (RR) of prevalence of HPR in CKD versus non-CKD patients and association of cardiovascular outcome with HPR in CKD patients treated with clopidogrel. Outcome measures included major adverse cardiac event, myocardial infarction and stent thrombosis. RRs and 95% confidence intervals (CIs) were used as estimates of effect size in random-effect models. Results. Ten studies comprising a total of 3028 CKD patients and 11138 non-CKD patients were included in the evaluation. Compared to patients with normal renal function, patients with CKD had a significantly higher risk of HPR (OR: 1.34, 95% CI: 1.23–1.46). In CKD patients, HPR was associated with increased risk of MACE (RR 2.99, 95% CI 1.19 to 7.53; p?p?=?0.0002), and stent thrombosis (RR 2.98, 95% CI 1.42 to 6.26; p?=?0.004). Conclusions. Based on pooled analysis, CKD appeared correlated with HPR and this association had prognostic significance. Further studies with standardised laboratory methods and specifically defined protocols are required to validate the clinical relevance of such response variability to clopidogrel in CKD patients.     

Atrial fibrillation after cardiac surgery: A systematic review and meta-analysis

ObjectiveNew-onset postoperative atrial fibrillation (POAF) after cardiac surgery is common, with rates up to 60%. POAF has been associated with early and late stroke, but its association with other cardiovascular outcomes is less known. The objective was to perform a meta-analysis of the studies reporting the association of POAF with perioperative and long-term outcomes in patients with cardiac surgery.MethodsWe performed a systematic review and a meta-analysis of studies that presented outcomes for cardiac surgery on the basis of the presence or absence of POAF. MEDLINE, EMBASE, and the Cochrane Library were assessed; 57 studies (246,340 patients) were selected. Perioperative mortality was the primary outcome. Inverse variance method and random model were performed. Leave-one-out analysis, subgroup analyses, and metaregression were conducted.ResultsPOAF was associated with perioperative mortality (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.58-2.33), perioperative stroke (OR, 2.17; 95% CI, 1.90-2.49), perioperative myocardial infarction (OR, 1.28; 95% CI, 1.06-1.54), perioperative acute renal failure (OR, 2.74; 95% CI, 2.42-3.11), hospital (standardized mean difference, 0.80; 95% CI, 0.53-1.07) and intensive care unit stay (standardized mean difference, 0.55; 95% CI, 0.24-0.86), long-term mortality (incidence rate ratio [IRR], 1.54; 95% CI, 1.40-1.69), long-term stroke (IRR, 1.33; 95% CI, 1.21-1.46), and longstanding persistent atrial fibrillation (IRR, 4.73; 95% CI, 3.36-6.66).ConclusionsThe results suggest that POAF after cardiac surgery is associated with an increased occurrence of most short- and long-term cardiovascular adverse events. However, the causality of this association remains to be established.     

Physical Activity and Psychosocial Factors Associated With Risk of Future Fractures in Middle-Aged Men and Women

Identification of risk factors for fractures is important for improving public health. We aimed to identify which factors related to physical activity and psychosocial situation were associated with incident fractures among 30,446 middle-aged women and men, followed from 1991–1996 to 2016, in a prospective population-based cohort study. The association between the baseline variables and first incident fracture was assessed by Cox regression models, and significant risk factors were summed into fracture risk scores. Any first incident fracture affecting spine, thoracic cage, arms, shoulders, hands, pelvis, hips, or legs was obtained from the National Patient Register, using the unique personal identity number of each citizen. A total of 8240 subjects (27%) had at least one fracture during the follow-up of median 20.7 years. Age, female sex, body mass index, previous fracture, reported family history of fracture >50 years (all p < .001), low leisure-time physical activity (p = .018), heavy work (p = .024), living alone (p = .002), smoking (p < .001), and no or high alcohol consumption (p = .005) were factors independently associated with incident fracture. The fracture risk score (0–9 points) was strongly associated with incident fracture (p for trend <.001). Among men without risk factors, the incidence rate was 5.3/1000 person-years compared with 23.2 in men with six or more risk factors (hazard ratio [HR] = 5.5; 95% confidence interval [CI] 3.7–8.2). Among women with no risk factors, the incidence rate was 10.7 compared with 28.4 in women with six or more risk factors (HR = 3.1; 95% CI 2.4–4.0). Even moderate levels of leisure-time physical activity in middle age are associated with lower risk of future fractures. In contrast, heavy work, living alone, smoking, and no or high alcohol consumption increase the risk of fracture. Our results emphasize the importance of these factors in public health initiatives for fracture prevention. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).     

Characteristics of patients at risk for perioperative myocardial infarction after infrainguinal bypass surgery: An exploratory study

Patients requiring infrainguinal bypass surgery often have diffuse atherosclerotic disease, and perioperative myocardial infarction (MI) is a potentially lethal complication that is not uncommon in these patients. To establish additional clinical characteristics that might be useful in identifying patients who require more extensive cardiac evaluation, we conducted an exploratory case-control study comparing 22 patients who had a perioperative MI following elective infrainguinal bypass surgery with 191 control subjects whose bypasses were uneventful. In addition to previously recognized risk factors (e.g., history of angina or prior MI), we examined the association of perioperative MI with (1) results of common preoperative laboratory tests and ECG, (2) preoperative use of certain medications, and (3) intraoperative factors that might be anticipated prior to surgery (e.g., duration of surgery or type of anesthesia). Perioperative MI was associated not only with a history of angina, prior MI, or coronary artery disease but also with the need for certain cardiac medications, higher white blood cell (WBC) counts, ST-segment depression, left bundle branch block, and lengthy surgical procedures. Multiple logistic regression analysis identified the following factors as being independently associated with perioperative MI: preoperative antiarrhythmic agents (odds ratio [OR]=26.4,p 0.006), nitrates (OR=8.4,p=0.006), calcium channel blockers (OR=5.5,p=0.04), and aspirin (OR=6.8,p <0.01) and ST-segment depression (OR=11.8,p=0.01), WBC count (OR=1.27/1000,p=0.005), and duration of surgery (OR=2.2/hr,p=0.0001). In patients undergoing infrainguinal bypass surgery, perioperative MI is associated not only with a history of previous cardiac events and ECG evidence of ischemia but also with regular use of certain cardiac medications, higher WBC counts, and longer surgical procedures. Incorporation of these variables into current methods of risk assessment might improve their predictive value sufficiently to provide an objective, inexpensive means of distinguishing patients who warrant extensive preoperative cardiac evaluation from those who do not.We are indebted to Maryann Barry, RN, for helping to collect the preoperative ECG reports and to Timothy Heeren, PhD, Boston University School of Public Health, for advice regarding statistical analysis.     

Cardiovascular disease in rheumatoid arthritis: single-center hospital-based cohort study in France

IntroductionRheumatoid arthritis (RA) was independently associated with cardiovascular events in several studies, most of which were conducted in the US.ObjectivesTo estimate the risk of cardiovascular events in a cohort of RA patients recruited at a hospital in France, to identify cardiovascular risk factors, and to measure the severity of cardiovascular events.MethodsTwo hundred and thirty-nine patients admitted between January 1, 1998, and March 31, 1999, for RA meeting American College of Rheumatology criteria, with a negative history for cardiovascular events, were sent a questionnaire in 2004 to evaluate the occurrence of myocardial infarction, stroke, or cardiovascular death.ResultsDuring the mean follow-up of 5.4 ± 1.8 years, there were 10 cases of myocardial infarction (0.8%/year), 3 cases of stroke (0.2%/year), and 9 cardiovascular deaths (0.7%/year). Of the 10 patients who experienced myocardial infarction, 5 had clinical symptoms of heart failure and 4 died from cardiovascular causes. Independent risk factors for cardiovascular events were older age (relative risk [RR], 2.5/10 years; 95% confidence interval [95%CI], 1.4–4.2), male gender (RR, 5.1; 95%CI, 1.8–14.6), treated hypertension (RR, 4.3; 95%CI, 1.4–13.2), and treated hypercholesterolemia (RR, 6.0; 95%CI, 1.8–20.7).ConclusionOur data suggest a higher risk of cardiovascular events in patients with RA compared to the general population in France (0.1–0.5%/year for myocardial infarction and 0.07%/year for stroke in the age group covered by our cohort). Cardiovascular events in the patients with RA seemed unusually severe. Patients with RA should be carefully screened for conventional cardiovascular risk factors.     

Sex differences in plaque morphology may explain the higher male prevalence of myocardial infarction compared to angina pectoris. The Tromsø Study

Objectives To study whether the degree of carotid atherosclerosis and the male predominance of echolucent plaques could explain the sex difference in myocardial infarction (MI) compared to angina pectoris (AP).

Design Ultrasound examination of the carotid artery was performed in 6727 persons. The presence of plaque, plaque thickness and number of segments with plaque were recorded. Plaque morphology in terms of echogenicity was scored as echolucent (soft plaque) or echogenic (hard plaque). A questionnaire was used to obtain information about coronary heart disease.

Results In men with the most advanced atherosclerosis, the risk (OR, 95% CI) of having MI compared to those with no carotid atherosclerosis was less than half as the corresponding risk in women (2.2, 1.4–3.3 vs 5.3, 2.6–10.6). For MI, the male-to-female ratio was highest in the group with no carotid plaque and declined by increasing burden of atherosclerosis. For AP, the sex ratio was independent of the degree of atherosclerosis.

Conclusions The findings support the hypothesis that the sex difference in MI compared to AP is due to the higher male prevalence of echolucent plaque.     

Body mass index predicts new-onset atrial fibrillation after cardiac surgery

Objective: New-onset postoperative atrial fibrillation (POAF) after cardiac surgery is associated with increased morbidity and mortality. Since obesity is becoming increasingly prevalent, identifying body mass index (BMI) as a risk factor for POAF could be of importance. The aim of our study is to investigate the effect of BMI on POAF, independent of other risk factors. Methods: We analyzed data of 6788 men and 2560 women who underwent coronary artery bypass grafting, valve surgery, or a combination of both, and who had no history of atrial fibrillation. Men and women were analyzed separately because risk factors of POAF were expected to be distributed unequally over both sexes. Results: The independent effect of gender was analyzed in a combined model. POAF occurred in 2517/9348 (27%) of patients. Multivariate logistic regression analyses showed that BMI (odds ratio (OR) 1.03; 95% confidence interval (CI): 1.01–1.04; p < 0.001 in men and OR 1.03; 95% CI: 1.02–1.05; p < 0.001 in women), age (OR 1.06; 95% CI: 1.05–1.07; p < 0.001 in men and OR 1.05; 95% CI: 1.04–1.06; p < 0.001 in women), valve surgery compared to coronary surgery (e.g., mitral valve surgery compared to coronary artery bypass grafting: OR 3.4; 95% CI: 2.4–4.6; p < 0.001 in men and OR 2.9; 95% CI: 2.0–4.3; p < 0.001 in women) and male gender (OR 1.23; 95% CI: 1.09–1.38; p = 0.001) were the only independent risk factors for POAF, whereas chronic obstructive pulmonary disease, hypertension, off-pump coronary artery bypass grafting, extra corporal circulation time, and transfusion of blood products were not. Conclusion: Body mass index, age, undergoing valve surgery and male gender, are independent risk factors for POAF.     

Coronary angiography and failure to rescue after postoperative myocardial infarction in patients with coronary stents undergoing noncardiac surgery

Background

We evaluated coronary angiography use among patients with coronary stents suffering postoperative myocardial infarction (MI) and the association with mortality.

Methods

Patients with prior coronary stenting who underwent inpatient noncardiac surgery in Veterans Affairs hospitals between 2000 and 2012 and experienced postoperative MI were identified. Predictors of 30-day post-MI mortality were evaluated.

Results

Following 12,096 operations, 353 (2.9%) patients had postoperative MI and 58 (16.4%) died. Post-MI coronary angiography was performed in 103 (29.2%) patients. Coronary angiography was not associated with 30-day mortality (odds ratio [OR]: .70, 95% CI: .35–1.42). Instead, 30-day mortality was predicted by revised cardiac risk index ≥3 (OR 1.91, 95% CI: 1.04–3.50) and prior bare metal stent (OR 2.12, 95% CI: 1.04–4.33).

Conclusions

Less than one-third of patients with coronary stents suffering postoperative MI underwent coronary angiography. Significant predictors of mortality were higher revised cardiac risk index and prior bare metal stent. These findings highlight the importance of comorbidities in predicting mortality following postoperative MI.