Effect of propranolol versus no propranolol on total mortality plus nonfatal myocardial infarction in older patients with prior myocardial infarction, congestive heart failure, and left ventricular ejection fraction > or = 40% treated with diuretics plus angiotensin-converting enzyme inhibitors

At 32-month follow-up of older patients with prior myocardial infarction, congestive heart failure, and a left ventricular ejection fraction > or = 40% treated with diuretics plus angiotensin-converting enzyme inhibitors, and also with digoxin if atrial fibrillation was present, propranolol caused a 35% significant reduction in total mortality and a 37% significant decrease in total mortality plus nonfatal myocardial infarction compared with no propranolol. At 1-year follow-up, propranolol caused a significantly greater increase in left ventricular ejection fraction (6%) and a significantly greater reduction in left ventricular mass (34 g) than did no propranolol (2% and 20 g, respectively).

Effect of simvastatin versus placebo on treadmill exercise time until the onset of intermittent claudication in older patients with peripheral arterial disease at six months and at one year after treatment

Simvastatin significantly increased treadmill exercise time until onset of intermittent claudication from baseline by 54 seconds (a 24% increase, p <0.0001) at 6 months after treatment and by 95 seconds (a 42% increase, p <0.0001) at 1 year after treatment. At 6 months and 1 year after treatment with placebo, treadmill exercise time until onset of intermittent claudication was not significantly different from baseline exercise time.

Congestive heart failure, coronary events and atherothrombotic brain infarction in elderly blacks and whites with systemic hypertension and with and without echocardiographic and electrocardiographic evidence of left ventricular hypertrophy

Hypertension was present in 50% of 196 blacks and in 36% of 382 whites (p less than 0.001). A prospective study of 84 elderly blacks (70% women) and 326 elderly whites (73% women) with hypertension correlated echocardiographic and electrocardiographic left ventricular (LV) hypertrophy with incidences of congestive heart failure (CHF), coronary events and atherothrombotic brain infarction (ABI). Echocardiographic LV hypertrophy (p less than 0.02) and concentric LV hypertrophy (p less than 0.001) were more prevalent in hypertensive blacks than in hypertensive whites. Hypertensive blacks were younger (78 +/- 9 years) than hypertensive whites (82 +/- 7 years) (p less than 0.001). Other coronary risk factors were similar, except for higher serum triglycerides in whites than in blacks (p less than 0.02). Follow-up was 37 +/- 18 months in blacks and 43 +/- 18 months in whites (p less than 0.01). Incidences of CHF and coronary events were not significantly different in blacks and whites. ABI incidence was 38% in blacks and 21% in whites (p less than 0.005). Multiple logistic regression analysis showed that prior CHF (p = 0.000), concentric LV hypertrophy (p = 0.018) and echocardiographic LV hypertrophy (p = 0.022) were independent risk factors for CHF. Echocardiographic LV hypertrophy (p = 0.001), serum total cholesterol (p = 0.002), concentric LV hypertrophy (p = 0.005) and prior coronary artery disease (p = 0.042) were independent risk factors for coronary events. Prior ABI (p = 0.001), echocardiographic LV hypertrophy (p = 0.001) and electrocardiographic LV hypertrophy (p = 0.034) were independent risk factors for ABI.

Effect of passive smoking on angina pectoris

The effect of passive smoking on exercis-induced angina in a well ventilated and in an unventilated room was evaluated in 10 patients with angina. Patients exposed to 15 cigarettes smoked within two hours in a well ventilated room or an unventilated room increased their resting heart rate, systolic and diastolic blood pressure, and venous carboxyhemoglobin and decreased their heart rate and systolic blood pressure at angina. Patients exposed to passive smoking in an unventilated room had a larger increase in resting heart rate, systolic and diastolic blood pressure, and venous carboxyhemoglobin and a greater reduction in heart rate and systolic blood pressure at angina. The duration of exercise until angina was decreased 22 per cent after passive smoking in a well ventilated room (P less than 0.001), and decreased 38 per cent after passive smoking in an unventilated room (P less than 0.001). Passive smoking aggravates angina pectoris.

Incidence of heart failure in 2,737 older persons with and without diabetes mellitus

STUDY OBJECTIVES

To investigate in older persons whether diabetes mellitus is an independent risk factor for congestive heart failure (CHF).

DESIGN

A prospective study was performed in 2,737 older persons investigating the incidence of new CHF in persons with and without diabetes mellitus.

SETTING

A long-term health-care facility.

PATIENTS

Eight hundred sixty-five men and 1,872 women, with a mean age of 81+/-9 years.

MEASUREMENTS AND RESULTS

At 43-month follow-up, new CHF developed in 272 of 690 persons (39%) with diabetes mellitus and in 467 of 2,047 persons (23%) without diabetes mellitus (p < 0.0001). Cox regression analysis showed that age (p = 0.0001, risk ratio = 1.048), hypertension (p = 0.0001, risk ratio = 2.524), coronary artery disease (p = 0.0001, risk ratio = 4.008), male gender (p = 0.0001, risk ratio = 1.399), and diabetes mellitus (p = 0.0003, risk ratio = 1.337) were significantly positively associated with the time to the development of CHF.

CONCLUSIONS

Older persons with diabetes mellitus had a 1.3 times higher chance of developing CHF than those without diabetes mellitus after controlling the confounding effects of other prognostic variables.

Association of postprandial hypotension with incidence of falls, syncope, coronary events, stroke, and total mortality at 29-month follow-up in 499 older nursing home residents

OBJECTIVE

To investigate whether a marked decrease in postprandial systolic blood pressure correlates with a higher incidence of falls, syncope, new coronary events, new stroke, and total mortality at long-term follow-up in older nursing home residents.

DESIGN

In a prospective study of 499 nursing home residents aged 62 years or older, at 29-month mean follow-up, the maximal reduction in postprandial systolic blood pressure was correlated with the incidence of falls, syncope, new coronary events, new stroke, and total mortality.

SETTING

A large long-term health care facility.

PATIENTS

The 499 ambulatory or wheelchair-bound residents included 354 women and 145 men, mean age 80 +/- 9 years (range 62-100).

MEASUREMENTS AND MAIN RESULTS

The mean follow-up was 29 +/- 10 months (range 1-36). At follow-up, falls had occurred in 199 persons (40%), syncope in 72 persons (14%), new coronary events in 139 persons (28%), new stroke in 61 persons (12%), and total mortality in 199 persons (40%). The mean maximal decrease in postprandial systolic blood pressure was 20 +/- 5 mm Hg for persons with falls and 12 +/- 4 mm Hg in persons without falls (P < 0.001); 23 +/- 5 mm Hg in persons with syncope and 14 +/- 5 mm Hg in persons without syncope (P < 0.001); 18 +/- 6 mm Hg in persons with coronary events and 14 +/- 5 mm Hg in persons without coronary events (P < 0.001); 21 +/- 6 mm Hg in persons with stroke and 15 +/- 5 mm Hg in persons without stroke (P < 0.001); and 17 +/- 6 mm Hg in persons who died and 15 +/- 5 mm Hg in persons who did not die (P < 0.001). Maximal decrease in postprandial systolic blood pressure was an independent risk factor for falls, syncope, new coronary events, new stroke, and total mortality. Age was an independent risk factor for new coronary events and for total mortality. Male sex was an independent risk factor for syncope, new coronary events, stroke, and total mortality. Prior falls was an independent risk factor for new falls. Prior syncope was an independent risk factor for new syncope. Prior stroke was an independent risk factor for new stroke.

CONCLUSIONS

A marked reduction in postprandial systolic blood pressure in older nursing home residents was associated at long-term follow-up with a higher incidence of falls, syncope, new coronary events, new stroke, and total mortality.

Epidemiology, pathophysiology, prognosis, and treatment of systolic and diastolic heart failure

Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF such as nonsteroidal antiinflammatory drugs should be stopped. Patients with HF and a low left ventricular ejection fraction (systolic heart failure) or normal ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL.

Comparison of incidences of congestive heart failure in older African-Americans, Hispanics, and whites

In a prospective study of 2,893 African-Americans, Hispanics, and whites, mean age 81 years, at 43-month follow-up, congestive heart failure (CHF) developed in 194 of 686 African-Americans (28%), in 67 of 257 Hispanics (26%), and in 533 of 1,950 whites (27%) (p = NS). The Cox regression model showed that significant independent risk factors for CHF were male gender (risk ratio = 1.4, p = 0.0001); hypertension (risk ratio = 2.5, p = 0.0001); coronary artery disease (risk ratio = 4.0, p = 0.0001); diabetes mellitus (risk ratio = 1.6, p = 0.0001); and age (risk ratio = 1.05, p = 0.0001).

Postprandial hypotension in 499 elderly persons in a long-term health care facility

OBJECTIVE

To present baseline data from a prospective study of postprandial hypotension in 499 elderly persons in a long-term health care facility.

DESIGN

Analyses of baseline data for a prospective study.

SETTING

A large long-term health care facility where 499 ambulatory or wheelchair-bound residents were studied.

PATIENTS

The 499 residents were > or = 62 years of age, mean age 80 +/- 9 years (range 62-100), 71% female, 29% male, 66% white, 27% black, 7% Hispanic, 68% ambulatory, and 32% wheelchair-bound.

MEASUREMENTS AND MAIN RESULTS

The mean maximal decrease in postprandial systolic and diastolic blood pressures was 15 +/- 6 mm Hg/6 +/- 2 mm Hg. The mean maximal decrease in postprandial systolic blood pressure occurred 15 minutes after eating in 13% of residents, 30 minutes after eating in 20% of residents, 45 minutes after eating in 26% of residents, 60 minutes after eating in 30% of residents, and 75 minutes after eating in 11% of residents. Of 499 residents, 118 (24%) had a maximal decrease in postprandial systolic blood pressure of > or = 20 mm Hg. The mean maximal decrease in postprandial systolic blood pressure was 24 +/- 5 mm Hg in residents with syncope in the prior 6 months and 14 +/- 5 mm Hg in residents without syncope (P < 0.0001). The mean maximal decrease in postprandial systolic blood pressure was 21 +/- 5 mm Hg in residents with falls in the preceding 6 months and 13 +/- 4 mm Hg in residents without falls (P < 0.0001). The mean maximal decrease in postprandial systolic blood pressure was significantly greater in residents treated with angiotensin-converting enzyme inhibitors, calcium channel blockers, diuretics, nitrates, digoxin, and psychotropic drugs than in residents not treated with these drugs. The mean maximal decrease in postprandial systolic and diastolic blood pressures was not significantly different in elderly blacks, Hispanics, and whites.

CONCLUSIONS

A more severe reduction in postprandial systolic blood pressure correlates with a history of syncope or falls in the previous 6 months. Long-term follow-up is being planned to determine whether a marked reduction in postprandial systolic blood pressure in elderly persons correlates with a higher incidence of falls, syncope, new coronary events, new stroke, and total mortality.

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).