Effects of verapamil on myocardial performance in coronary disease

Verapamil, a calcium antagonist, has been used extensively for treatment of cardiac arrhythmias. Concern persists, however, that it may seriously depress myocardial function in cardiac patients. To investigate this possibility, 20 patients with coronary artery disease (CAD) but no heart failure were given intravenous verapamil (0.1 mg/kg bolus, followed by 0.005 mg/kg/min infusion), and studied hemodynamically and angiographically. Verapamil markedly lowered mean aortic pressure (94 +/- 17 to 82 +/- 13 mm Hg, p less than 0.0005) and systemic vascular resistance (1413 +/- 429 to 1069 +/- 235 dyn-sec-cm5, p less than 0.0005). Simultaneously, all indices of left ventricular (LV) performance greatly improved: cardiac index rose from 2.8 +/- 0.6 to 3.1 +/- 0.7 1/min/m2 (p less than 0.0005), mean velocity of circumferential fiber shortening increased from 0.85 +/- 0.39 to 0.97 +/- 0.46 circ/sec (p less than 0.01), and ejection fraction improved from 55 +/- 16 to 61 +/- 18% (p less than 0.01). No significant changes were noted in the heart rate before and after verapamil administration, and verapamil did not worsen the extent of LV asynergy in the majority of patients. In patients with CAD, the intrinsic negative inotropic effect of verapamil is of negligible importance because its potent vasodilatory properties more than compensate for any intrinsic decrease in LV contractility, and thereby improve the overall cardiac function.

Mortality and size of abdominal aortic aneurysm at long-term follow-up of patients not treated surgically and treated with and without statins

Of 130 patients with abdominal aortic aneurysms (AAAs) not treated surgically, 75 (58%) were treated with statins. The sizes of the AAAs were 4.6 +/- 0.6 cm at baseline and 4.5 +/- 0.6 cm at 23-month follow-up in patients treated with statins (p = NS) and 4.5 +/- 0.6 cm at baseline and 5.3 +/- 0.6 cm at 24-month follow-up in patients not treated with statins (p < 0.001). Four of 75 patients (5%) treated with statins died at 45-month follow-up, and 9 of 55 patients (16%) not treated with statins died at 44-month follow-up (p < 0.05).

Higher New York Heart Association classes and increased mortality and hospitalization in patients with heart failure and preserved left ventricular function

BACKGROUND

The association between higher New York Heart Association (NYHA) class and outcomes in patients with heart failure and preserved systolic function is not well known.

METHODS

We performed a retrospective follow-up study of 988 patients with heart failure with ejection fraction > 45% who participated in the DIG trial. Using Cox proportional hazard models, we estimated risks and all-cause mortality, heart failure mortality, all-cause hospitalization, and hospitalization due to worsening heart failure during a median follow-up of 38.5 months.

RESULTS

Patients had a median age of 68 years; 41.2% were women and 13.9%, nonwhites. Overall, 23.4% of patients died, and 19.9% were hospitalized because of worsening heart failure. Proportion of patients with NYHA classes I, II, III, and IV were 19.9%, 58.0%, 20.9%, and 1.2%, respectively, and 14.7%, 21.1%, 35.9%, and 58.3%, respectively, died of all causes (P < .001 for trend). Respective rates for heart failure-related hospitalizations were 14.2%, 17.1%, 32.5%, and 33.3% (P < .001 for trend). Compared with NYHA class I patients, adjusted hazard ratios (HRs) for all-cause mortality for class II, III, and IV patients were 1.54 (95% CI 1.02-2.32, P = .042), 2.56 (95% CI 1.64-24.01, P < .001), and 8.46 (95% CI 3.57-20.03, P < .001), respectively. Respective adjusted HRs (95% CI) for hospitalization due to heart failure for class II, III, and IV patients were 1.16 (0.76-1.77) (P = .502), 2.27 (1.45-3.56) (P < .001), and 3.71 (1.25-11.02) (P = 018). New York Heart Association classes II through IV were also associated with higher risk of all-cause hospitalization.

CONCLUSION

Higher NYHA classes were associated with poorer outcomes in patients with heart failure and preserved systolic function.

Cardiovascular Toxicities of Immune Checkpoint Inhibitors: JACC Review Topic of the Week

Immune checkpoint inhibitors (ICIs) have been an important therapeutic advance in the field of cancer medicine, resulting in a significant improvement in survival of patients with advanced malignancies. Recent reports provided greater insights into the incidence of cardiovascular adverse events (CVAEs) with ICI use. Myocarditis is the most common CVAE associated with ICI. Pericardial diseases, Takotsubo syndrome, arrhythmias, and vasculitis constitute other significant AEs. Physicians should be aware of these infrequent, but potentially fatal toxicities associated with ICIs as their therapeutic use becomes widespread with a myriad of approvals by the U.S. Food and Drug Administration. Management involves prompt administration of high-dose corticosteroids and discontinuation of ICIs in severe myocarditis. This review summarizes the most updated evidence on epidemiology, pathophysiological mechanisms, and management strategies of various CVAEs associated with ICIs. Highlights from recent guidelines published by National Comprehensive Cancer Network on ICI-related CV toxicities have also been incorporated.

Thirty-Day Readmissions After Transcatheter Aortic Valve Replacement in the United States: Insights From the Nationwide Readmissions Database

BACKGROUND

Readmissions after cardiac procedures are common and contribute to increased healthcare utilization and costs. Data on 30-day readmissions after transcatheter aortic valve replacement (TAVR) are limited.

METHODS AND RESULTS

Patients undergoing TAVR (International Classification of Diseases-Ninth Revision-CM codes 35.05 and 35.06) between January and November 2013 who survived the index hospitalization were identified in the Nationwide Readmissions Database. Incidence, predictors, causes, and costs of 30-day readmissions were analyzed. Of 12 221 TAVR patients, 2188 (17.9%) were readmitted within 30 days. Length of stay >5 days during index hospitalization (hazard ratio [HR], 1.47; 95% confidence interval [CI], 1.24-1.73), acute kidney injury (HR, 1.23; 95% CI, 1.05-1.44), >4 Elixhauser comorbidities (HR, 1.22; 95% CI, 1.03-1.46), transapical TAVR (HR, 1.21; 95% CI, 1.05-1.39), chronic kidney disease (HR, 1.20; 95% CI, 1.04-1.39), chronic lung disease (HR, 1.16; 95% CI, 1.01-1.34), and discharge to skilled nursing facility (HR, 1.16; 95% CI, 1.01-1.34) were independent predictors of 30-day readmission. Readmissions were because of noncardiac causes in 61.8% of cases and because of cardiac causes in 38.2% of cases. Respiratory (14.7%), infections (12.8%), bleeding (7.6%), and peripheral vascular disease (4.3%) were the most common noncardiac causes, whereas heart failure (22.5%) and arrhythmias (6.6%) were the most common cardiac causes of readmission. Median length of stay and cost of readmissions were 4 days (interquartile range, 2-7 days) and $8302 (interquartile range, $5229-16 021), respectively.

CONCLUSIONS

Thirty-day readmissions after TAVR are frequent and are related to baseline comorbidities, TAVR access site, and post-procedure complications. Awareness of these predictors can help identify and target high-risk patients for interventions to reduce readmissions and costs.

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.

Hemodynamics and antianginal effects of high dose oral isosorbide dinitrate after chronic use

In a randomized, double-blind, crossover study, 19 patients with angina were exercised 2 min after 0.4 mg sublingual nitroglycerin and after sublingual placebo and before and 1, 3, and 5 hours after oral isosorbide dinitrate (ISDN) and oral placebo. After initial testing, patients took the dose of ISDN they had had during the study (mean dose 29 mg) for a mean period of 5.6 months before retesting using the same protocol. Compared to placebo, exercise time after sublingual nitroglycerin increased 56% (P less than 0.001) initially and 51% (P less than 0.001) at retest. Compared to placebo, exercise time increased 58% (P less than 0.05) initially and 58% (P less than 0.005) at retest 1 hour after ISDN, 38% (P less than 0.05) initially and 27% (P less than 0.005) at retest 3 hours after ISDN, and 13% (NS) initially and 21% (P less than 0.02) at retest five hours after ISDN. The mean exericse times initially and at retest were not significantly different. Hemodynamic changes (decrease in systolic blood pressure and increase in heart rate) at 15 min persisted through 300 min after ISDN during both initial testing and during retesting. However, these changes were significantly less during retesting. We conclude that a partial tolerance to the hemodynamic effects of the drug develops after chronic use of high dose oral ISDN but that the antianginal efficacy of both sublingual nitroglycerin and oral ISDN is unimpaired.

Hypokalemia and outcomes in patients with chronic heart failure and chronic kidney disease: findings from propensity-matched studies

BACKGROUND

Little is known about the effects of hypokalemia on outcomes in patients with chronic heart failure (HF) and chronic kidney disease.

METHODS AND RESULTS

Of the 7788 patients with chronic HF in the Digitalis Investigation Group trial, 2793 had chronic kidney disease, defined as estimated glomerular filtration rate <60 mL/min per 1.73 m(2). Of these, 527 had hypokalemia (serum potassium <4 mEq/L; mild) and 2266 had normokalemia (4 to 4.9 mEq/L). Propensity scores for hypokalemia were used to assemble a balanced cohort of 522 pairs of patients with hypokalemia and normokalemia. All-cause mortality occurred in 48% and 36% of patients with hypokalemia and normokalemia, respectively, during 57 months of follow-up (matched hazard ratio when hypokalemia was compared with normokalemia, 1.56; 95% CI, 1.25 to 1.95; P<0.0001). Matched hazard ratios (95% CIs) for cardiovascular and HF mortalities and all-cause, cardiovascular, and HF hospitalizations were 1.65 (1.29 to 2.11; P<0.0001), 1.82 (1.28 to 2.57; P<0.0001), 1.16 (1.00 to 1.35; P=0.036), 1.27 (1.08 to 1.50; P=0.004), and 1.29 (1.05 to 1.58; P=0.014), respectively. Among 453 pairs of balanced patients with HF and chronic kidney disease, all-cause mortality occurred in 47% and 38% of patients with mild hypokalemia (3.5 to 3.9 mEq/L) and normokalemia, respectively (matched hazard ratio, 1.31; 95% CI, 1.03 to 1.66; P=0.027). Among 169 pairs of balanced patients with estimated glomerular filtration rate <45 mL/min per 1.73 m(2), all-cause mortality occurred in 57% and 47% of patients with hypokalemia (<4 mEq/L; mild) and normokalemia, respectively (matched hazard ratio, 1.53; 95% CI, 1.07 to 2.19; P=0.020).

CONCLUSIONS

In patients with HF and chronic kidney disease, hypokalemia (serum potassium <4 mEq/L) is common and associated with increased mortality and hospitalization.

Catheter ablation of postinfarction ventricular tachycardia: ten-year trends in utilization, in-hospital complications, and in-hospital mortality in the United States

BACKGROUND

There is a paucity of data regarding the complications and in-hospital mortality after catheter ablation for ventricular tachycardia (VT) in patients with ischemic heart disease.

OBJECTIVE

The purpose of this study was to determine the temporal trends in utilization, in-hospital mortality, and complications of catheter ablation of postinfarction VT in the United States.

METHODS

We used the 2002-2011 Nationwide Inpatient Sample (NIS) database to identify all patients ≥18 years of age with a primary diagnosis of VT (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] code 427.1) and who also had a secondary diagnosis of prior history of myocardial infarction (ICD-9-CM 412). Patients with supraventricular arrhythmias were excluded. Patients who underwent catheter ablation were identified using ICD-9-CM procedure code 37.34. Temporal trends in catheter ablation, in-hospital complications, and in-hospital mortality were analyzed.

RESULTS

Of 81,539 patients with postinfarct VT, 4653 (5.7%) underwent catheter ablation. Utilization of catheter ablation increased significantly from 2.8% in 2002 to 10.8% in 2011 (Ptrend < .001). The overall rate of any in-hospital complication was 11.2% (523/4653), with vascular complications in 6.9%, cardiac in 4.3%, and neurologic in 0.5%. In-hospital mortality was 1.6% (75/4653). From 2002 to 2011, there was no significant change in the overall complication rates (8.4% to 10.2%, Ptrend = .101; adjusted odds ratio [per year] 1.02, 95% confidence interval 0.98-1.06) or in-hospital mortality (1.3% to 1.8%, Ptrend = .266; adjusted odds ratio [per year] 1.03, 95% confidence interval 0.92-1.15).

CONCLUSION

The utilization rate of catheter ablation as therapy for postinfarct VT has steadily increased over the past decade. However, procedural complication rates and in-hospital mortality have not changed significantly during this period.

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.

Sustained hemodynamic and antianginal effect of high dose oral isosorbide dinitrate

Twenty-one patients with documented coronary atherosclerotic heart disease were studied to determine the effect of high dose oral isosorbide dinitrate (ISDN) on heart rate, blood pressure, and exercise time until angina pectoris. Patients were tested in two phases, initially with 0.4 mg of sublingual nitroglycerin and with sublingual placebo, and then with oral ISDN, mean dose 29 mg, and oral placebo. Both phases of the study were conducted in a randomized, double-blind, crossover manner. After ISDN was compared to oral placebo, heart rate increased at 30 to 300 min (P less than 0.01) (peak increase 18 beats/min at 60 min), and systolic blood pressure decreased from 45 to 300 min (P less than 0.005) (peak decrease 18 mm Hg at 60 min). Exercise time at 2 min after sublingual nitroglycerin increased 51% as compared to oral placebo, exercise time increased 54% at 1 hr (P less than 0.005), 37% at 3 hr (P less than 0.01), and 12% at 5 hr (NS). Twelve of 21 patients (57%) improved their exercise time until angina larger than or equal to 25% at 1 hr after oral ISDN. The exercise response to sublingual nitroglycerin was a good predictor of this response to oral ISDN.

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.

Regional variation in the incidence and outcomes of in-hospital cardiac arrest in the United States

BACKGROUND

Regional variation in the incidence and outcomes of in-hospital cardiac arrest (IHCA) is not well studied and may have important health and policy implications.

METHODS AND RESULTS

We used the 2003 to 2011 Nationwide Inpatient Sample databases to identify patients≥18 years of age who underwent cardiopulmonary resuscitation (International Classification of Diseases, Ninth Edition, Clinical Modification procedure codes 99.60 and 99.63) for IHCA. Regional differences in IHCA incidence, survival to hospital discharge, and resource use (total hospital cost and discharge disposition among survivors) were analyzed. Of 838,465 patients with IHCA, 162,270 (19.4%) were in the Northeast, 159,581 (19.0%) were in the Midwest, 316,201 (37.7%) were in the South, and 200,413 (23.9%) were in the West. Overall IHCA incidence in the United States was 2.85 per 1000 hospital admissions. IHCA incidence was lowest in the Midwest and highest in the West (2.33 and 3.73 per 1000 hospital admissions, respectively). Compared with the Northeast, risk-adjusted survival to discharge was significantly higher in the Midwest (odds ratio, 1.33; 95% confidence interval, 1.31-1.36), South (odds ratio, 1.21; 95% confidence interval, 1.19-1.23), and West (odds ratio, 1.25; 95% confidence interval, 1.23-1.27). IHCA survival increased significantly from 2003 to 2011 in the United States and in all regions (all Ptrend<0.001). Total hospital cost was highest in the West, whereas discharge to skilled nursing facility and use of home health care among survivors was highest in the Northeast.

CONCLUSIONS

We observed significant regional variation in IHCA incidence, survival, and resource use in the United States. This variation was explained only partially by differences in patient and hospital characteristics. Further studies are needed to identify other potential factors responsible for these regional differences to improve outcomes after IHCA.

Association of Chronic Kidney Disease With In-Hospital Outcomes of Transcatheter Aortic Valve Replacement

OBJECTIVES

This study sought to determine the association of chronic kidney disease (CKD) with in-hospital outcomes of transcatheter aortic valve replacement (TAVR).

BACKGROUND

CKD is a known independent risk factor for worse outcomes after surgical aortic valve replacement (SAVR). However, data on outcomes of patients with CKD undergoing TAVR are limited, especially in those on chronic dialysis.

METHODS

The authors used data from the 2012 to 2014 National Inpatient Sample database to identify all patients ≥18 years of age who underwent TAVR. International Classification of Diseases-Ninth Revision-Clinical Modification codes were used to identify patients with no CKD, CKD (without chronic dialysis), or end-stage renal disease (ESRD) on long-term dialysis. Multivariable logistic regression models were constructed using generalized estimating equations to examine in-hospital outcomes.

RESULTS

Of 41,025 patients undergoing TAVR from 2012 to 2014, 25,585 (62.4%) had no CKD, 13,750 (33.5%) had CKD, and 1,690 (4.1%) had ESRD. Compared with patients with no CKD, in-hospital mortality was significantly higher in patients with CKD or ESRD (3.8% vs. 4.5% vs. 8.3%; adjusted odds ratio [no CKD as reference]: 1.39 [95% confidence interval: 1.24 to 1.55] for CKD and 2.58 [95% confidence interval: 2.09 to 3.13] for ESRD). Patients with CKD or ESRD had a higher incidence of major adverse cardiovascular events (composite of death, myocardial infarction, or stroke), net adverse cardiovascular events (composite of major adverse cardiovascular events, major bleeding, or vascular complications), and pacemaker implantation compared with patients without CKD. Acute kidney injury (AKI) and AKI requiring dialysis were associated with several-fold higher risk-adjusted in-hospital mortality in patients in the no CKD and CKD groups. Moreover, the incidence of AKI and AKI requiring dialysis did not decline during the study period.

CONCLUSIONS

Patients with CKD or ESRD have worse in-hospital outcomes after TAVR. AKI is associated with higher in-hospital mortality in patients undergoing TAVR and the incidence of AKI has not declined over the years.

Cardiovascular drug therapy in the elderly: benefits and challenges

Increasing life expectancy in industrialized societies has resulted in a huge population of older adults with cardiovascular disease. Despite advances in device therapy and surgery, the mainstay of treatment for these disorders remains pharmacological. Hypertension affects two-thirds of older adults and remains a potent risk factor for coronary artery disease, chronic heart failure, atrial fibrillation, and stroke in this age group. Numerous trials have demonstrated reduction in these adverse outcomes with antihypertensive drugs. After acute myocardial infarction, β-adrenergic blockers reduce mortality regardless of patient age. Statins and antiplatelet drugs have proven beneficial in both primary and, especially, secondary prevention of coronary events in older adults. In elders with chronic heart failure, loop diuretics must be used cautiously, owing to their higher potential for adverse effects, whereas angiotensin-converting-enzyme inhibitors and β-blockers reduce symptoms and prolong survival. The high risk of stroke in elderly patients with atrial fibrillation is markedly reduced with warfarin, although bleeding risk is increased. The high prevalence of polypharmacy among older adults with cardiovascular disease, coupled with age-associated physiological changes and comorbidities, provides major challenges in adherence and avoidance of drug-related adverse events.

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.

Modifiable Risk Factors in Young Adults With First Myocardial Infarction

BACKGROUND

Modifiable risk factors (RFs) play an important role in the development and prognosis of acute myocardial infarction (AMI).

OBJECTIVES

This study sought to study the prevalence rates of modifiable RFs during a first AMI, sex/race differences, and temporal trends in U.S. young adults.

METHODS

This was a retrospective cohort analysis of the U.S. National Inpatient Sample years 2005 and 2015 to identify adults 18 to 59 years of age hospitalized for a first AMI. Prevalence rates, race and sex differences, and temporal trends of hypertension, diabetes mellitus, obesity, smoking, dyslipidemia, and drug abuse were analyzed in these patients.

RESULTS

The authors' study included 1,462,168 young adults with a first AMI (mean age 50 ± 7 years, 71.5% men, 58.3% white) of whom 19.2% were 18 to 44 years of age, and 80.8% were 45 to 59 years of age. In the 18- to 44-year group, smoking (56.8%), dyslipidemia (51.7%), and hypertension (49.8%) were most prevalent, and 90.3% of patients had at least 1 RF. In the 45- to 59-year group, hypertension (59.8%), dyslipidemia (57.5%), and smoking (51.9%) were most prevalent, and 92% patients had at least 1 RF. Significant sex and racial disparities were observed in the prevalence of individual RFs. Women had a higher prevalence of diabetes mellitus, hypertension, and obesity, and men had a higher prevalence of dyslipidemia, drug abuse, and smoking. The prevalence of all these RFs increased temporally except for the rate of dyslipidemia, which decreased more recently. Trends were generally consistent across sex and racial groups.

CONCLUSIONS

During a first AMI in young adults in whom preventive measures are more likely to be effective, modifiable RFs were highly prevalent and progressively increased over time. Significant sex and racial disparities were observed for individual RFs.

Statin intolerance - an attempt at a unified definition. Position paper from an International Lipid Expert Panel

Statins are one of the most commonly prescribed drugs in clinical practice. They are usually well tolerated and effectively prevent cardiovascular events. Most adverse effects associated with statin therapy are muscle-related. The recent statement of the European Atherosclerosis Society (EAS) has focused on statin-associated muscle symptoms (SAMS), and avoided the use of the term 'statin intolerance'. Although muscle syndromes are the most common adverse effects observed after statin therapy, excluding other side effects might underestimate the number of patients with statin intolerance, which might be observed in 10 - 15% of patients. In clinical practice, statin intolerance limits effective treatment of patients at risk of, or with, cardiovascular disease. Knowledge of the most common adverse effects of statin therapy that might cause statin intolerance and the clear definition of this phenomenon is crucial to effectively treat patients with lipid disorders. Therefore, the aim of this position paper was to suggest a unified definition of statin intolerance, and to complement the recent EAS statement on SAMS, where the pathophysiology, diagnosis and the management were comprehensively presented.