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

Current approaches to the treatment of hypertension in older persons

Hypertension is a major risk factor for cardiovascular disease and is present in 69% of patients with a first myocardial infarction, in 77% of patients with a first stroke, in 74% of patients with chronic heart failure, and in 60% of patients with peripheral arterial disease. Double-blind, randomized, placebo-controlled trials have demonstrated that antihypertensive drug therapy reduces cardiovascular events in patients aged 65 to 79 years. In the Hypertension in the Very Elderly Trial, patients aged ≥ 80 years who were treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30% reduction in fatal or nonfatal stroke (P = 0.06), a 39% reduction in fatal stroke (P = 0.05), a 21% reduction in all-cause mortality (P = 0.02), a 23% reduction in cardiovascular death (P = 0.06), and a 64% reduction in heart failure (P < 0.001). Although the optimal blood pressure (BP) treatment goal in the elderly has not been determined, existing epidemiologic and clinical trial data suggest that a reasonable therapeutic BP goal should be < 140/90 mm Hg in persons aged < 80 years and a systolic BP of 140 to 145 mm Hg if tolerated in persons aged ≥ 80 years. Nonpharmacologic lifestyle measures should be encouraged both to prevent development of hypertension and as adjunctive therapy in persons with hypertension. Diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and calcium channel blockers have all shown benefit in reducing cardiovascular events in randomized trials. The choice of specific drugs depends on efficacy, tolerability, presence of specific comorbidities, and cost. Adverse effects from treatment, such as electrolyte disturbances, renal dysfunction, and excessive orthostatic BP reduction, should be avoided.

Lipids, blood pressure, kidney - what was new in 2011?

The year 2011 was very interesting regarding new studies, trials and guidelines in the field of lipidology, hypertensiology and nephrology. Suffice it to mention the new European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines on the management of dyslipidaemias, American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines on hypertension in the elderly, and many important trials presented among others during the American Society of Nephrology (ASN) Annual Congress in Philadelphia and the AHA Annual Congress in Orlando. The paper is an attempt to summarize the most important events and reports in the mentioned areas in the passing year.

A propensity-matched study of the association of diabetes mellitus with incident heart failure and mortality among community-dwelling older adults

Diabetes mellitus (DM) is a risk factor for incident heart failure (HF) in older adults. However, the extent to which this association is independent of other risk factors remains unclear. Of 5,464 community-dwelling adults ≥65 years old in the Cardiovascular Health Study without baseline HF, 862 had DM (fasting plasma glucose levels ≥126 mg/dl or treatment with insulin or oral hypoglycemic agents). Propensity scores for DM were estimated for each of the 5,464 participants and were used to assemble a cohort of 717 pairs of participants with and without DM who were balanced in 65 baseline characteristics. Incident HF occurred in 31% and 26% of matched participants with and without DM, respectively, during >13 years of follow-up (hazard ratio 1.45 for DM vs no DM, 95% confidence interval [CI] 1.14 to 1.86, p = 0.003). Of the 5,464 participants before matching unadjusted and multivariable-adjusted hazard ratios for incident HF associated with DM were 2.22 (95% CI 1.94 to 2.55, p <0.001) and 1.52 (95% CI 1.30 to 1.78, p <0.001), respectively. All-cause mortality occurred in 57% and 47% of matched participants with and without DM, respectively (hazard ratio 1.35, 95% CI 1.13 to 1.61, p = 0.001). Of matched participants DM-associated hazard ratios for incident peripheral arterial disease, incident acute myocardial infarction, and incident stroke were 2.50 (95% CI 1.45 to 4.32, p = 0.001), 1.37 (95% CI 0.97 to 1.93, p = 0.072), and 1.11 (95% CI 0.81 to 1.51, p = 0.527), respectively. In conclusion, the association of DM with incident HF and all-cause mortality in community-dwelling older adults without HF is independent of major baseline cardiovascular risk factors.

Pathological ankle-brachial index is equivalent of advanced age in acute coronary syndromes

BACKGROUND

Age is one the factors associated with poor prognosis in acute coronary syndromes (ACS) and elderly patients are a high-risk collective with few parameters for mid-term cardiovascular stratification. We aimed to assess the predictive value of ankle-brachial index (ABI) in patients (> 75 years) for 1-year mortality after an ACS.

MATERIALS AND METHODS

Prospective, observational and multicentre study of ACS patients in whom ABI was assessed during hospitalization.

RESULTS

A total of 1·054 patients were included, mean age 66·6 (11·7) years from whom 26·6% were > 75 years. Elderly patients showed more history of cardiovascular disease and higher prevalence of all risk factors, except current smoking. Angiography and revascularization were performed less frequently in the elderly. Patients > 75 years showed higher presence of three vessel coronary disease and received fewer guideline-recommended treatments. Patients who died through the follow-up, mean time 387·9 ± 7·2 days, had lower ABI (0·73 ± 0·24 vs. 0·92 ± 0·22; P < 0·01), also in the elderly patients (0·73 ± 0·24 vs. 0·86 ± 0·23; P < 0·01). Cox regression analysis identified age > 75 years (HR: 2·30; IC 95% 1·26-4·18; P < 0·01) and ABI < 0·90 (HR: 3·58; IC 95% 1·80-7·15; P < 0·01) as risk factors for to 1-year mortality. Mortality was similar in elderly patients with ABI > 0·90 and young patients with ABI < 0·90; the worst prognosis was observed in elderly patients with ABI < 0·90 (HR: 10·01; 95% CI 3·74-27·15).

CONCLUSIONS

Elderly patients represent a relevant collective of patients with ACS and are treated less optimally. ABI predicts 1-year mortality after an ACS in elderly patients.

Relation of baseline systolic blood pressure and long-term outcomes in ambulatory patients with chronic mild to moderate heart failure

We studied the impact of baseline systolic blood pressure (SBP) on outcomes in patients with mild to moderate chronic systolic and diastolic heart failure (HF) in the Digitalis Investigation Group trial using a propensity-matched design. Of 7,788 patients, 7,785 had baseline SBP data and 3,538 had SBP ≤ 120 mm Hg. Propensity scores for SBP ≤ 120 mm Hg, calculated for each of the 7,785 patients, were used to assemble a matched cohort of 3,738 patients with SBP ≤ 120 and >120 mm Hg who were well-balanced in 32 baseline characteristics. All-cause mortality occurred in 35% and 32% of matched patients with SBPs ≤ 120 and >120 mm Hg respectively, during 5 years of follow-up (hazard ratio [HR] when SBP ≤ 120 was compared to >120 mm Hg 1.10, 95% confidence interval [CI] 0.99 to 1.23, p = 0.088). HRs for cardiovascular and HF mortalities associated with SBP ≤ 120 mm Hg were 1.15 (95% CI 1.01 to 1.30, p = 0.031) and 1.30 (95% CI 1.08 to 1.57, p = 0.006). Cardiovascular hospitalization occurred in 53% and 49% of matched patients with SBPs ≤ 120 and > 120 mm Hg, respectively (HR 1.13, 95% CI 1.03 to 1.24, p = 0.008). HRs for all-cause and HF hospitalizations associated with SBP ≤ 120 mm Hg were 1.10 (95% CI 1.02 to 1.194, p = 0.017) and 1.21 (95% CI 1.07 to 1.36, p = 0.002). In conclusion, in patients with mild to moderate long-term systolic and diastolic HF, baseline SBP ≤ 120 mm Hg was associated with increased cardiovascular and HF mortalities and all-cause, cardiovascular, and HF hospitalizations that was independent of other baseline characteristics.

Diagnosis, treatment, and referral of hypertension or prehypertension in an emergency department after an educational program: preliminary results

The authors prospectively audited 602 randomly selected charts of patients seen in an academic emergency department (ED) for prevalence of hypertension and its management after an educational program (EP) because of results found in auditing 500 charts before the EP. Blood pressure was not measured in 11 of 500 patients (2.2%) before the EP and in 1 of 602 patients (0.2%) after the EP (P < .005). Hypertension was treated in the ED in 14 of 187 patients (8%) before the EP and in 29 of 282 patients (10%) after the EP (P = not significant). Of 187 patients with hypertension before the EP, 99 (53%) were referred to a physician or clinic for follow-up of hypertension, and 281 of 282 patients (99.6%) with hypertension were referred to a physician or clinic for follow-up of hypertension after the EP (P < .001). These data show that an EP administered to the staff of an academic ED significantly increased measurement of blood pressure in the ED, significantly increased obtaining a history of hypertension and of its treatment in ED patients, and significantly increased referral of patients with hypertension to a physician or clinic for follow-up of hypertension.

Office management of peripheral arterial disease

Patients with peripheral arterial disease are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Smoking should be stopped, and hypertension, diabetes mellitus, and dyslipidemia should be treated. Statins reduce the incidence of intermittent claudication and increase exercise duration until the onset of intermittent claudication in patients with peripheral arterial disease and hypercholesterolemia. Antiplatelet drugs, such as aspirin or clopidogrel, angiotensin-converting enzyme inhibitors, and statins, should be given to all patients with peripheral arterial disease. Beta-blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol improve exercise time until the onset of intermittent claudication. Indications for lower-extremity angioplasty, preferably with stenting, or bypass surgery are incapacitating claudication interfering with work or lifestyle in patients; limb salvage in patients with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, infection, or gangrene; and vasculogenic impotence.

History of cancer and mortality in community-dwelling older adults

BACKGROUND

The association between a history of cancer and mortality has not been studied in a propensity-matched population of community-dwelling older adults.

METHODS

Of the 5795 participants in the Cardiovascular Health Study, 827 (14%) had self-reported physician-diagnosed cancer at baseline. Propensity scores for cancer were used to assemble a cohort of 789 and 3118 participants with and without cancer respectively who were balanced on 45 baseline characteristics. Cox regression models were used to determine the association between cancer and all-cause mortality among matched patients, and to identify independent predictors of mortality among unmatched cancer patients.

RESULTS

Matched participants had a mean (SD) age of 74 (6) years, 57% were women, 10% were African Americans, and 38% died from all causes during 12 years of follow-up. All-cause mortality occurred in 41% and 37% of matched participants with and without a history of cancer respectively (hazard ratio when cancer was compared with no cancer, 1.16; 95% confidence interval, 1.02-1.31; P=0.019). Among those with cancer, older age, male gender, smoking, lower than college education, fair-to-poor self-reported health, coronary artery disease, diabetes mellitus, chronic kidney disease, left ventricular hypertrophy, increased heart rate, low hemoglobin and low baseline albumin were associated with increased risk of mortality.

CONCLUSIONS

Among community-dwelling older adults, a history of cancer was associated with increased mortality and among those with cancer, several socio-demographic variables and morbidities predicted mortality. These findings suggest that addressing traditional risk factors for cardiovascular mortality may help improve outcomes in older adults with a history of cancer.

Effects of peripheral arterial disease on outcomes in advanced chronic systolic heart failure: a propensity-matched study

BACKGROUND

The effect of peripheral arterial disease (PAD) on outcomes in patients with chronic heart failure (HF) has not been examined in propensity-matched studies.

METHODS AND RESULTS

Of the 2689 patients with advanced chronic systolic HF in the Beta-Blocker Evaluation of Survival Trial, 441 had a history of PAD. Propensity scores for a history of PAD, calculated for each patient using a multivariable logistic regression model, were used to assemble a matched cohort of 299 and 1015 patients, respectively, with and without PAD who were well balanced on 65 measured baseline characteristics. Cox regression models were used to estimate hazard ratios and 95% CIs for associations between PAD and outcomes during 4.1 years of follow-up. Patients had a mean age of 63+/-11 years, 19% were women, and 19% were black. All-cause mortality occurred in 43% and 33% of patients with and without a history of PAD, respectively (hazard ratio when PAD was compared with no history of PAD, 1.40; 95% CI, 1.14 to 1.72; P=0.001). All-cause hospitalization occurred in 75% and 63% of patients with and without PAD, respectively (hazard ratio when PAD was compared with no history of PAD, 1.36; 95% CI, 1.16 to 1.58; P<0.0001). PAD-associated hazard ratios for cardiovascular mortality, HF mortality, and HF hospitalization were 1.31 (95% CI, 1.04 to 1.63; P=0.019), 1.40 (95% CI, 0.97 to 2.02; P=0.076), and 1.05 (95% CI, 0.86 to 1.29; P=0.635), respectively.

CONCLUSIONS

In a well-balanced propensity-matched population of chronic systolic HF patients, a history of PAD was independently associated with increased mortality and hospitalization.

Uncontrolled hypertension and increased risk for incident heart failure in older adults with hypertension: findings from a propensity-matched prospective population study

Hypertension is a risk factor for incident heart failure (HF). However, the effect of uncontrolled blood pressure (BP) on incident HF in older adults with hypertension has not been prospectively examined in propensity-matched studies. Of the 5795 Cardiovascular Health Study participants, > or =65 years, 2562 with self-reported physician-diagnosed hypertension had no baseline HF. Of these, 1391 had uncontrolled hypertension, defined as systolic BP (SBP) > or =140 (n = 1373) or diastolic BP > or =90 mm Hg (n = 18). Propensity scores for uncontrolled hypertension, calculated for each participant, were used to assemble a cohort of 1021 pairs of participants with controlled and uncontrolled hypertension who were balanced on 31 baseline characteristics. Centrally adjudicated incident HF developed in 23% and 26% of participants with controlled and uncontrolled hypertension respectively during 13 years of follow-up (matched hazard ratio [HR] when uncontrolled hypertension was compared with controlled hypertension, 1.39; 95% confidence interval [CI], 1.12 to 1.73; P = .003). HRs (95% CI) for incident HF for those with (n = 503) and without (n = 1539) chronic kidney disease (CKD) were 1.73 (95% CI, 1.26 to 2.38; P = .001) and 1.08 (95% CI, 0.87 to 1.34; P = .486) respectively (P for interaction, .012). Compared with participants with controlled hypertension, HRs for incident HF associated with SBP 140 to 159 and > or =160 mm Hg were 1.06 (95% CI, 0.86 to 1.31; P = .572) and 1.58 (95% CI, 1.27 to 1.96; P < .0001), respectively. In community-dwelling older adults with hypertension, those with uncontrolled (versus controlled) BP have increased risk of new-onset HF, which is more pronounced in those with SBP > or =160 mm Hg and with CKD.

Peripheral arterial disease in women

Peripheral arterial disease (PAD) is chronic arterial occlusive disease of the lower extremities caused by atherosclerosis whose prevalence increases with age. Only one-half of women with PAD are symptomatic. Symptomatic and asymptomatic women with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Modifiable risk factors that predispose women to PAD include active cigarette smoking, passive smoking, diabetes mellitus, hypertension, dyslipidemia, increased plasma homocysteine levels and hypothyroidism. With regard to management, women who smoke should be encouraged to quit and referred to a smoking cessation program. Hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism require treatment. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in women with PAD and hypercholesterolemia. Anti-platelet drugs such as aspirin or especially clopidogrel, angiotensin-converting enzyme inhibitors and statins should be given to all women with PAD. Beta blockers are recommended if coronary artery disease is present. Exercise rehabilitation programs and cilostazol increase exercise time until intermittent claudication develops. Chelation therapy should be avoided as it is ineffective. Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery in women are (1) incapacitating claudication interfering with work or lifestyle; and (2) limb salvage in women with limb-threatening ischemia as manifested by rest pain, non-healing ulcers, and/or infection or gangrene. Future research includes investigation of mechanisms underlying why women have a higher risk of graft failure and major amputation.

Hypertension in the elderly

Many elderly patients have hypertension, although it is more likely to go untreated in this population. Treatment goals are the same in elderly patients as in younger patients, but elderly patients are more likely to have multiple comorbidities, which must be factored into treatment plans. This article highlights the unique challenges in treating this population.

Diagnosis, treatment, and referral of hypertension in an emergency department

The authors prospectively audited 500 randomly selected charts of patients seen during a 6-month period ending in October 2008, in the emergency department of a university medical center for the prevalence of hypertension and how it was managed. Of the 187 patients with hypertension, 14 (8%) were treated for hypertension in the emergency department and 99 (53%) were hospitalized or referred to a physician or clinic for follow-up of their hypertension. Much improvement is needed, especially since many of the patients seen in the emergency department do not have a primary care physician.