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

Dapagliflozin Improves Angiogenesis after Hindlimb Ischemia through the PI3K-Akt-eNOS Pathway

Recently, the vascular protective effect of anti-diabetic agents has been receiving much attention. Sodium glucose cotransporter 2 (SGLT2) inhibitors had demonstrated reductions in cardiovascular (CV) events. However, the therapeutic effect of dapagliflozin on angiogenesis in peripheral arterial disease was unclear. This study aimed to explore the effect and mechanism of dapagliflozin on angiogenesis after hindlimb ischemia. We first evaluated the effect of dapagliflozin on post-ischemic angiogenesis in the hindlimbs of rats. Laser doppler imaging was used to detect the hindlimb blood perfusion. In addition, we used immunohistochemistry to detect the density of new capillaries after ischemia. The relevant signaling pathways of dapagliflozin affecting post-ischemic angiogenesis were screened through phosphoproteomic detection, and then the mechanism of dapagliflozin affecting post-ischemic angiogenesis was verified at the level of human umbilical vein endothelial cells (HUVECs). After subjection to excision of the left femoral artery, all rats were randomly distributed into two groups: the dapagliflozin group (left femoral artery resection, receiving intragastric feeding with dapagliflozin (1 mg/kg/d), for 21 consecutive days) and the model group, that is, the positive control group (left femoral artery resection, receiving intragastric feeding with citric acid-sodium citrate buffer solution (1 mg/kg/d), for 21 consecutive days). In addition, the control group, that is the negative control group (without left femoral artery resection, receiving intragastric feeding with citric acid-sodium citrate buffer solution (1 mg/kg/d), for 21 consecutive days) was added. At day 21 post-surgery, the dapagliflozin-treatment group had the greatest blood perfusion, accompanied by elevated capillary density. The results showed that dapagliflozin could promote angiogenesis after hindlimb ischemia. Then, the ischemic hindlimb adductor-muscle tissue samples from three rats of model group and dapagliflozin group were taken for phosphoproteomic testing. The results showed that the PI3K-Akt-eNOS signaling pathway was closely related to the effect of dapagliflozin on post-ischemic angiogenesis. Our study intended to verify this mechanism from the perspective of endothelial cells. In vitro, dapagliflozin enhanced the tube formation, migration, and proliferation of HUVECs under ischemic and hypoxic conditions. Additionally, the dapagliflozin administration upregulated the expression of angiogenic factors phosphorylated Akt (p-Akt) and phosphorylated endothelial nitric oxide synthase (p-eNOS), as well as vascular endothelial growth factor A (VEGFA), both in vivo and in vitro. These benefits could be blocked by either phosphoinositide 3-kinase (PI3K) or eNOS inhibitor. dapagliflozin could promote angiogenesis after ischemia. This effect might be achieved by promoting the activation of the PI3K-Akt-eNOS signaling pathway. This study provided a new perspective, new ideas, and a theoretical basis for the treatment of peripheral arterial disease.

Development of a new non invasive prognostic stroke scale (NIPSS) including triage elements for sleep apnea and peripheral artery disease

BACKGROUND

Although sleep apnea and peripheral artery disease are prognostic factors for stroke, their added benefit in the acute stage to further prognosticate strokes has not been evaluated.

OBJECTIVES

We tested the accuracy in the acute stroke stage of a novel score called the Non-Invasive Prognostic Stroke Scale (NIPSS).

PATIENTS AND METHODS

Prospective cohort with imaging-confirmed ischemic stroke. Clinical data, sleep apnea risk score (STOPBANG) and blood pressure measures were collected at baseline. Primary outcome was the 90-day modified Rankin Scale (mRS), with poor outcome defined as mRS 3-6. Area under the ROC curve (AUC) was calculated for NIPSS and compared to six other stroke prognostic scores in our cohort: SPAN-100 index, S-SMART, SOAR, ASTRAL, THRIVE, and Dutch Stroke scores.

RESULTS

We enrolled 386 participants. After 90 days, there were 56% with poor outcome, more frequently older, female predominant and with higher admission National Institute of Health Stroke Scale (NIHSS). Four variables remained significantly associated with primary endpoint in the multivariable model: age (OR 1.87), NIHSS (OR 7.08), STOPBANG category (OR 1.61), and ankle-braquial index (OR 2.11). NIPSS AUC was 0.86 (0.82-0.89); 0.83 (0.79-0.87) with bootstrapping. When compared to the other scores, NIPSS, ASTRAL, S-SMART and DUTCH scores had good abilities in predicting poor outcome, with AUC of 0.86, 0.86, 0.83 and 0.82, respectively. THRIVE, SOAR and SPAN-100 scores were fairly predictive.

DISCUSSION AND CONCLUSIONS

Non-invasive and easily acquired emergency room data can predict clinical outcome after stroke. NIPSS performed equal to or better than other prognostic stroke scales.

Risk factors associated with amputation-free survival for patients with peripheral arterial disease: a systematic review

AIMS

Peripheral arterial disease (PAD) is associated with morbidity and mortality, comprising a significant percentage of amputations. As it affects the quality of life of patients with PAD, it is an important health issue. Therefore, the risk factors affecting the outcomes of limb salvage after revascularization should be well investigated. The aim of this review is to summarize risk factors of amputation-free survival (AFS) after interventions targeting patients with PAD to develop evidence-based intervention for improving patient outcomes.

METHODS AND RESULTS

A systematic review following PRISMA guidelines was conducted, and the protocol was registered on PROSPERO (CRD42020183076). PubMed, CINAHL, EMBASE, Cochrane Library, and Web of Science were searched for observational studies published between 2008 and 2019. Search terms included 'peripheral arterial disease', 'risk factors', and 'amputation-free survival'. The quality of the studies was evaluated using the Joanna Briggs Institute's Critical Appraisal Tools. Seventeen cohort studies were included in our study, and 16 risk factors were identified. Risk factors exemplifying a significant influence on decreased AFS were divided into three categories: sociodemographic (e.g. older age, male gender, African-American race, low body mass index, high nutritional risk, frailty), disease-related characteristics (e.g. severity of the disease, intervention site), and comorbidities (e.g. cardiovascular disease, kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, dementia, wide pulse pressure).

CONCLUSION

We found that managing modifiable risk factors, as well as addressing high-risk populations, has the potential to improve outcomes of PAD interventions. More high-quality cohort studies are needed to confirm these findings.

Reducing residual thrombotic risk in patients with peripheral artery disease: impact of the COMPASS trial

Patients with peripheral artery disease (PAD) are at a high risk not only for the classical cardiovascular (CV) outcomes (major adverse cardiovascular events; MACE) but also for vascular limb events (major adverse limb events; MALE). Therefore, a comprehensive approach for these patients should include both goals. However, the traditional antithrombotic approach with only antiplatelet agents (single or dual antiplatelet therapy) does not sufficiently reduce the risk of recurrent thrombotic events. Importantly, the underlying cause of atherosclerosis in patients with PAD implies both platelet activation and the initiation and promotion of coagulation cascade, in which Factor Xa plays a key role. Therefore, to reduce residual vascular risk, it is necessary to address both targets. In the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial that included patients with stable atherosclerotic vascular disease, the rivaroxaban plus aspirin strategy (versus aspirin) markedly reduced the risk of both CV and limb outcomes, and related complications, with a good safety profile. In fact, the net clinical benefit outcome composed of MACE; MALE, including major amputation, and fatal or critical organ bleeding was significantly reduced by 28% with the COMPASS strategy, (hazard ratio: 0.72; 95% confidence interval: 0.59-0.87). Therefore, the rivaroxaban plus aspirin approach provides comprehensive protection and should be considered for most patients with PAD at high risk of such events.

Managing Hypertension in the elderly: What's new?

Hypertension is the leading modifiable risk factor for cardiovascular events and mortality in the world. Hypertension is a major risk factor for cardiovascular events and mortality in the elderly. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling persons aged 65 years and older with an average systolic blood pressure of 130 ​mm Hg or higher or a diastolic blood pressure of 80 ​mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 ​mm Hg For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment. Randomized clinical trials need to be performed in frail elderly patients with hypertension living in nursing homes. Elderly frail persons with prevalent and frequent falls, marked cognitive impairment, and multiple comorbidities requiring multiple antihypertensive drugs also need to be included in randomized clinical trials. Data on patients older than 85 years treated for hypertension are also sparse. These patients need clinical trial data. Finally, the effect of different antihypertensive drugs on clinical outcomes including serious adverse events needs to be investigated in elderly frail patients with hypertension and different comorbidities.

Managing the elderly patient with hypertension: current strategies, challenges, and considerations

Introduction: Hypertension is the leading modifiable risk factor for cardiovascular events and mortality in the world.Areas covered: An extensive literature review of articles and clinical trials on PUBMED on the topic of hypertension in the elderly from 1976 through January 2020 was conducted. This review article discusses clinical trials on treatment of hypertension in the elderly, the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines, the 2018 European Society of Cardiology/European Society of Hypertension guidelines, and the treatment of hypertension and of resistant hypertension in the elderly.Expert opinion: The 2017 ACC/AHA hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling adults aged 65 years and older with an average systolic blood pressure of 130 mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 mm Hg. For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment.

Endovascular Revascularization Improves the Central Hemodynamics and Augmentation Index in Patients with Peripheral Artery Disease

Objective To evaluate the effect of endovascular therapy (EVT) on the central blood pressure (CBP) and augmentation index (AIx) in patients with peripheral artery disease (PAD). Methods The CBP and AIx were assessed by radial applanation tonometry the day before and the day after EVT. We compared the differences in the therapeutic effects between the stenotic and occlusive lesions and between the iliac and superficial femoral artery (SFA) lesions. Patients We enrolled 60 consecutive patients with PAD who underwent EVT for de novo lesions. Results Both the CBP and AIx were significantly decreased after EVT (125±22 mmHg to 112±22 mmHg; p=0.002 and 84%±16% to 73%±15%; p<0.001, respectively). The effects of EVT on the CBP and AIx were equivalent, regardless of whether the target lesion was the stenotic lesion or the occlusive lesion. There were no significant differences between the iliac and SFA lesions in the effects of EVT on the CBP and AIx. Conclusion EVT improved the CBP and AIx in patients with PAD, regardless of the morphology or site of the lesions.

Implications of the New 2017 American College of Cardiology/American Heart Association Guidelines for Hypertension

Automated validated devices should be used for measuring blood pressure (BP). The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines recommend that a systolic BP between 120-129 mmHg with a diastolic BP less than 80 mmHg should be treated with lifestyle measures. These guidelines recommend treatment with lifestyle measures plus BP lowering drugs for secondary prevention of cardiovascular events in persons with clinical cardiovascular disease and an average systolic BP of ≥130 mmHg or an average diastolic BP≥80 mmHg. These guidelines recommend treatment with lifestyle measures plus BP lowering drugs for primary prevention of cardiovascular disease in persons with an estimated 10-year risk of atherosclerotic cardiovascular disease ≥ 10% and an average systolic BP ≥130 mmHg or an average diastolic BP ≥80 mmHg. These guidelines recommend treatment with lifestyle measures plus BP lowering drugs for primary prevention of cardiovascular disease in persons with an estimated 10-year risk of atherosclerotic cardiovascular disease of < 10% and an average systolic BP ≥140 mmHg or an average diastolic BP ≥ 90 mmHg. These guidelines recommend initiating antihypertensive drug therapy with 2 first-line drugs from different classes either as separate agents or in a fixed-dose combination in persons with a BP ≥140/90 mmHg or with a BP > 20/10 mmHg above their BP target. White coat hypertension must be excluded before starting treatment with antihypertensive drugs in persons with hypertension at low risk for atherosclerotic cardiovascular disease. Antihypertensive drug treatment for different disorders is discussed.

One- to 10-Day Versus 11- to 30-Day All-Cause Readmission and Mortality in Older Patients With Heart Failure

Heart failure (HF) is the leading cause for 30-day all-cause readmission in older Medicare beneficiaries and 30-day all-cause readmission is associated with a higher risk of mortality. In the current analysis, we examined if that association varied by timing of 30-day all-cause readmission. Of the 8,049 Medicare beneficiaries hospitalized for HF, 1,688 had 30-day all-cause readmissions, of whom 1,519 were alive at 30 days. Of these, 626 (41%) had early (first 10 days) 30-day readmission. Propensity scores for early 30-day readmission, estimated for all 1,519 patients, were used to assemble a matched cohort of 596 pairs of patients with early versus late (11 to 30 days) all-cause readmission balanced on 34 baseline characteristics. Two-year all-cause mortality occurred in 51% and 57% of matched patients with early versus late 30-day all-cause readmissions, respectively (hazard ratio [HR] associated with late 30-day readmission, 1.22; 95% confidence interval [CI], 1.04 to 1.42; p = 0.014). This association was not observed in the subset of 436 patients whose 30-day all-cause readmission was due to HF (HR, 1.01; 95% CI, 0.79 to 1.28; p = 0.963), but was observed in the subset of 756 patients whose 30-day all-cause readmission was not due to HF (HR, 1.37; 95% CI, 1.12 to 1.67; p = 0.002; p for interaction, 0.057). In conclusion, in a high-risk subset of older hospitalized HF patients readmitted within 30 days, readmission during 11 to 30 (vs 1 to 10) days was associated with a higher risk of death and this association appeared to be more pronounced in those readmitted for non-HF-related reasons.

Contemporary Drug Treatment of Hypertension: Focus on Recent Guidelines

The 2017 American College of Cardiology/American Heart Association hypertension guidelines diagnose hypertension if systolic blood pressure (SBP) is ≥ 130 mmHg or diastolic blood pressure (DBP) is ≥ 80 mmHg. Increased BP is SBP 120-129 mmHg with DBP < 80 mmHg. Lifestyle measures should be used to treat individuals with increased BP. Lifestyle measures plus BP-lowering drugs should be used for secondary prevention of recurrent cardiovascular events in individuals with clinical cardiovascular disease (coronary heart disease, congestive heart failure, or stroke) and an average SBP ≥ 130 mmHg or an average DBP ≥ 80 mmHg. Lifestyle measures plus BP-lowering drugs should be used for primary prevention of cardiovascular disease in individuals with an estimated 10-year risk of atherosclerotic cardiovascular disease (ASCVD) ≥ 10% and an average SBP ≥ 130 mmHg or an average DBP ≥ 80 mmHg. Lifestyle measures plus BP-lowering drugs should be used for primary prevention of cardiovascular disease in individuals with an estimated 10-year risk of ASCVD < 10% and an average SBP ≥ 140 mmHg or an average DBP ≥ 90 mmHg. White coat hypertension must be excluded before starting antihypertensive drug treatment in individuals with hypertension with a low risk for ASCVD. BP should be lowered to < 130/80 mmHg in patients with coronary heart disease, heart failure, or chronic kidney disease; after renal transplantation; for secondary stroke prevention; in lacunar stroke, peripheral arterial disease, and diabetes mellitus; and in ambulatory community-dwelling adults aged > 65 years. The selection of antihypertensive drug treatment is discussed.

Implications of the New National Guidelines for Hypertension

Automated validated devices should be used for measuring blood pressure (BP). A systolic BP between 120 and 129 mm Hg with a diastolic BP < 80 mm Hg should be treated by lifestyle measures. Lifestyle measures plus BP lowering drugs should be used for secondary prevention of recurrent cardiovascular disease (CVD) events in persons with clinical CVD (coronary heart disease, congestive heart failure, and stroke) and an average systolic BP of ≥130 mm Hg or an average diastolic BP ≥ 80 mm Hg. Lifestyle measures plus BP lowering drugs should be used for primary prevention of CVD in persons with an estimated 10-year risk of atherosclerotic CVD ≥ 10% and an average systolic BP ≥130 mm Hg or an average diastolic BP ≥ 80 mm Hg. Lifestyle measures plus BP lowering drugs should be used for primary prevention of CVD in persons with an estimated 10-year risk of atherosclerotic CVD of <10% and an average systolic BP ≥ 140 mm Hg or an average diastolic BP ≥ 90 mm Hg. Initiate antihypertensive drug therapy with 2 first-line drugs from different classes either as separate agents or in a fixed-dose combination in persons with a BP ≥ 140/90 mm Hg or with a BP > 20/10 mm Hg above their BP target. White coat hypertension must be excluded before initiating treatment with antihypertensive drugs in persons with hypertension at low risk for atherosclerotic CVD. Antihypertensive drug treatment for different disorders is discussed.

Predictive Value of Underweight Status for Patients With Peripheral Artery Disease With Claudication

We evaluated whether underweight status is associated with poor prognosis in patients with peripheral artery disease (PAD) with claudication, excluding critical limb ischemia. We identified 441 claudicants hospitalized for cardiovascular disease between 2005 and 2012. Patients were divided into 4 groups according to body mass index (BMI): an underweight group (BMI < 18.5 kg/m2; n = 48), a normal group (BMI = 18.5-25.0 kg/m2; n = 286), an overweight group (BMI = 25.0-30.0 kg/m2; n = 92), and an obese group (BMI ≥ 30.0 kg/m2; n = 15). The mean follow-up period was 3.5 ± 1.9 years. The underweight group had significantly lower levels of hemoglobin, albumin, estimated glomerular filtration rate, triglycerides, and hemoglobin A1c; higher levels of C-reactive protein and B-type natriuretic peptide; and a higher prevalence of hemodialysis. The incidence of all-cause death and cardiovascular death was significantly higher in the underweight group (underweight vs normal, 77.1% vs 33.0%; P < .001 and 43.3% vs 14.4%; P < .001, respectively). In a multivariate Cox analysis, underweight status was an independent predictor of all-cause death (hazard ratio, 2.53; 95% confidence interval, 1.58-4.18; P < .001). Therefore, promoting weight gain, as well as managing cardiovascular disease, may be important for underweight patients with PAD.

Prediction and Subtyping of Hypertension from Pan-Tissue Transcriptomic and Genetic Analyses

Hypertension (HT) is a complex systemic disease involving transcriptional changes in multiple organs. Here we systematically investigate the pan-tissue transcriptional and genetic landscape of HT spanning dozens of tissues in hundreds of individuals. We find that in several tissues, previously identified HT-linked genes are dysregulated and the gene expression profile is predictive of HT. Importantly, many expression quantitative trait loci (eQTL) SNPs associated with the population variance of the dysregulated genes are linked with blood pressure in an independent genome-wide association study, suggesting that the functional effect of HT-associated SNPs may be mediated through tissue-specific transcriptional dysregulation. Analyses of pan-tissue transcriptional dysregulation profile, as well as eQTL SNPs underlying the dysregulated genes, reveals substantial heterogeneity among the HT patients, revealing two broad groupings - a Diffused group where several tissues exhibit HT-associated molecular alterations and a Localized group where such alterations are localized to very few tissues. These two patient subgroups differ in several clinical phenotypes including respiratory, cerebrovascular, diabetes, and heart disease. These findings suggest that the Diffused and Localized subgroups may be driven by different molecular mechanisms and have different genetic underpinning.

Ankle-brachial Index for the Prognosis of Cardiovascular Disease in Patients with Mild Renal Insufficiency

Objective A low ankle-brachial index (ABI) is a known predictor for future cardiovascular events and mortality in patients with chronic kidney disease (CKD). While most prior studies have defined CKD as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, recent reports have suggested that the cardiovascular risk may be increased even in early stages of renal insufficiency. We hypothesized that a low ABI may predict future cardiovascular morbidity and mortality in patients with mild impairment of the renal function. Methods The IMPACT-ABI study was a retrospective, single-center, cohort study that enrolled and obtained ABI measurements for 3,131 patients hospitalized for cardiovascular disease between January 2005 and December 2012. From this cohort, we identified 1,500 patients with mild renal insufficiency (eGFR =60-89 mL/min/1.73 m2), and stratified them into 2 groups: ABI ≤0.9 (low ABI group; 9.2%) and ABI >0.9 (90.8%). The primary outcome measured was the cumulative incidence of major adverse cardiovascular events (MACE; cardiovascular death, myocardial infarction, and stroke). Results Over a mean follow-up of 5.0 years, 101 MACE occurred. The incidence of MACE was significantly higher in patients with low ABI than in those with ABI >0.9 (30.2% vs. 14.4%, log rank p<0.001). A low ABI was associated with MACE in a univariate Cox proportional hazard analysis. A low ABI remained an independent predictor of MACE in a multivariate analysis adjusted for cardiovascular risk factors (hazard ratio (HR): 2.27; 95% confidence interval (CI): 1.33-3.86; p=0.002). Conclusion Low ABI was an independent predictor for MACE in patients with mild renal insufficiency.

Managing Hypertension in the Elderly: What is Different, What is the Same?

PURPOSE OF REVIEW

The goal is to discuss management of hypertension in the elderly.

RECENT FINDINGS

At 3.14-year follow-up of 2636 persons ≥75 years in the Systolic Blood Pressure Intervention Trial (SPRINT), compared with a systolic blood pressure (SBP) goal of <140 mmHg, a SBP goal of <120 mmHg reduced the primary endpoint of myocardial infarction, other acute coronary syndrome, stroke, heart failure, or cardiovascular death by 34% (p = 0.001), all-cause mortality by 33% (p = 0.009), heart failure by 38% (p = 0.003), and the primary outcome or death by 32% (p < 0.001). Absolute cardiovascular event rates were lower for the intensive treatment group within each frailty stratum. The incidence of serious adverse events was similar in both treatment groups. The SPRINT trial provides very important information on the efficacy and safety of lowering the SBP to <120 mmHg in elderly adults with hypertension.

Collagen-binding nanoparticles for extracellular anti-inflammatory peptide delivery decrease platelet activation, promote endothelial migration, and suppress inflammation

Peripheral artery disease is an atherosclerotic stenosis in the peripheral vasculature that is typically treated via percutaneous transluminal angioplasty. Deployment of the angioplasty balloon damages the endothelial layer, exposing the underlying collagen and allowing for the binding and activation of circulating platelets which initiate an inflammatory cascade leading to eventual restenosis. Here, we report on collagen-binding sulfated poly(N-isopropylacrylamide) nanoparticles that are able to target to the denuded endothelium. Once bound, these nanoparticles present a barrier that reduces cellular and platelet adhesion to the collagenous surface by 67% in whole blood and 59% in platelet-rich plasma under biologically relevant shear rates. In vitro studies indicate that the collagen-binding nanoparticles are able to load and release therapeutic quantities of anti-inflammatory peptides, with the particles reducing inflammation in endothelial and smooth muscle cells by 30% and 40% respectively. Once bound to collagen, the nanoparticles increased endothelial migration while avoiding uptake by smooth muscle cells, indicating that they may promote regeneration of the damaged endothelium while remaining anchored to the collagenous matrix and locally releasing anti-inflammatory peptides into the injured area. Combined, these collagen-binding nanoparticles have the potential to reduce inflammation, and the subsequent restenosis, while simultaneously promoting endothelial regeneration following balloon angioplasty.

STATEMENT OF SIGNIFICANCE

In this manuscript, we present our work on the development and characterization of a novel temperature sensitive collagen-binding nanoparticle system. We demonstrate that when bound to a collagenous matrix, the nanoparticles are able to promote endothelial migration while avoiding cellular uptake. We also show that the nanoparticles are able to reduce inflammation via the release of anti-inflammatory peptides which, when combined with its ability to inhibit platelet binding, could lead to reduced intimal hyperplasia following balloon angioplasty. The drug delivery platform presented represents a unique dual therapy biomaterial wherein the nanoparticle itself plays a crucial role in the system's overall therapeutic potential while simultaneously releasing anti-inflammatory peptides.

Clinical Characteristics and Outcomes of Patients with High Ankle-Brachial Index from the IMPACT-ABI Study

Background

Reduced ankle–brachial index (ABI) is a predictor of cardiovascular events. However, the significance of high ABI remains poorly understood. This study aimed to assess the characteristics and outcomes of patients with high ABI.

Methods

The IMPACT-ABI study was a retrospective cohort study that enrolled and examined ABI in 3,131 patients hospitalized for cardiovascular disease between January 2005 and December 2012. From this cohort, 2,419 patients were identified and stratified into two groups: high ABI (> 1.4; 2.6%) and normal ABI (1.0–1.4; 97.3%). The primary endpoint was the cumulative incidence of major adverse cardiovascular events (MACE), including cardiovascular-associated death, myocardial infarction, and stroke.

Results

Compared with the normal ABI group, patients in the high ABI group showed significantly lower body mass index (BMI) and hemoglobin level, but had higher incidence of chronic kidney disease and hemodialysis. Multivariate logistic regression analysis revealed that hemodialysis was the strongest predictor of high ABI (odds ratio, 6.18; 95% confidence interval (CI), 3.05–12.52; P < 0.001). During the follow-up (median, 4.7 years), 172 cases of MACE occurred. Cumulative MACE incidence in patients with high ABI was significantly increased compared to that in those with normal ABI (32.5% vs. 14.5%; P = 0.005). In traditional cardiovascular risk factors-adjusted multivariate Cox proportional hazard analysis, high ABI was an independent predictor of MACE (hazard ratio, 2.07; 95% CI, 1.02–4.20; P = 0.044).

Conclusion

Lower BMI, chronic kidney disease, and hemodialysis are more frequent in patients with high ABI. Hemodialysis is the strongest predictor of high ABI. High ABI is a parameter that independently predicts MACE.

Ankle-brachial index and brachial-ankle pulse wave velocity are associated with albuminuria in community-based Han Chinese

BACKGROUND/OBJECTIVES

Our study aimed to explore whether the ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) were associated with albuminuria in community-based Han Chinese.

METHODS

Total 2127 subjects (860 men and 1267 women) aged 60 years and over were recruited in Beijing. Albuminuria was assessed by the urinary albumin-to-creatinine ratio (UACR) of ≥30 mg/g. BaPWV was divided by quartile. The logistic regression was used to determine the odds ratio (OR) and 95% confidence intervals (CIs) of ABI and baPWV with albuminuria.

RESULTS

ABI was associated with albuminuria in the interaction model (OR 0.89, 95% CI 0.81-0.99 by every 0.1 unit increase of ABI), especially in hypertension (OR 0.82, 95% CI 0.73-0.92) and diabetes (OR 0.83, 95% CI 0.68-0.98) groups. BaPWV groups were also significantly associated with albuminuria, ORs of having albuminuria for baPWV quartile II, III, and IV were 1.02(0.65-1.52), 1.05(0.72-1.61), and 1.18(1.04-1.47) in the interaction model. For hypertension and diabetes patients, only the baPWV quartile IV group had higher OR.

CONCLUSIONS

ABI and baPWV were associated with albuminuria after adjusting for other risk factors in Chinese community-based elderly Han population. The association of ABI with albuminuria was stronger in hypertension and diabetes patients.

Prognostic value of ankle brachial index for future incident heart failure in patients without previous heart failure: data from the impressive predictive value of ankle brachial index for clinical long term outcome in patients with cardiovascular disease examined by ABI study

The ankle brachial index (ABI) is regarded as a predictor of future cardiovascular events. However, the relationship between ABI and incident heart failure (HF) in patients without previous HF is poorly understood. This study aimed to assess the prognostic value of ABI for incident HF in patients without previous HF. The IMPACT-ABI study was a retrospective, single-center, cohort study that enrolled and measured ABI in 3131 patients hospitalized for cardiovascular disease between January 2005 and December 2012. From this cohort, 307 patients were excluded because of previous HF and high (>1.4) ABI. The remaining 2824 patients were stratified into three groups: low ABI (≤0.9), borderline ABI (0.91-0.99), and normal ABI (1.0-1.4). The primary endpoint was hospitalization for HF. Over a mean 4.8-year follow-up, 105 cases of HF occurred. The cumulative incidence of HF was significantly higher in patients with low and borderline ABIs than in those with normal ABI (19.3 vs. 21.0 vs. 10.4 %, log rank P <0.001). In multivariate Cox proportional hazard analysis, low ABI and borderline ABI were independent predictors of incident HF [hazard ratio (HR) 3.00; 95 % confidence interval (CI) 1.70-5.28; P < 0.001 and HR 2.68; 95 % CI 1.35-5.34; P = 0.005, respectively]. In conclusion, low and borderline ABI were strong predictors for future incident HF in patients without previous HF.

Peripheral arterial disease and atrial fibrillation and risk of stroke, heart failure hospitalization and cardiovascular death: A nationwide cohort study

BACKGROUND

Peripheral arterial disease (PAD) and atrial fibrillation (AF) share several comorbidities and contribute to similar cardiovascular (CV) outcomes. Only few studies have evaluated the correlation between PAD, AF, and their interaction effects on CV outcomes.

METHODS

We included 597,164 adults from Taiwan's National Health Insurance Research Database to conduct a cohort study to assess whether PAD was an independent risk factor of AF and vice versa. We also examined if PAD and AF increased the incident stroke, heart failure hospitalization and CV death.

RESULTS

People with PAD had a significant higher risk of incident AF than those without PAD [adjusted hazard ratio (HR): 1.29, 95% confidence interval (CI): 1.17-1.42]. Meanwhile, people with AF did not have an increased risk of incident PAD compared to those without AF (adjusted HR: 1.00, 95% CI: 0.89-1.11). Both AF and PAD increased the risk of stroke [adjusted HR being 1.29 (95% CI: 1.17-1.43) and 1.41 (95% CI: 1.35-1.47), respectively], heart failure hospitalization [adjusted HR being 1.96 (95% CI: 1.77-2.17) and 1.35 (95% CI: 1.28-1.42), respectively], and CV death [adjusted HR being 3.33 (95% CI: 2.58-4.30) and 2.08 (95% CI: 1.80-2.41), respectively]. However, we found no interaction effects of AF and PAD on these outcomes.

CONCLUSIONS

PAD is an independent risk factor of incident AF but not vice versa. Both PAD and AF are independent risk factors for stroke, heart failure hospitalization, and CV death.

Optimal Blood Pressure Goals in Patients With Hypertension at High Risk for Cardiovascular Events

Existing epidemiologic and clinical trial data suggest that the blood pressure in patients with hypertension at high risk for cardiovascular events because of coronary artery disease, diabetes mellitus, chronic kidney disease, stroke, or heart failure should be reduced to <140/90 mm Hg in patients younger than 80 years and the systolic blood pressure be reduced to 140-145 mm Hg if tolerated in patients aged 80 years and older. Studies from patients with coronary artery disease, diabetes mellitus, chronic kidney disease, stroke, and heart failure will be discussed that support a blood pressure goal of <140/90 mm Hg in patients younger than 80 years at high risk for cardiovascular events.

Prevention of Collagen-Induced Platelet Binding and Activation by Thermosensitive Nanoparticles

Peripheral artery disease is an atherosclerotic occlusion in the peripheral vasculature that is typically treated via percutaneous transluminal angioplasty. Unfortunately, deployment of the angioplasty balloon damages the endothelial layer, exposing the underlying collagen and allowing for the binding and activation of circulating platelets, which initiate an inflammatory cascade leading to eventual restenosis. Here, we report on the development of poly(NIPAm-MBA-AMPS-AAc) nanoparticles that have a collagen I-binding peptide crosslinked to their surface allowing them to bind to exposed collagen. Once bound, these particles mask the exposed collagen from circulating platelets, effectively reducing collagen-mediated platelet activation. Using collagen I-coated plates, we demonstrate that these particles are able to bind to collagen at concentrations above 0.5 mg/mL. Once bound, these particles inhibit collagen-mediated platelet activation by over 60%. Using light scattering and zeta potential measurements, we investigated the potential of the nanoparticles as a drug delivery platform. We have verified that the collagen-binding nanoparticles retain the temperature sensitivity common to poly(NIPAm)-based nanoparticles while remaining colloidally stable in aqueous environments. We also demonstrate that they are able to passively load and release anti-inflammatory cell penetrating peptides. Combined, we have developed a collagen-binding nanoparticle that has dual therapy potential, preventing collagen-mediated platelet activation while delivering water-soluble therapeutics directly to the damaged area.

Blood Pressure Goals and Targets in the Elderly

The American College of Cardiology (ACC)/American Heart Association (AHA) 2011 expert consensus document on hypertension in the elderly recommends that the blood pressure be reduced to less than 140/90 mmHg in adults aged 60-79 years and the systolic blood pressure to 140 to 145 mmHg if tolerated in adults aged 80 years and older. I strongly support these guidelines based on clinical trial data, especially from the Systolic Hypertension in the Elderly trial and from the Hypertension in the Very Elderly trial (HYVET). Other guidelines supporting reducing the blood pressure to less than 140/90 mmHg in adults aged 60 to 79 years of age include the European Society of Hypertension (ESH)/European Society of Cardiology (ESC) 2013 guidelines, the minority report from the 2013 Eighth Joint National Committee (JNC 8) guidelines, the 2013 Canadian Hypertension Education Program guidelines, the 2011 UK guidelines, the 2014 American Society of Hypertension (ASH)/International Society of Hypertension (ISH) guidelines, and the 2015 AHA/ACC/ASH scientific statement on treatment of hypertension in patients with coronary artery disease. I support these guidelines. In adults aged 80 years and older, a blood pressure below 150/90 mm Hg has been recommended by these guidelines, with a target goal of less than 140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease. I support these guidelines. The 2013 JNC 8 guidelines recommend reducing the blood pressure to less than 140/90 mmHg in adults aged 60 years and older with diabetes mellitus or chronic kidney disease but to less than 150/90 mmHg in adults aged 60 years and older without diabetes mellitus or chronic kidney disease. I strongly disagree with this recommendation and am very much concerned that the higher systolic blood pressure goal recommended by JNC 8 guidelines in adults aged 60 years and older without diabetes mellitus or chronic kidney disease will lead to an increase in cardiovascular events and mortality in these adults.

Impact of peripheral artery disease on prognosis in hospitalized heart failure patients

BACKGROUND

The impact of peripheral artery disease (PAD) on heart failure (HF) prognosis remains unclear.

METHODS AND RESULTS

A total of 388 consecutive decompensated HF patients were divided into 2 groups based on the presence of PAD: HF with PAD (PAD group, n=101, 26.0%) and HF without PAD (non-PAD group, n=287, 74.0%). We compared clinical features, echocardiographic parameters, cardiopulmonary exercise testing results, laboratory findings, as well as cardiac, non-cardiac, and all-cause mortality between the 2 groups. The PAD group, as compared with the non-PAD group, had (1) higher prevalence of coronary artery disease (40.6 vs. 27.5%, P=0.011) and cerebrovascular disease (34.7 vs. 18.2%, P=0.001); (2) higher tumor necrosis factor-α (1.82 vs. 1.49 pg/ml, P=0.023), C-reactive protein (0.32 vs. 0.19 mg/dl, P=0.045), and troponin T (0.039 vs. 0.021 ng/ml, P=0.019); (3) lower LVEF (42.4 vs. 48.5%, P<0.001); (4) lower peak V̇O2(13.4 vs. 15.9 ml·kg(-1)·min(-1), P=0.001); and (5) higher V̇E/V̇CO2slope (38.8 vs. 33.7, P<0.001). On Kaplan-Meier analysis, cardiac, non-cardiac, and all-cause mortality were significantly higher in the PAD group than in the non-PAD group (P<0.05, respectively). On Cox proportional hazard analysis after adjusting for confounding factors, PAD was an independent predictor of cardiac and all-cause mortality (P<0.05, respectively) in HF patients.

CONCLUSIONS

PAD was common and an independent predictor of cardiac and all-cause mortality in HF patients.

Treating hypertension and prehypertension in older people: when, whom and how

Prehypertension should be treated with lifestyle measures and not with antihypertensive drug therapy in older adults. Lifestyle measures should be encouraged both to retard development of hypertension and as adjunctive therapy in those with hypertension. A meta-analysis of 11 randomized controlled trials of 40,325 older persons showed that antihypertensive drug therapy significantly reduced all-cause mortality 13% (7-19%), cardiovascular death 18% (7-27%), cardiovascular events 21% (13-27%), stroke 30% (23-37%), and fatal stroke by 33% (9-50%) (Ostrowski et al., 2014 [32]). The American College of Cardiology/American Heart Association 2011 expert consensus document on hypertension in the elderly recommended that the systolic blood pressure be lowered to <140 mm Hg in older persons younger than 80 years and to 140-145 mm Hg if tolerated in adults aged 80 years and older. A meta-analysis of 147 randomized trials including 464,000 persons with hypertension showed that except for the extra protective effect of beta blockers given after myocardial infarction and a minor additional effect of calcium channel blockers in preventing stroke, the use of beta blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), diuretics, and calcium channel blockers cause a similar reduction in coronary events and stroke for a given decrease in blood pressure. The choice of specific antihypertensive drugs such as diuretics, ACE inhibitors, ARBs, beta blockers, or calcium channel blockers depends on efficacy, tolerability, presence of specific comorbidities and cost.

Heart failure risk across the spectrum of ankle-brachial index: the ARIC study (Atherosclerosis Risk In Communities)

OBJECTIVES

The aim of this study was to describe the relationship between ankle brachial index (ABI) and the risk for heart failure (HF).

BACKGROUND

The ABI is a simple, noninvasive measure associated with atherosclerotic cardiovascular disease and death; however, the relationship between ABI and risk for HF is less well characterized.

METHODS

Between 1987 and 1989 in the ARIC (Atherosclerosis Risk In Communities) study, an oscillometric device was used to measure blood pressure in a single upper and randomly chosen lower extremity to determine the ABI. Incident HF events were defined by the first hospitalization with an International Classification of Diseases, Ninth Revision, code of 428.x through 2008. The risk for HF was assessed across the ABI range using restricted cubic splines and Cox proportional hazards models.

RESULTS

ABI was available in 13,150 participants free from prevalent HF. Over a mean 17.7 years of follow-up, 1,809 incident HF events occurred. After adjustment for traditional HF risk factors, prevalent coronary heart disease, subclinical carotid atherosclerosis, and interim myocardial infarction, compared with an ABI of 1.01 to 1.40, participants with ABIs ≤0.90 were at increased risk for HF (hazard ratio: 1.40; 95% confidence interval: 1.12 to 1.74), as were participants with ABIs of 0.91 to 1.00 (hazard ratio: 1.36; 95% confidence interval: 1.17 to 1.59).

CONCLUSIONS

In a middle-age community cohort, an ABI ≤1.00 was significantly associated with an increased risk for HF, independent of traditional HF risk factors, prevalent coronary heart disease, carotid atherosclerosis, and interim myocardial infarction. Low ABI may reflect not only overt atherosclerosis but also pathologic processes in the development of HF beyond epicardial atherosclerotic disease and myocardial infarction alone. A low ABI, as a simple, noninvasive measure, may be a risk marker for HF.

Angiotensin-converting enzyme inhibitors and outcomes in heart failure and preserved ejection fraction

BACKGROUND

The role of angiotensin-converting enzyme (ACE) inhibitors in patients with heart failure and preserved ejection fraction remains unclear.

METHODS

Of the 10,570 patients aged ≥65 years with heart failure and preserved ejection fraction (≥40%) in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (2003-2004) linked to Medicare (through December 2008), 7304 were not receiving angiotensin receptor blockers and had no contraindications to ACE inhibitors. After excluding 3115 patients with pre-admission ACE inhibitor use, the remaining 4189 were eligible for new discharge prescriptions for ACE inhibitors, and 1706 received them. Propensity scores for the receipt of ACE inhibitors, calculated for each of the 4189 patients, were used to assemble a cohort of 1337 pairs of patients, balanced on 114 baseline characteristics.

RESULTS

Matched patients had a mean age of 81 years and mean ejection fraction of 55%, 64% were women, and 9% were African American. Initiation of ACE inhibitor therapy was associated with a lower risk of the primary composite end point of all-cause mortality or heart failure hospitalization during 2.4 years of median follow-up (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84-0.99; P = .028), but not with individual end points of all-cause mortality (HR, 0.96; 95% CI, 0.88-1.05; P = .373) or heart failure hospitalization (HR, 0.93; 95% CI, 0.83-1.05; P = .257).

CONCLUSION

In hospitalized older patients with heart failure and preserved ejection fraction not receiving angiotensin receptor blockers, discharge initiation of ACE inhibitor therapy was associated with a modest improvement in the composite end point of total mortality or heart failure hospitalization but had no association with individual end point components.

Comparison of the prognostic value of normal regadenoson with normal adenosine myocardial perfusion imaging with propensity score matching

OBJECTIVES

The aim of this study was to test the hypothesis that patients with normal regadenoson myocardial perfusion imaging (MPI) have a low rate of cardiac events, similar to patients with normal adenosine MPI.

BACKGROUND

Regadenoson, a new selective adenosine A(2A) receptor agonist, is now a widely used stress agent for MPI. The low rate of cardiac events in patients with normal adenosine MPI is well-documented, but the prognostic implications of a normal regadenoson MPI have not been examined and compared with those with adenosine.

METHODS

Data on primary composite endpoint (cardiac death, myocardial infarction, and coronary revascularization) were collected for 2,000 patients (1,000 regadenoson, and 1,000 adenosine stress) with normal myocardial perfusion and left ventricular ejection fraction referred for vasodilator MPI. In addition, propensity scores were used to assemble a balanced cohort of 505 pairs of patients who were balanced on 36 baseline characteristics.

RESULTS

The primary endpoint occurred in 21 (2.1%; 1.1%/year) patients in the regadenoson group and 33 (3.3%; 1.7%/year) patients in the adenosine group (hazard ratio [HR] for regadenoson vs. adenosine: 0.62; 95% confidence interval [CI]: 0.36 to 1.08; p = 0.090). In the propensity-matched pairs, the primary endpoint occurred in 7 (1.4%; 0.7%/year) patients in the regadenoson group and 13 (2.6%; 1.3%/year) patients in the adenosine group (matched HR: 0.58; 95% CI: 0.23 to 1.48; p = 0.257). Cardiac deaths were infrequent in the entire sample and in the propensity-matched groups; the cardiac death rate was 0.9%/year and 1.15%/year in the regadenoson and adenosine groups (HR: 0.77; 95% CI: 0.42 to 1.43; p = 0.404) in the pre-match sample and 0.5%/year and 0.7%/year in the matched groups, respectively (HR: 0.83; 95% CI: 0.25 to 2.73; p = 0.763).

CONCLUSIONS

Major cardiac events are infrequent in patients with normal regadenoson MPI. These findings provide assurance that normal MPI using a simpler stress protocol with regadenoson provides prognostic data similar to normal adenosine MPI.

9p21 Polymorphisms increase the risk of peripheral artery disease in the Han Chinese population

Objective

A case–control study to investigate the association of the 9p21 single nucleotide polymorphisms (SNPs) rs10757274 and rs10757278 (known to be associated with coronary artery disease [CAD] risk) with peripheral arterial disease (PAD), in a Han Chinese population.

Methods

The rs10757274 and rs10757278 genotypes of patients with PAD, and age- and sex-matched control subjects, were determined. Multivariate unconditional logistic regression analyses were performed, with adjustments for age, sex, hypertension, dyslipidaemia, diabetes and smoking status.

Results

The study included 420 patients with PAD and 418 control subjects. Variant forms of both SNPs were associated with increased risk of PAD in the total study population, when excluding patients with CAD or stroke (additive genetic model). The GG haplotype increased the risk of PAD, but this association did not remain significant after further sensitivity analysis. Both SNPs were associated with PAD risk in patients aged <65 years, but not in those aged ≥65 years (additive model).

Conclusions

9p21 is associated with PAD. When stratified according to age, 9p21 increases PAD risk in individuals aged <65 years, but not in those aged ≥65 years.

What should the blood pressure goal be in patients with hypertension who are at high risk for cardiovascular disease?

Epidemiologic and clinical trial data suggest that blood pressure in patients with hypertension who are at high risk for cardiovascular events because of coronary artery disease, diabetes, chronic kidney disease, stroke, or heart failure should be reduced to < 140/90 mm Hg in patients aged < 80 years, and that systolic blood pressure should be reduced to 140 to 145 mm Hg, if tolerated, in patients aged ≥ 80 years. Studies on patients with coronary artery disease, diabetes, chronic kidney disease, stroke, and heart failure are discussed, supporting a blood pressure goal of < 140/90 mm Hg in patients aged < 80 years who are at high risk for cardiovascular events.

Treatment of systemic hypertension

Systemic 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 found that antihypertensive drug therapy reduces cardiovascular events in patients aged younger than 80 years and in patients aged 80 years and older in the Hypertension in the Very Elderly Trial. Although the optimal blood pressure treatment goal has not been determined, existing epidemiologic and clinical trial data suggest that a reasonable therapeutic blood pressure goal should be <140/90 mm Hg in patients younger than 80 years and a systolic blood pressure of 140-145 mm Hg if tolerated in patients aged 80 years and older. Non-pharmacologic lifestyle measures should be encouraged both to prevent development of hypertension and as adjunctive therapy in patients with hypertension. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, calcium channel blockers, and diuretics have all reduced cardiovascular events in randomized trials. The choice of specific drugs depends on efficacy, tolerability, presence of specific comorbidities, and cost.

Secondary medical prevention after primary vascular surgery between 1996 and 2006: a shift towards more evidence-based treatment

OBJECTIVE

The implementation of evidence-based secondary medical prevention in peripheral arterial disease (PAD) patients has received increasing attention in recent years, but population-based data are sparse. This study examined the use of secondary medical prophylaxis in unselected symptomatic PAD patients in Denmark.

DESIGN

A nationwide follow-up study based on individual-level record linkages of population-based healthcare registers was performed.

PARTICIPANTS

All patients who underwent primary vascular reconstruction in Denmark between 1996 and 2006 with a minimum of 6 months of follow-up were included (n = 16,492).

METHODS

Data were obtained from prescriptions that were filled six months after primary vascular reconstruction (±90 days). The use of secondary medical prevention was examined according to calendar year and place of residence.

RESULTS

The use of lipid-lowering drugs increased from 32.2% in 1996 to 76.1% in 2006 (adjusted relative risk (RR) 1.95, 95% CI 1.81-2.10). The overall use of antihypertensive therapy was unchanged during the study period, but treatment shifted from diuretics/calcium antagonists towards angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists. The use of combination therapy (concomitant lipid-lowering, antiplatelet and any antihypertensive therapies) increased from 29.1% in 1996 to 67.6% in 2006 (adjusted RR 1.95, 95% CI 1.80-2.12). This shift in the use of secondary medical prevention was independent of sociodemographic and clinical factors. No substantial differences in pharmacological use based on place of residence were observed.

CONCLUSION

The use of evidence-based secondary medical prevention, especially lipid-lowering drugs, increased substantially among symptomatic PAD patients in Denmark from 1996 to 2006. However, recommendations in current clinical guidelines suggest that room for improvement remains.

Cardiovascular disease in women: implications for improving health outcomes

OBJECTIVE

To collate data on women and cardiovascular disease in Australia and globally to inform public health campaigns and health care interventions.

DESIGN

Literature review.

RESULTS

Women with acute coronary syndromes show consistently poorer outcomes than men, independent of comorbidity and management, despite less anatomical obstruction of coronary arteries and relatively preserved left ventricular function. Higher mortality and complication rates are best documented amongst younger women and those with ST-segment-elevation myocardial infarction. Sex differences in atherogenesis and cardiovascular adaptation have been hypothesised, but not proven. Atrial fibrillation carries a relatively greater risk of stroke in women than in men, and anticoagulation therapy is associated with higher risk of bleeding complications. The degree of risk conferred by single cardiovascular risk factors and combinations of risk factors may differ between the sexes, and marked postmenopausal changes are seen in some risk factors. Sociocultural factors, delays in seeking care and differences in self-management behaviours may contribute to poorer outcomes in women. Differences in clinical management for women, including higher rates of misdiagnosis and less aggressive treatment, have been reported, but there is a lack of evidence to determine their effects on outcomes, especially in angina. Although enrolment of women in randomised clinical trials has increased since the 1970s, women remain underrepresented in cardiovascular clinical trials.

CONCLUSIONS

Improvement in the prevention and management of CVD in women will require a deeper understanding of women's needs by the community, health care professionals, researchers and government.

Peripheral arterial disease of the lower extremities

Persons with peripheral arterial disease (PAD) are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Smoking should be stopped and hypertension, dyslipidemia, diabetes mellitus, and hypothyroidism treated. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. The serum low-density lipoprotein cholesterol should be reduced to < 70 mg/dl. Antiplatelet drugs such as aspirin or clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to persons with PAD. β-Blockers should be given if coronary artery disease is present. Cilostazol improves exercise time until intermittent claudication. Exercise rehabilitation programs should be used. Revascularization should be performed if indicated.

Incidence of new cardiovascular events in patients with and without peripheral arterial disease seen in a vascular surgery clinic

BACKGROUND

To investigate the incidence of death and of new cardiovascular events at long-term follow-up of patients with and without PAD seen in a vascular surgery clinic.

MATERIAL/METHODS

We investigated the incidence of death, new stroke/transient ischemic attack, new myocardial infarction, new coronary revascularization, new carotid endarterectomy, new peripheral arterial disease (PAD) revascularization, or at least one of the above outcomes at long-term follow-up of patients with and without PAD followed in a vascular surgery clinic.

RESULTS

At least one of the above outcomes occurred in 259 of 414 patients (63%) with PAD at 33-month follow-up and in 21 of 89 patients (24%) without PAD at 48-month follow-up (p<0.0001). Death occurred in 112 of 414 patients (27%) with PAD and in 10 of 89 patients (11%) without PAD (p=0.002). Stepwise Cox regression analysis for the time to at least one of the 6 outcomes showed that significant independent risk factors were men (hazard ratio =1.394; 95% CI, 1.072-1.813; p=0.013), estimated glomerular filtration rate (hazard ratio =0.992; 95% CI, 0.987-0.997; p=0.003), and PAD (hazard ratio =3.520; 95% CI, 2.196-5.641; p<0.0001). Stepwise Cox regression analysis for the time to death showed that significant independent risk factors were age (hazard ratio =1.024; 95% CI, 1.000-1.049; p=0.048), estimated glomerular filtration rate (hazard ratio =0.985; 95% CI, 0.974-0.996; p=0.007), and PAD (hazard ratio =2.157; 95% CI, 1.118-4.160; p=0.022).

CONCLUSIONS

Patients with PAD have a significantly higher incidence of cardiovascular outcomes, especially death, new PAD revascularization, and new carotid endarterectomy, than patients without PAD followed in a vascular surgery clinic.

Ten most important things to learn from the ACCF/AHA 2011 expert consensus document on hypertension in the elderly

The American College of Cardiology Foundation/American Heart Association 2011 Expert Consensus Document on Hypertension in the Elderly has been published in the Journal of the American College of Cardiology and in Circulation, and will be published in the Journal of the American Society of Hypertension and the Journal of Geriatric Cardiology. This document has also been developed in collaboration with the American Academy of Neurology, the American Geriatrics Society, the American Society of Preventive Cardiology, the American Society of Hypertension, the American Society of Nephrology, the Association of Black Cardiologists, and the European Society of Hypertension. The present article is a short summary emphasizing the 10 most important things to learn from this document.

Effect of warfarin on outcomes in septuagenarian patients with atrial fibrillation

Anticoagulation has been shown to decrease ischemic stroke in atrial fibrillation (AF). However, concerns remain regarding their safety and efficacy in those ≥70 years of age who constitute most patients with AF. Of the 4,060 patients (mean age 65 years, range 49 to 80) in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 2,248 (55% of 4,060) were 70 to 80 years of age, 1,901 of whom were receiving warfarin. Propensity score for warfarin use, estimated for each of the 2,248 patients, was used to match 227 of the 347 patients not on warfarin (in 1:1, 1:2, or 1:3 sets) to 616 patients on warfarin who were balanced in 45 baseline characteristics. All-cause mortality occurred in 18% and 33% of matched patients receiving and not receiving warfarin, respectively, during up to 6 years (mean 3.4) of follow-up (hazard ratio [HR] when warfarin use was compared to its nonuse 0.58, 95% confidence interval [CI] 0.43 to 0.77, p <0.001). All-cause hospitalization occurred in 64% and 67% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.93, 95% CI 0.77 to 1.12, p = 0.423). Ischemic stroke occurred in 4% and 8% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.57, 95% CI 0.31 to 1.04, p = 0.068). Major bleeding occurred in 7% and 10% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.73, 95% CI 0.44 to 1.22, p = 0.229). In conclusion, warfarin use was associated with decreased mortality in septuagenarian patients with AF but had no association with hospitalization or major bleeding.