Blood pressure j-curve: current concepts

The blood pressure (BP) J-curve debate started in 1979, and we still cannot definitively answer all the questions. However, available studies of antihypertensive treatment provide strong evidence for J-shaped relationships between both diastolic and systolic BP and main outcomes in the general population of hypertensive patients, as well as in high-risk populations, including subjects with coronary artery disease, diabetes mellitus, left ventricular hypertrophy, and elderly patients. However, further studies are still necessary in order to clarify this issue. This is connected to the fact that most available studies were observational, and randomized trials did not have or lost their statistical power and were inconclusive. Perhaps only the Systolic Blood Pressure Intervention Trial (SPRINT) and Optimal Blood Pressure and Cholesterol Targets for Preventing Recurrent Stroke in Hypertensives (ESH-CHL-SHOT) will be able to finally answer all the questions. According to the current state of knowledge, it seems reasonable to suggest lowering BP to values within the 130-139/80-85 mmHg range, possibly close to the lower values in this range, in all hypertensive patients and to be very careful with further BP level reductions, especially in high-risk hypertensive patients.

Long-term treatment with the apolipoprotein A1 mimetic peptide increases antioxidants and vascular repair in type I diabetic rats

Apolipoprotein A1 mimetic peptide (D-4F), synthesized from D-amino acid, enhances the ability of high-density lipoprotein to protect low-density lipoprotein (LDL) against oxidation in atherosclerotic disease. Using a rat model of type I diabetes, we investigated whether chronic use of D-4F would lead to up-regulation of heme oxygenase (HO)-1, endothelial cell marker (CD31(+)), and thrombomodulin (TM) expression and increase the number of endothelial progenitor cells (EPCs). Sprague-Dawley rats were rendered diabetic with streptozotocin (STZ) and either D-4F or vehicle was administered, by i.p. injection, daily for 6 weeks (100 microg/100 g b.wt.). HO activity was measured in liver, kidney, heart, and aorta. After 6 weeks of D-4F treatment, HO activity significantly increased in the heart and aorta by 29 and 31% (p < 0.05 and p < 0.49), respectively. Long-term D-4F treatment also caused a significant increase in TM and CD31(+) expression. D-4F administration increased antioxidant capacity, as reflected by the decrease in oxidized protein and oxidized LDL, and enhanced EPC function and/or repair, as evidenced by the increase in EPC endothelial nitric-oxide synthase (eNOS) and prevention of vascular TM and CD31(+) loss. In conclusion, HO-1 and eNOS are relevant targets for D-4F and may contribute to the D-4F-mediated increase in TM and CD31(+), the antioxidant and anti-inflammatory properties, and confers robust vascular protection in this animal model of type 1 diabetes.

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.

Association Between Hospital Volume and 30-Day Readmissions Following Transcatheter Aortic Valve Replacement

IMPORTANCE

With the approval of transcatheter aortic valve replacement (TAVR) for patients with severe symptomatic aortic stenosis at intermediate surgical risk, TAVR volume is projected to increase exponentially in the United States. The 30-day readmission rate for TAVR was recently reported at 17.9%. The association between institutional TAVR volume and the 30-day readmission metric has not been examined.

OBJECTIVE

To assess the association between hospital TAVR volume and 30-day readmission.

DESIGN, SETTING, AND PARTICIPANTS

In this observational study, we used the 2014 Nationwide Readmissions Database to identify hospitals with established TAVR programs (performing at least 5 TAVRs in the first quarter of 2014). Based on annual TAVR volume, hospitals were classified as low (<50), medium (≥50 to <100), and high (≥100) volume. Rates, causes, and costs of 30-day readmissions were compared between low-, medium-, and high-volume hospitals. Data were analyzed from November to December 2016.

EXPOSURE

Transcatheter aortic valve replacement.

MAIN OUTCOMES AND MEASURES

Thirty-day readmissions.

RESULTS

Of 129 hospitals included in this study, 20 (15.5%) were categorized as low volume, 47 (36.4%) as medium volume, and 62 (48.1%) as high volume. Of 16 252 index TAVR procedures, 663 (4.1%), 3067 (18.9%), and 12 522 (77.0%) were performed at low-, medium-, and high-volume hospitals, respectively. Thirty-day readmission rates were significantly lower in high-volume compared with medium-volume (adjusted odds ratio, 0.76; 95% CI, 0.68-0.85; P < .001) and low-volume (adjusted odds ratio, 0.75; 95% CI, 0.60-0.92; P = .007) hospitals. Noncardiac readmissions were more common in low-volume hospitals (65.6% vs 60.6% in high-volume hospitals), whereas cardiac readmissions were more common in high-volume hospitals (39.4% vs 34.4% in low-volume hospitals). There were no significant differences in length of stay and costs per readmission among the 3 groups (mean [SD], 5.5 [5.0] days vs 5.9 [7.5] days vs 6.0 [5.8] days; P = .74, and $13 886 [18 333] vs $14 135 [17 939] vs $13 432 [15 725]; P = .63, respectively).

CONCLUSIONS AND RELEVANCE

We report for the first time, to our knowledge, an inverse association between hospital TAVR volume and 30-day readmissions. Lower readmission at higher-volume hospitals was associated with significantly lower cost to the health care system.

Cardiac Complications of Cancer Therapy: Pathophysiology, Identification, Prevention, Treatment, and Future Directions

PURPOSE OF REVIEW

Cardiotoxicity is an important complication of cancer therapy. With a significant improvement in the overall survival and prognosis of patients undergoing cancer therapy, cardiovascular toxicity of cancer therapy has become an important public health issue. Several well-established as well as newer anticancer therapies such as anthracyclines, trastuzumab, and other HER2 receptor blockers, antimetabolites, alkylating agents, tyrosine kinase inhibitors, angiogenesis inhibitors, checkpoint inhibitors, and thoracic irradiation are associated with significant cardiotoxicity.

RECENT FINDINGS

Cardiovascular imaging employing radionuclide imaging, echocardiography, and magnetic resonance imaging is helpful in early detection of the cardiotoxicity and prevention of overt heart failure. These techniques also provide important tools for understanding the mechanism of cardiotoxicity of these modalities, which would help develop strategies for the prevention of cardiac morbidity and mortality related to the use of these agents. An understanding of the mechanism of the cardiotoxicity of cancer therapies can help prevent and treat their adverse cardiovascular consequences. Clinical implementation of algorithms based upon cardiac imaging and several non-imaging biomarkers can prevent cardiac morbidity and mortality associated with the use of cardiotoxic cancer therapies.

A history of atrial fibrillation and outcomes in chronic advanced systolic heart failure: a propensity-matched study

AIMS

Atrial fibrillation (AF)-associated poor outcomes in heart failure (HF) are often attributed to older age, advanced disease, and comorbidity burden of HF patients with AF. Therefore, we examined the effect of AF on outcomes in a propensity-matched study in which patients with and without AF were well balanced on all measured baseline characteristics.

METHODS AND RESULTS

Of the 2708 advanced chronic systolic HF patients in the Beta-Blocker Evaluation of Survival Trial, 653 had a history of AF. Propensity scores for AF were calculated for each patient and were used to assemble a cohort of 487 pairs of patients with and without AF who were balanced on 74 baseline characteristics. Matched Cox regression analyses were used to estimate associations of AF with outcomes during 23 months of mean follow-up. All-cause mortality occurred in 187 (rate, 2046/10,000 person-years of follow-up) and 181 (rate, 1885/10,000 person-years) matched patients with and without AF, respectively [matched hazard ratio (HR) when AF was compared with no-AF 1.03, 95% confidence interval (CI) 0.79-1.33; P = 0.84]. Heart failure hospitalization occurred in 215 (rate, 3171/10,000 person-years) and 184 (rate, 2405/10,000 person-years) matched patients with and without AF, respectively (matched HR when AF was compared with no-AF 1.28, 95% CI 1.00-1.63; P = 0.049). Hazard ratios and 95% CIs for AF-associated HF hospitalization for bucindolol and placebo groups were, respectively, 1.08 (0.81-1.43) and 1.54 (1.17-2.03; P for interaction = 0.09).

CONCLUSION

A history of AF had no intrinsic association with mortality but was associated with HF hospitalization in chronic systolic HF.

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.

Smoker's Paradox in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND

Prior studies have found that smokers undergoing thrombolytic therapy for ST-segment elevation myocardial infarction have lower in-hospital mortality than nonsmokers, a phenomenon called the "smoker's paradox." Evidence, however, has been conflicting regarding whether this paradoxical association persists in the era of primary percutaneous coronary intervention.

METHODS AND RESULTS

We used the 2003-2012 National Inpatient Sample databases to identify all patients aged ≥18 years who underwent primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Multivariable logistic regression was used to compare in-hospital mortality between smokers (current and former) and nonsmokers. Of the 985 174 patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention, 438 954 (44.6%) were smokers. Smokers were younger, were more often men, and were less likely to have traditional vascular risk factors than nonsmokers. Smokers had lower observed in-hospital mortality compared with nonsmokers (2.0% versus 5.9%; unadjusted odds ratio 0.32, 95% CI 0.31-0.33, P<0.001). Although the association between smoking and lower in-hospital mortality was partly attenuated after baseline risk adjustment, a significant residual association remained (adjusted odds ratio 0.60, 95% CI 0.58-0.62, P<0.001). This association largely persisted in age-stratified analyses. Smoking status was also associated with shorter average length of stay (3.5 versus 4.5 days, P<0.001) and lower incidence of postprocedure hemorrhage (4.2% versus 6.1%; adjusted odds ratio 0.81, 95% CI 0.80-0.83, P<0.001) and in-hospital cardiac arrest (1.3% versus 2.1%; adjusted OR 0.78, 95% CI 0.76-0.81, P<0.001).

CONCLUSIONS

In this nationwide cohort of patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, we observed significantly lower risk-adjusted in-hospital mortality in smokers, suggesting that the smoker's paradox also applies to ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

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.

Hydroxychloroquine in systemic lupus erythematosus and rheumatoid arthritis and its safety in pregnancy

INTRODUCTION

The antimalarial drug hydroxychloroquine (HCQ) is widely used to treat various rheumatic diseases. Many autoimmune diseases occur in women of child-bearing age who may become pregnant while on therapy, which raises concerns regarding the teratogenicity of HCQ and its effect on the outcome of the pregnancy. There is a lack of data regarding the safety of HCQ during pregnancy.

AREAS COVERED

In this review, the authors attempt to identify relevant publications by searching MEDLINE, Cochrane database, Ovid-Currents Clinical Medicine, Ovid-Embase:Drugs and Pharmacology, EBSCO, Web of Science and SCOPUS using the search terms HCQ and/or pregnancy. A basis for the mechanism of action of HCQ is provided.

EXPERT OPINION

HCQ has been shown by numerous studies over the past 15 years to be efficacious in the treatment of autoimmune diseases, including systemic lupus erythematosus, discoid lupus erythematosus and rheumatoid arthritis. HCQ does not appear to be associated with any increased risk of congenital defects, spontaneous abortions, fetal death, prematurity or decreased numbers of live births in patients with autoimmune diseases. Therefore, in the author's opinion, HCQ is safe for the treatment of autoimmune diseases during pregnancy.

Meta-Analysis of Direct-Acting Oral Anticoagulants Compared With Warfarin in Patients >75 Years of Age

Older patients with atrial fibrillation (AF) are at higher risk of thromboembolic events and oral anticoagulant (OAC)-related bleeding complications. This meta-analysis evaluates the efficacy and safety of direct-acting OACs (DOACs) compared with warfarin in older patients with nonvalvular AF. PubMed, Embase, and Cochrane Central databases were searched for randomized controlled trials assessing the efficacy and safety of DOACs compared with warfarin in AF patients who were >75 years old. Treatment effects and relevant standard errors were calculated from the available data. These values were imputed in software R to perform meta-analysis through generic inverse variance method. Additionally, we performed a network meta-analysis to compare the relative efficacy and safety of each OAC. Five substudies of randomized controlled trials, comprising 28,135 older participants, were included in the analysis. DOACs as a group were found to have superior efficacy compared with warfarin in reducing stroke or systemic embolization (hazard ratio 0.76, 95% confidence intervals 0.67 to 0.86, p <0.01). The rate of major bleeding was similar, but intracranial hemorrhage was significantly lower in patients randomized to a DOAC (hazard ratio 0.48, 95% confidence intervals 0.34 to 0.67, p <0.01). Apixaban was the only DOAC that significantly reduced all 3 outcomes of systemic embolization, major bleeding, and intracranial hemorrhage compared with warfarin (by 29%, 36%, and 66%, respectively). In conclusion, DOACs were found to be safer and more effective than warfarin for the treatment of nonvalvular AF in older patients. Apixaban appears to provide the best combination of efficacy and safety in this population.

Five-year follow-up of maximal treadmill stress test in asymptomatic men and women

A five-year follow-up of 888 asymptomatic men and women without known coronary heart disease (CHD) who had a maximal treadmill stress test (MTST) revealed a CHD incidence of 1.1% per year. In women, exercise duration of 3 minutes or less by the Ellestad protocol correlated with subsequent development of CHD (p less than 0.001), although abnormal ST-segment and R-wave responses did not. In men 40 years of age or younger, the MTST did not correlate with subsequent CHD. In men older than 40 years, ischemic ST response (p less than 0.01), an increase or no change in R wave (p less than 0.01), and an exercise duration of 5 minutes of less (p less than 0.001) all correlated with subsequent development of CHD. Five of five men (100%) who had all three criteria developed CHD within 5 years. When men older than 40 years who had all three criteria either present or absent were considered, specificity was 100%. The sensitivity, specificity, predictive value of an abnormal test, and risk ratio for developing CHD within 5 years for the various MTST criteria alone and in combination are tabulated.

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).

ST-elevation myocardial infarction in the elderly--temporal trends in incidence, utilization of percutaneous coronary intervention and outcomes in the United States

BACKGROUND

Elderly patients with ST-elevation myocardial infarction (STEMI) are often underrepresented in major percutaneous coronary intervention (PCI) trials. Use of PCI for STEMI, and associated outcomes in patients aged ≥65 years with STEMI needed further investigation.

METHODS

We used the 2001-2010 United States Nationwide Inpatient Sample (NIS) database to examine the temporal trends in STEMI, use of PCI for STEMI, and outcomes among patients aged 65-79 and ≥80 years.

RESULTS

During 2001-2010, of 4,017,367 patients aged ≥65 years with acute myocardial infarction (AMI), 1,434,579 (35.7%) had STEMI. Over this period, among patients aged 65-79 and ≥80 years, STEMI decreased by 16.4% and 19%, whereas the use of PCI for STEMI increased by 33.5% and 22%, respectively (Ptrend<0.001). There was a significant decrease in age-adjusted in-hospital mortality (per 1000) in patients aged ≥80 years (150 versus 116, Ptrend=0.02) but not in patients aged 65-79 years (63 versus 59, Ptrend=0.886). Stepwise logistic regression identified intra-aortic balloon pump use, acute renal failure, acute cerebrovascular disease, age ≥80 years, peripheral vascular disease, gastrointestinal bleeding, female gender, congestive heart failure, chronic lung disease, weekend admission and multivessel PCI as independent predictors of in-hospital mortality among all patients ≥65 years of age who underwent PCI for STEMI.

CONCLUSIONS

In this large, multi-institutional cohort of elderly patients, a decreasing trend in STEMI, an increasing trend in PCI utilization for STEMI, and reduction in in-hospital mortality were observed from 2001 to 2010.

Trends in Coronary Angiography, Revascularization, and Outcomes of Cardiogenic Shock Complicating Non-ST-Elevation Myocardial Infarction

Early revascularization is the mainstay of treatment for cardiogenic shock (CS) complicating acute myocardial infarction. However, data on the contemporary trends in management and outcomes of CS complicating non-ST-elevation myocardial infarction (NSTEMI) are limited. We used the 2006 to 2012 Nationwide Inpatient Sample databases to identify patients aged ≥ 18 years with NSTEMI with or without CS. Temporal trends and differences in coronary angiography, revascularization, and outcomes were analyzed. Of 2,191,772 patients with NSTEMI, 53,800 (2.5%) had a diagnosis of CS. From 2006 to 2012, coronary angiography rates increased from 53.6% to 60.4% in patients with NSTEMI with CS (ptrend <0.001). Among patients who underwent coronary angiography, revascularization rates were significantly higher in patients with CS versus without CS (72.5% vs 62.6%, p <0.001). Patients with NSTEMI with CS had significantly higher risk-adjusted in-hospital mortality (odds ratio 10.09, 95% confidence interval 9.88 to 10.32) as compared to those without CS. In patients with CS, an invasive strategy was associated with lower risk-adjusted in-hospital mortality (odds ratio 0.43, 95% confidence interval 0.42 to 0.45). Risk-adjusted in-hospital mortality, length of stay, and total hospital costs decreased over the study period in patients with and without CS (ptrend <0.001). In conclusion, we observed an increasing trend in coronary angiography and decreasing trend in in-hospital mortality, length of stay, and total hospital costs in patients with NSTEMI with and without CS. Despite these positive trends, overall coronary angiography and revascularization rates remain less than optimal and in-hospital mortality unacceptably high in patients with NSTEMI and CS.

Risk factors for symptomatic peripheral arterial disease in older persons in an academic hospital-based geriatrics practice

OBJECTIVE

To investigate risk factors for symptomatic peripheral arterial disease (PAD) in older persons.

DESIGN

A retrospective analysis of charts from all older persons seen from January 1, 1998, through June 15, 1999, at an academic, hospital-based geriatrics practice.

SETTING

An academic, hospital-based geriatrics practice staffed by fellows in a geriatrics training program and full-time faculty geriatricians.

PATIENTS

A total of 467 men, mean age 80 +/- 8 years, and 1444 women, mean age 81 +/- 8 years, were included in the study.

MEASUREMENTS AND MAIN RESULTS

Symptomatic PAD was present in 93 of 467 men (20%) and in 191 of 1444 women (13%) (P = .001). Significant risk factors for symptomatic PAD by univariate analysis were: age (P = .021 in women); cigarette smoking, hypertension, diabetes mellitus, serum total cholesterol, serum high-density lipoprotein (HDL) cholesterol (inverse association), and serum low-density lipoprotein (LDL) cholesterol (P < .001 in men and women); obesity (P = .013 in men and .002 in women); and serum triglycerides (P = .027 in women). Significant independent risk factors for symptomatic PAD by stepwise logistic regression analysis were: age (odds ratio = 1.052 in men and 1.025 in women); cigarette smoking (odds ratio = 2.552 in men and 4.634 in women); hypertension (odds ratio = 2.196 in men and 2.777 in women); diabetes mellitus (odds ratio = 6.054 in men and 3.594 in women); serum HDL cholesterol (odds ratio = .948 in men and .965 in women); and serum LDL cholesterol (odds ratio = 1.019 in men and women).

CONCLUSIONS

Significant independent risk factors for symptomatic PAD in older men and women were age, cigarette smoking, hypertension, diabetes mellitus, serum HDL cholesterol (inverse association), and serum LDL cholesterol.