Risk factors for new coronary events in a large cohort of very elderly patients with and without coronary artery disease

Independent risk factors for new coronary events in older men include age, prior coronary artery disease, cigarette smoking, systemic hypertension, diabetes mellitus, serum total cholesterol, and serum high-density lipoprotein cholesterol (inverse association). Independent risk factors for new coronary events in older women include age, prior coronary artery disease, cigarette smoking, systemic hypertension, diabetes mellitus, serum total cholesterol, serum high-density lipoprotein cholesterol (inverse association), and serum triglycerides (weak association).

Normal left ventricular ejection fraction in older persons with congestive heart failure

STUDY OBJECTIVES

To investigate in older patients with congestive heart failure (CHF) associated with prior myocardial infarction or hypertension the relationship between normal left ventricular (LV) ejection fraction and age, gender, hypertension, prior myocardial infarction, and atrial fibrillation.

DESIGN

A prospective study was performed in 572 older patients (age >60 years) with CHF associated with prior myocardial infarction or hypertension and technically adequate two-dimensional echocardiograms for measuring LV ejection fraction.

SETTING

A long-term health-care facility.

PATIENTS

One hundred seventy-seven men and 395 women, mean age 82+/-8 years, with CHF associated with prior myocardial infarction or hypertension.

MEASUREMENTS AND RESULTS

Normal LV ejection fraction (> or = 50%) occurred in 66 of 177 men (37%) and in 221 of 395 women (56%) (p<0.0001). Multiple logistic regression analysis showed that independent risk factors for normal LV ejection fraction in patients with CHF were no prior myocardial infarction (p=0.0001; odds ratio=3.048), female gender (p=0.0004; odds ratio=1.978), and age (p=0.016; odds ratio=1.029).

CONCLUSIONS

Normal LV ejection fraction occurred in 50% of 572 older patients with CHF associated with prior myocardial infarction or hypertension. Independent risk factors for normal LV ejection fraction in patients with CHF were no prior myocardial infarction, female gender, and age.

A propensity-matched study of the association of peripheral arterial disease with cardiovascular outcomes in community-dwelling older adults

The association between peripheral arterial disease (PAD) and outcomes has not been studied in a propensity-matched population of community-dwelling older adults. A public-use copy of the Cardiovascular Health Study (CHS) data was analyzed to test the hypothesis that baseline PAD is associated with increased all-cause mortality and cardiovascular morbidity. Of the 5,795 CHS participants, 5,630 had data on baseline ankle-brachial index, and 767 had PAD, defined as ankle-brachial index <0.9. Propensity scores for PAD were calculated for each participant using 66 baseline covariates and were used to match 679 pairs of participants with and without PAD. Matched Cox regression models were used to estimate associations of PAD with outcomes during a median follow-up period of 7.5 years. Overall, 55% of matched participants died from all causes during 9,958 patient-years of follow-up. All-cause mortality occurred in 61% (rate 8,710/100,000 patient-years) and 50% (rate 6,503/100,000 patient-years) of participants, respectively, with and without PAD (matched hazard ratio for PAD vs no PAD 1.47, 95% confidence interval (CI) 1.23 to 1.76, p <0.0001). Prematch unadjusted, multivariable-adjusted, and propensity-adjusted hazard ratios for PAD-associated all-cause mortality were 2.90 (95% CI 2.61 to 3.21, p <0.0001), 1.53 (95% CI 1.36 to 1.71, p <0.0001), and 1.57 (95% CI 1.39 to 1.78, p <0.0001), respectively. Matched hazard ratios for PAD for incident heart failure and symptomatic PAD were 1.32 (95% CI 1.00 to 1.73, p = 0.052) and 3.92 (95% CI 2.13 to 7.21, p <0.0001), respectively. In conclusion, in a propensity-matched well-balanced population of community-dwelling older adults, baseline PAD was associated with increased all-cause mortality and cardiovascular morbidity.

Prevalence of atrial fibrillation and association of atrial fibrillation with prior and new thromboembolic stroke in older patients

OBJECTIVE

To correlate atrial fibrillation with the incidence of new thromboembolic (TE) stroke in older patients with and without prior TE stroke.

DESIGN

In a prospective study of 2101 older patients, electrocardiograms showed that atrial fibrillation was present in 283 patients (13%). At 42-month mean follow-up, atrial fibrillation was associated with the incidence of new TE stroke in patients with and without prior TE stroke.

SETTING

A large long-term health care facility where 2101 older patients were studied.

PATIENTS

The 2101 patients included 1451 women and 650 men, mean age 81 +/- 8 years (range 60 to 103).

MEASUREMENTS AND MAIN RESULTS

Atrial fibrillation was present in 283 of 2101 patients (13%). The mean age was 84 +/- 7 years in patients with atrial fibrillation and 81 +/- 8 years in patients with sinus rhythm (P = .0001). The prevalence of atrial fibrillation was 5% in patients aged 60 to 70 years, 14% in patients aged 71 to 80 years, 13% in patients aged 81 to 90 years, and 22% in patients aged 91 to 103 years (P < .0001). Mean follow-up was 31 +/- 18 months in patients with atrial fibrillation and 44 +/- 27 months in patients with sinus rhythm (P = .0001). Previous TE stroke occurred in 123 of 283 patients (43%) with atrial fibrillation and in 431 of 1818 patients (24%) with sinus rhythm (P < .0001). New TE stroke occurred in 131 of 283 patients (46%) with atrial fibrillation and in 303 of 1818 patients (17%) with sinus rhythm (P < .0001). The log-rank test showed that patients with atrial fibrillation had a significantly higher probability of developing new TE stroke than those with sinus rhythm (P < .0001). The multivariate Cox regression model showed that independent risk factors for new TE stroke were male sex (relative risk = 1.3), prior TE stroke (relative risk = 3.1), and atrial fibrillation (relative risk = 3.3).

CONCLUSIONS

Atrial fibrillation, prior TE stroke, and male sex are independent risk factors for the development of new TE stroke in older patients.

Effect of smoking marihuana and of a high-nicotine cigarette on angina pectoris

The purpose of this study was to determine the effect of smoking marihuana and of high-nicotine cigarettes on exercise-induced angina pectoris. Smoking 1 marihuana cigarette increased the resting product of systolic blood pressure times heart rate 54%, increased the venous carboxyhemoglobin level, and decreased the exercise time until angina 50% in 10 patients with angina pectoris. Smoking 1 high-nicotine cigarette increased the resting product of systolic blood pressure times heart rate 36%, increased the venous carboxyhemoglobin level, and decreased the exercise time until angina 23%. Smoking either marihuana or high-nicotine cigarettes decreases exercise performance until angina by increasing myocardial oxygen demand and by decreasing myocardial oxygen delivery. Smoking 1 marihuana cigarette decreased the exercise time until angina more than smoking 1 high-nicotine cigarette (p less than 0.001).

Risk factors for new thromboembolic stroke in patients > or = 62 years of age with chronic atrial fibrillation

In a prospective study of 312 older patients with chronic atrial fibrillation, at 36-month follow-up evaluation, new thromboembolic stroke developed in 162 of 312 patients (52%). Significant independent risk factors for new thromboembolic stroke were prior stroke (risk ratio = 1.6), rheumatic mitral stenosis (risk ratio = 2.0), left ventricular (LV) hypertrophy (risk ratio = 2.8), abnormal LV ejection fraction (risk ratio = 1.8), serum total cholesterol (risk ratio = 1.005), and serum high-density lipoprotein cholesterol (risk ratio = 0.96).

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

BACKGROUND

We report the prevalence and incidence of cardiovascular disease in older men and women in a long-term health care facility.

METHODS

The prevalence of hypertension, chronic atrial fibrillation, pacemaker rhythm, coronary artery disease (CAD), thromboembolic stroke, and symptomatic peripheral arterial disease (PAD) and the incidence of new coronary events, thromboembolic stroke, and congestive heart failure (CHF) were investigated in 1160 men, mean age 80 +/- 8 years, and in 2464 women, mean age 81 +/- 8 years, in a long-term health care facility. Mean follow-up was 46 +/- 30 months.

RESULTS

The prevalences of hypertension, pacemaker rhythm, CAD, and thromboembolic stroke were similar in men and women. The prevalence of atrial fibrillation was higher in men (16%) than in women (13%; p =.019). The prevalence of PAD was higher in men (32%) than in women (26%; p =.0001). At the 46-month follow-up, the incidences of new coronary events, thromboembolic stroke, and CHF were similar in men and women.

CONCLUSIONS

Older men and women in a long-term health care facility have a high prevalence and incidence of cardiovascular disease. The prevalences of hypertension, pacemaker rhythm, CAD, and thromboembolic stroke and the incidences of new coronary events, thromboembolic stroke, and CHF were similar in men and women. However, the prevalences of atrial fibrillation and of PAD were higher in men than in women.

Effect of carbon monoxide exposure on intermittent claudication

The effect of breathing 50 ppm of carbon monoxide for two hours versus compressed, purified air for two hours on intermittent claudication was evaluated in ten men in a double-blind study. The mean venous carboxyhemoglobin level insignificantly decreased from 1.12% to 0.90% after breathing compressed, purified air but significantly increased from 1.08% to 2.77% after breathing carbon monoxide ( P < 0.001). The mean exercise time until the onset of intermittent claudication insignificantly increased from 169 sec to 173 sec after breathing compressed, purified air but significantly decreased from 174 sec to 144 sec after breathing carbon monoxide ( P < 0.001). Breathing 50 ppm of carbon monoxide for 2 hr significantly aggravated intermittent claudication of the calf or thigh due to angiographically documented occlusive arterial disease.

Effect of carbon monoxide on maximal treadmill exercise. A study in normal persons

The effect of breathing 100 ppm of carbon monoxide versus compressed, purified air for 1 h on maximal treadmill exericse was studied (double-blind crossover design) in 10 middle-aged, healthy nonsmokers. The mean venous carboxyhemoglobin level significantly increased from 1.67% to 3.95% after breathing carbon monoxide (P less than 0.001) and significantly decreased from 1.63% to 1.30% after breathing compressed, purified air (P less than 0.001). The mean exercise time until exhaustion significantly decreased from 697.7 to 662.7 s after breathing carbon monoxide (P less than 0.001) and insignificantly increased from 694.9 s to 703.4 s after breathing compressed, purified air. Ischemic S-T segment depression larger than or equal to 1.0 mm after exercise occurred in 1 of 10 subjects after exercise following carbon monoxide inhalation. Increased carboxyhemoglobin levels of the magnitude encountered after smoking or heavy atmospheric pollution impair exercise performance in normal persons.

Prognosis of congestive heart failure after prior myocardial infarction in older persons with atrial fibrillation versus sinus rhythm

In a prospective study of 651 older persons with congestive heart failure after prior myocardial infarction, persons with atrial fibrillation had a significantly higher mortality than those with sinus rhythm if they had an abnormal (p = 0.005) or normal (p = 0.0001) left ventricular ejection fraction. The Cox regression model showed that significant independent risk factors for total mortality were age (risk ratio 1.03 for an increment of 1 year of age), hypertension (risk ratio 1.2), diabetes mellitus (risk ratio 1.4), abnormal left ventricular ejection fraction (risk ratio 2.1), and atrial fibrillation (risk ratio 1.5).

Association of average heart rate on 24-hour ambulatory electrocardiograms with incidence of new coronary events at 48-month follow-up in 1,311 patients (mean age 81 years) with heart disease and sinus rhythm

A prospective study performed in 1,311 men and women, mean age 81 years, with heart disease and sinus rhythm showed at 48-month follow-up that male sex, increasing age, and average 24-hour heart rate measured from 24-hour ambulatory electrocardiograms were independent risk factors for new coronary events. There was a 1.14 times higher chance of developing new coronary events for an increment of 5 beats/min of heart rate after controlling the confounding effect of other risk factors.

Five year follow-up of double Master's test, maximal treadmill stress test, and resting and postexercise apexcardiogram in asymptomatic persons

The double Master's test, the maximal treadmill stress test, the resting apexcardiogram, and the postexercise apexcardiogram significantly correlated with the development of subsequent coronary heart disease within five years in 100 asymptomatic persons. The maximal treadmill stress test correlated better than the double Master's test in predicting subsequent coronary heart disease. The presence of both an abnormal maximal treadmill stress and an abnormal a-wave ratio in the postexercise apexcardiogram had the best value in predicting subsequent coronary heart disease.