Pre-operative echocardiography among patients with coronary artery disease in the United States Veterans Affairs healthcare system: A retrospective cohort study

Background

Echocardiography is not recommended for routine pre-surgical evaluation but may have value for patients at high risk of major adverse cardiovascular events (MACE). The objective of this study was to evaluate whether pre-operative echocardiography is associated with lower risk of post-operative MACE among patients with coronary artery disease.

Methods

Using administrative and registry data, we examined associations of echocardiography within 3 months prior to surgery with postoperative MACE (myocardial infarction, revascularization, or death within 30 days) among patients with coronary artery disease undergoing elective, non-cardiac surgeries in the United States Veterans Affairs healthcare system in 2000–2012.

Results

Echocardiography preceded 4,378 (16.4 %) of 26,641 surgeries. MACE occurred within 30 days following 944 (3.5 %) surgeries. A 10 % higher case-mix adjusted rate of pre-operative echocardiography assessed at the hospital level was associated with a hospital-level risk of MACE that was 1.0 % (95 % confidence interval [CI] 0.1 %, 2.0 %) higher overall and 1.7 % (95 % CI 0.2 %, 3.2 %) higher among patients with recent myocardial infarction, valvular heart disease, or heart failure. At the patient level, pre-operative echocardiography was associated with an odds ratio for MACE of 1.9 (95 % CI 1.7, 2.2) overall and 1.8 (95 % CI 1.5, 2.2) among patients with recent myocardial infarction, valvular heart disease, or heart failure adjusting for MACE risk factors.

Conclusions

Pre-operative echocardiography was not associated with lower risk of post-operative MACE, even in a high risk population. Future guidelines should encourage pre-operative echocardiography only in specific patients with cardiovascular disease among whom findings can be translated into effective changes in care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0357-5) contains supplementary material, which is available to authorized users.

Mediterranean diet score and left ventricular structure and function: the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Data are limited on the relation between dietary patterns and left ventricular (LV) structure and function.

OBJECTIVE

We examined cross-sectional associations of a diet-score assessment of a Mediterranean dietary pattern with LV mass, volume, mass-to-volume ratio, stroke volume, and ejection fraction.

DESIGN

We measured LV variables with the use of cardiac MRI in 4497 participants in the Multi-Ethnic Study of Atherosclerosis study who were aged 45-84 y and without clinical cardiovascular disease. We calculated a Mediterranean diet score from intakes of fruit, vegetables, nuts, legumes, whole grains, fish, red meat, the monounsaturated fat:saturated fat ratio, and alcohol that were self-reported with the use of a food-frequency questionnaire. We used linear regression with adjustment for body size, physical activity, and cardiovascular disease risk factors to model associations and assess the shape of these associations (linear or quadratic).

RESULTS

The Mediterranean diet score had a slight U-shaped association with LV mass (adjusted means: 146, 145, 146, and 147 g across quartiles of diet score, respectively; P-quadratic trend = 0.04). The score was linearly associated with LV volume, stroke volume, and ejection fraction: for each +1-U difference in score, LV volume was 0.4 mL higher (95% CI: 0.0, 0.8 mL higher), the stroke volume was 0.5 mL higher (95% CI: 0.2, 0.8 mL higher), and the ejection fraction was 0.2 percentage points higher (95% CI: 0.1, 0.3 percentage points higher). The score was not associated with the mass-to-volume ratio.

CONCLUSIONS

A higher Mediterranean diet score is cross-sectionally associated with a higher LV mass, which is balanced by a higher LV volume as well as a higher ejection fraction and stroke volume. Participants in this healthy, multiethnic sample whose dietary patterns most closely conformed to a Mediterranean-type pattern had a modestly better LV structure and function than did participants with less-Mediterranean-like dietary patterns. This trial was registered at clinicaltrials.gov as NCT00005487.

Comparison of Length of Stay, 30-Day Mortality, and 30-Day Readmission Rates in Medicare Patients With Heart Failure and With Reduced Versus Preserved Ejection Fraction

Length of stay (LOS), 30-day mortality, and 30-day readmission rates have not been compared between Medicare beneficiaries with heart failure (HF) with reduced ejection fraction (HFrEF) and beneficiaries with heart failure with preserved ejection fraction (HFpEF), although HFpEF is common in patients with HF. To determine whether type of HF (HFrEF or HFpEF) was associated with LOS, 30-day mortality, and 30-day readmission, we used a cohort of 19,477 Medicare beneficiaries admitted to the hospital and discharged alive with a primary discharge diagnosis of HF between 2007 and 2011. Gamma regression, Poisson regression, and Cox proportional hazards with a competing risk for death were used to model LOS, 30-day mortality, and 30-day readmission rate, respectively. All models were adjusted for HF severity, co-morbidities, demographics, nursing home residence, and calendar year of admission. Beneficiaries with HFpEF had an LOS 0.02 days shorter than beneficiaries with HFrEF and a nearly identical 30-day readmission rate. Thirty-day mortality was 10% lower in beneficiaries with HFpEF versus HFrEF. In conclusion, readmission rates were as high in those with HFpEF as they are in those with HFrEF, with comparable LOS in the hospital.

Farm-to-Consumer Retail Outlet Use, Fruit and Vegetable Intake, and Obesity Status among WIC Program Participants in Alabama

OBJECTIVES

We studied whether use of farm-to-consumer (FTC) retail outlets (eg, farmers market, farm/roadside stand) was associated with daily fruit and vegetable (F&V) intake or obesity status among women who participate in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Birmingham, AL.

METHODS

We used a cross-sectional study design and recruited a convenience sample of 312 women (mean age = 27.6; 67.0% non-Hispanic black; 45.6% obese) participating in Birmingham's WIC Program. Participants were recruited between October 2014 and January 2015. Participants who self-reported purchasing produce from a FTC outlet during the 2014 farmers' market season were classified as FTC outlet users. Multivariable-adjusted regression models were used to examine associations between FTC outlet use, daily F&V intake, and obesity status (ie, body mass index ≥ 30).

RESULTS

Approximately 26.1% of participants were classified as FTC outlet users. After adjusting for socio-demographic factors and WIC Cash Value Voucher redemption, FTC outlet use was associated with increased odds of consuming ≥ 5 servings of F&Vs per day (OR: 2.01; 95%: 1.15 - 3.50), but not obesity status (OR: 0.68; 95% CI: 0.39 - 1.20).

CONCLUSIONS

FTC retail outlet use was associated with F&V intake among program participants but not obesity status.

Perceived Barriers and Facilitators of Farm-to-Consumer Retail Outlet Use Among Participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Alabama

This research aimed to identify perceived barriers and facilitators of farm-to-consumer (FTC) retail outlet (eg, farmers' markets, farm/roadside stands) usage among Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants residing in Birmingham, Alabama. Additionally, associations between barriers and facilitators reported and daily fruit and vegetable (F&V) intake were examined. A sample of 312 lower income women (mean age = 27.6; 67.0% non-Hispanic black; 45.3% obese) who participate in the Birmingham WIC program were surveyed between October 2014 and January 2015. Fischer's exact test was used to assess associations between barriers (eg, outlet location, price, transportation), facilitators (eg, produce quality, produce variety), and high F&V intake (ie, consuming ≥ 5 servings per day). Approximately 81 (26.1%) participants reported using an FTC outlet to purchase produce in 2014. Lack of awareness (39.3%), outlet location (32.8%), and lack of interest (28.4%) were the barriers most often reported. Produce quality (69.1%), produce variety (49.4%), and price (39.5%) were the facilitators most often reported. Barriers and facilitators mentioned were not associated with high F&V intake. Lack of awareness and lack of interest are key barriers to FTC outlet usage among Birmingham WIC recipients. Interventions aiming to promote use of FTC outlets should consider the perceived barriers and facilitators to usage.

Short-Term Risk of Serious Fall Injuries in Older Adults Initiating and Intensifying Treatment With Antihypertensive Medication

BACKGROUND

Antihypertensive medication use has been associated with an increased risk of falls in some but not all studies. Few data are available on the short-term risk of falls after antihypertensive medication initiation and intensification.

METHODS AND RESULTS

We examined the association between initiating and intensifying antihypertensive medication and serious fall injuries in a case-crossover study of 90 127 Medicare beneficiaries who were ≥65 years old and had a serious fall injury between July 1, 2007, and December 31, 2012, based on emergency department and inpatient claims. Antihypertensive medication initiation was defined by a prescription fill with no fills in the previous year. Intensification was defined by the addition of a new antihypertensive class, and separately, titration by the addition of a new class or increase in dosage of a current class. Exposures were ascertained for the 15 days before the fall (case period) and six 15-day earlier periods (control periods). Overall, 272, 1508, and 3113 Medicare beneficiaries initiated, added a new class of antihypertensive medication or titrated therapy within 15 days of their serious fall injury. The odds for a serious fall injury was increased during the 15 days after antihypertensive medication initiation (odds ratio, 1.36 [95% confidence interval, 1.19-1.55]), adding a new class (odds ratio, 1.16 [95% confidence interval, 1.10-1.23]), and titration [odds ratio, 1.13 [95% confidence interval, 1.08-1.18]). These associations were attenuated beyond 15 days.

CONCLUSIONS

Antihypertensive medication initiation and intensification was associated with a short-term, but not long-term, increased risk of serious fall injuries among older adults.

Comparative Risk of Hospitalized Infection Associated With Biologic Agents in Rheumatoid Arthritis Patients Enrolled in Medicare

OBJECTIVE

The risks of hospitalized infection associated with biologic agents used to treat rheumatoid arthritis (RA) are unclear. The aim of this study was to determine whether the associated risk of hospitalized infections differed between specific biologic agents used to treat RA.

METHODS

In a retrospective cohort study using Medicare data from 2006-2011 for all enrolled patients with RA, new episodes of treatment with etanercept, adalimumab, certolizumab, golimumab, infliximab, abatacept, rituximab, and tocilizumab were identified. Patients were required to have received another biologic agent previously and to have been continuously enrolled in Medicare medical and pharmacy plans during the baseline period and throughout followup. Followup started on the date of initiation of treatment with the new biologic agent (after previous treatment with a different biologic agent) and ended on the date of the earliest hospitalized infection, at 12 months, after an exposure gap of >30 days, or at the time of death or loss of Medicare coverage. Cox regression analysis was used to calculate the adjusted hazard ratio (HR) for hospitalized infection, adjusting for an infection risk score and other confounders.

RESULTS

Of 31,801 new biologic treatment episodes in patients who had previously received another biologic agent, 12.0% were with etanercept, 15.2% with adalimumab, 5.9% with certolizumab, 4.4% with golimumab, 12.4% with infliximab, 28.9% with abatacept, 14.8% with rituximab, and 6.3% with tocilizumab. During followup, we identified 2,530 hospitalized infections; incidence rates ranged from 13.1 per 100 person-years (abatacept) to 18.7 per 100 person-years (rituximab). After adjustment, etanercept (HR 1.24, 95% confidence interval [95% CI] 1.07-1.45), infliximab (HR 1.39, 95% CI 1.21-1.60), and rituximab (HR 1.36, 95% CI 1.21-1.53) had significantly higher HRs for hospitalized infection compared with abatacept.

CONCLUSION

In RA patients with prior exposure to a biologic agent, exposure to etanercept, infliximab, or rituximab was associated with a greater 1-year risk of hospitalized infection compared with the risk associated with exposure to abatacept.

Multiple Healthful Dietary Patterns and Type 2 Diabetes in the Women's Health Initiative

The relationship between various diet quality indices and risk of type 2 diabetes (T2D) remains unsettled. We compared associations of 4 diet quality indices--the Alternate Mediterranean Diet Index, Healthy Eating Index 2010, Alternate Healthy Eating Index 2010, and the Dietary Approaches to Stop Hypertension (DASH) Index--with reported T2D in the Women's Health Initiative, overall, by race/ethnicity, and with/without adjustment for overweight/obesity at enrollment (a potential mediator). This cohort (n = 101,504) included postmenopausal women without T2D who completed a baseline food frequency questionnaire from which the 4 diet quality index scores were derived. Higher scores on the indices indicated a better diet. Cox regression was used to estimate multivariate hazard ratios for T2D. Pearson coefficients for correlation among the indices ranged from 0.55 to 0.74. Follow-up took place from 1993 to 2013. During a median 15 years of follow-up, 10,815 incident cases of T2D occurred. For each diet quality index, a 1-standard-deviation higher score was associated with 10%-14% lower T2D risk (P < 0.001). Adjusting for overweight/obesity at enrollment attenuated but did not eliminate associations to 5%-10% lower risk per 1-standard-deviation higher score (P < 0.001). For all 4 dietary indices examined, higher scores were inversely associated with T2D overall and across racial/ethnic groups. Multiple forms of a healthful diet were inversely associated with T2D in these postmenopausal women.

Driving with pets and motor vehicle collision involvement among older drivers: A prospective population-based study

OBJECTIVE

Distracted driving is a major cause of motor vehicle collision (MVC) involvement. Pets have been identified as potential distraction to drivers, particularly in the front. This type of distraction could be worse for those with impairment in the cognitive aspects of visual processing. The purpose of this study is to evaluate the association between driving with pets and rates of motor vehicle collision involvement in a cohort of older drivers.

METHODS

A three-year prospective study was conducted in a population-based sample of 2000 licensed drivers aged 70 years and older. At the baseline visit, a trained interviewer asked participants about pet ownership, whether they drive with pets, how frequently, and where the pet sits in the vehicle. Motor vehicle collision (MVC) involvement during the three-year study period was obtained from the Alabama Department of Public Safety. At-fault status was determined by the police officer who arrived on the scene. Participants were followed until the earliest of death, driving cessation, or end of the study period. Poisson regression was used to calculate crude and adjusted rate ratios (RR) examining the association between pet ownership, presence of a pet in a vehicle, frequency of driving with a pet, and location of the pet inside with vehicle with any and at-fault MVC involvement. We examined whether the associations differed by higher order visual processing impairment status, as measured by Useful Field of View, Trails B, and Motor-free Visual Perception Test.

RESULTS

Rates of crash involvement were similar for older adults who have ever driven with a pet compared to those who never drove with their pet (RR=1.15, 95% CI 0.76-1.75). Drivers who reported always or sometimes driving with their pet had higher MVC rates compared to pet owners who never drive with a pet, but this association was not statistically significant (RR=1.39, 95% CI 0.86-2.24). In terms of location, those reporting having a pet frequently ride in the front of the vehicle had similar rates of MVC involvement compared to those who did not drive with a pet in the front. A similar pattern of results was observed for at-fault MVCs. This association was not modified by visual processing impairment status.

CONCLUSION

The current study demonstrates a positive but non-significant association between frequently driving with pets and MVC involvement. More research is needed, particularly on restraint use and whether the pet was in the car at the time of the crash, to help characterize the public safety benefit of regulations on driving with pets.

Impact of Driving Cessation on Trajectories of Life-Space Scores Among Community-Dwelling Older Adults

The purpose of this study was to examine the trajectories of life-space before and after the transition to driving cessation among a diverse sample of community-dwelling older adults. Life-space scores and self-reported driving cessation were assessed at annual visits from baseline through Year 6 among participants in the University of Alabama at Birmingham Study of Aging. Approximately 58% of older adults reported having stopped driving during the 6 years of follow-up. After adjusting for potential confounders, results from a random intercept model indicate that mean life-space scores decreased about 1 to 2 points every year ( p = .0011) and approximately 28 points at the time of driving cessation ( p < .0001). The rate of life-space decline post driving cessation was not significantly different from the rate of decline prior to driving cessation. Driving cessation was associated with a precipitous decline in life-space score; however, the driving cessation event did not accelerate the rate of life-space decline.

Rates of Atrial Fibrillation in Black Versus White Patients With Pacemakers

BACKGROUND

Black US residents experience higher rates of ischemic stroke than white residents but have lower rates of clinically apparent atrial fibrillation (AF), a strong risk factor for stroke. It is unclear whether black persons truly have less AF or simply more undiagnosed AF.

METHODS AND RESULTS

We obtained administrative claims data from state health agencies regarding all emergency department visits and hospitalizations in California, Florida, and New York. We identified a cohort of patients with pacemakers, the regular interrogation of which reduces the likelihood of undiagnosed AF. We compared rates of documented AF or atrial flutter at follow-up visits using Kaplan-Meier survival statistics and Cox proportional hazards models adjusted for demographic characteristics and vascular risk factors. We identified 10 393 black and 91 380 white patients without documented AF or atrial flutter before or at the index visit for pacemaker implantation. During 3.7 (±1.8) years of follow-up, black patients had a significantly lower rate of AF (21.4%; 95% CI 19.8-23.2) than white patients (25.5%; 95% CI 24.9-26.0). After adjustment for demographic characteristics and comorbidities, black patients had a lower hazard of AF (hazard ratio 0.91; 95% CI 0.86-0.96), a higher hazard of atrial flutter (hazard ratio 1.29; 95% CI 1.11-1.49), and a lower hazard of the composite of AF or atrial flutter (hazard ratio 0.94; 95% CI 0.88-99).

CONCLUSIONS

In a population-based sample of patients with pacemakers, black patients had a lower rate of AF compared with white patients. These findings indicate that the persistent racial disparities in rates of ischemic stroke are likely to be related to factors other than undiagnosed AF.

Comparative effects of biologics on cardiovascular risk among older patients with rheumatoid arthritis

OBJECTIVES

To compare the coronary heart disease risk among patients with rheumatoid arthritis (RA) initiating common biologic disease-modifying antirheumatic drugs of different mechanisms.

METHODS

We conducted a retrospective cohort study of patients with RA enrolled in Medicare, a public health plan covering >90% of US residents 65 years or older, from 2006 to 2012 who (1) initiated a biologic, (2) had complete medical and pharmacy coverage for at least 12 months before biologic initiation and (3) were free of coronary heart disease at the time of initiation. We compared the incidence rates (IRs) of (1) acute myocardial infarction (AMI) and (2) a composite outcome of AMI or coronary revascularisation and used multivariable adjusted Cox regression models to examine the associations between the type of biologic and the two outcomes.

RESULTS

We identified 47 193 eligible patients with RA with mean age 64 (SD 13) years; 85% were women. Crude IRs for AMI ranged from 5.7 to 8.8 cases per 1000 person-years (PYs). AMI risk was significantly elevated among antitumour necrosis factor (anti-TNF) initiators overall (adjusted HR (aHR) 1.3; 95% CI 1.0 to 1.6) and individually among etanercept (aHR 1.3; 95% CI 1.0 to 1.8) and infliximab (aHR 1.3; 95% CI 1.0 to 1.6) compared with abatacept initiators. Crude IRs for the composite outcome ranged from 7.6 to 14.5 per 1000 PYs. Tocilizumab initiators were at reduced risk of the composite outcome compared with abatacept initiators (aHR 0.64, 95% CI 0.41 to 0.99).

DISCUSSION

Findings from this observational study of patients with RA suggested that anti-TNF biologics may be associated with higher AMI risk compared with abatacept.

Association of Serum Lipids and Coronary Heart Disease in Contemporary Observational Studies

BACKGROUND

The use of statins increased among US adults with high coronary heart disease (CHD) risk after publication of the 2001 cholesterol treatment guidelines.

METHODS AND RESULTS

We analyzed the association between lipids and CHD among 9578 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants and 346,595 Kaiser Permanente Southern California (KPSC) members with baseline lipid measurements in 2003 to 2007. We performed the same analyses among 14,590 Atherosclerosis Risk In Communities (ARIC) study participants with lipid measurements in 1987 to 1989. Analyses were restricted to blacks and whites 45 to 64 years of age without CHD who were not taking statins at baseline. Total cholesterol, high-density lipoprotein cholesterol, and triglycerides were measured at baseline. Low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and ratios of total to high-density lipoprotein cholesterol and triglycerides to high-density lipoprotein cholesterol were calculated. The prevalence of diabetes mellitus, history of stroke, and antihypertensive medication use increased at higher low-density lipoprotein cholesterol in ARIC but not in REGARDS or KPSC. Over 8.9 years of follow-up, 225 CHD events occurred in REGARDS, 6547 events in KPSC, and 583 events in ARIC. After multivariable adjustment, less favorable lipid levels were associated with higher hazard ratios for CHD in ARIC. These associations were attenuated in REGARDS and KPSC. For example, the hazard ratio associated with the highest versus lowest quartile of low-density lipoprotein cholesterol (≥ 146 versus ≤ 102 mg/dL) was 1.89 (95% confidence interval, 1.42-2.51) in ARIC, 1.25 (95% confidence interval, 0.81-1.92) in REGARDS, and 1.49 (95% confidence interval, 1.38-1.61) in KPSC.

CONCLUSION

The association between lipids and CHD in contemporary studies may be attenuated by the preferential use of statins by high-risk individuals.

Optimal use of available claims to identify a Medicare population free of coronary heart disease

We examined claims-based approaches for identifying a study population free of coronary heart disease (CHD) using data from 8,937 US blacks and whites enrolled during 2003-2007 in a prospective cohort study linked to Medicare claims. Our goal was to minimize the percentage of persons at study entry with self-reported CHD (previous myocardial infarction or coronary revascularization). We assembled 6 cohorts without CHD claims by requiring 6 months, 1 year, or 2 years of continuous Medicare fee-for-service insurance coverage prior to study entry and using either a fixed-window or all-available look-back period. We examined adding CHD-related claims to our "base algorithm," which included claims for myocardial infarction and coronary revascularization. Using a 6-month fixed-window look-back period, 17.8% of participants without claims in the base algorithm reported having CHD. This was reduced to 3.6% using an all-available look-back period and adding other CHD claims to the base algorithm. Among cohorts using all-available look-back periods, increasing the length of continuous coverage from 6 months to 1 or 2 years reduced the sample size available without lowering the percentage of persons with self-reported CHD. This analysis demonstrates approaches for developing a CHD-free cohort using Medicare claims.

Visit-to-Visit Variability of Blood Pressure and Coronary Heart Disease, Stroke, Heart Failure, and Mortality: A Cohort Study

BACKGROUND

Variability of blood pressure (BP) across outpatient visits is frequently dismissed as random fluctuation around a patient's underlying BP.

OBJECTIVE

To examine the association of visit-to-visit variability (VVV) of systolic BP (SBP) and diastolic BP with cardiovascular disease (CVD) and mortality outcomes.

DESIGN

Prospective cohort study.

SETTING

Post hoc analysis of ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial).

PARTICIPANTS

25 814 ALLHAT participants.

MEASUREMENTS

The VVV of SBP was defined as the SD across SBP measurements obtained at 7 visits conducted from 6 to 28 months after ALLHAT enrollment. Participants without CVD events during the first 28 months of follow-up were followed from the 28-month visit through the end of active ALLHAT follow-up. Outcomes included fatal coronary heart disease (CHD) or nonfatal myocardial infarction, all-cause mortality, stroke, and heart failure.

RESULTS

During follow-up, 1194 fatal CHD or nonfatal MI events, 1948 deaths, 606 strokes, and 921 heart failure events occurred. After multivariable adjustment, including for mean SBP, the hazard ratio comparing participants in the highest versus lowest quintile of SD of SBP (≥14.4 mm Hg vs. <6.5 mm Hg) was 1.30 (95% CI, 1.06 to 1.59) for fatal CHD or nonfatal MI, 1.58 (CI, 1.32 to 1.90) for all-cause mortality, 1.46 (CI, 1.06 to 2.01) for stroke, and 1.25 (CI, 0.97 to 1.61) for heart failure. Higher VVV of diastolic BP was also associated with CVD events and mortality.

LIMITATION

Long-term outcomes were not available.

CONCLUSION

Higher VVV of SBP is associated with an increased risk for CVD and mortality. Future studies should examine whether reducing VVV of BP lowers this risk.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Trends in mortality and recurrent coronary heart disease events after an acute myocardial infarction among Medicare beneficiaries, 2001-2009

BACKGROUND

Few contemporary studies examine trends in recurrent coronary heart disease (CHD) events and mortality after acute myocardial infarction (AMI) and whether these trends vary by race or sex.

METHODS

We used data from the national 5% random sample of Medicare fee-for-service beneficiaries for 1999 to 2010. We included beneficiaries who experienced an AMI (International Classification of Disease [ICD] 9 410.xx, except 410.x2) between January 1, 2001, and December 31, 2009. Each beneficiary's first AMI was included as their index event. Outcomes included all-cause mortality, recurrent AMI, and recurrent CHD events during the 365days after discharge for the index AMI. To examine secular trends, we pooled calendar years into 3 periods (2001-2003, 2004-2006, and 2007-2009).

RESULTS

Among 48,688 beneficiaries with index AMIs from 2001 to 2009, we observed decreases in the age-adjusted rates for mortality (-3.8% for each 3-year period, 95% CI -6.1% to -1.6%, P trend = .001), recurrent AMI (-15.0%, 95% CI -18.6% to -11.2%, P trend < .001), and recurrent CHD events (-11.1%, 95% CI -14.0% to -8.0%, P trend < .001) in the 365days after the index AMI. In 2007 to 2009, blacks had excess risk relative to whites for mortality and recurrent AMI (black/white incidence rate ratio of 1.38 for mortality [95% CI 1.21-1.57] and 1.38 for recurrent AMI [95% CI 1.07-1.79]).

CONCLUSIONS

Despite overall favorable trends in lower mortality and recurrent events after AMI, efforts are needed to reduce racial disparities.

Risks of herpes zoster in patients with rheumatoid arthritis according to biologic disease-modifying therapy

OBJECTIVE

To evaluate whether the risks of herpes zoster (HZ) differed by biologic agents with different mechanisms of action (MOAs) in older rheumatoid arthritis (RA) patients.

METHODS

Using Medicare data from 2006-2011, among RA patients with prior biologic agent use and no history of cancer or other autoimmune diseases, this retrospective cohort study identified new treatment episodes of abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, rituximab, and tocilizumab. Followup started on initiation of the new biologic agent and ended at any of the following: first incidence of HZ, a 30-day gap in current exposure, death, a diagnosis of other autoimmune disease or cancer, loss of insurance coverage, or December 31, 2011. We calculated the proportion of RA patients vaccinated for HZ in each calendar year prior to biologic agent initiation and HZ incidence rate for each biologic agent. We compared HZ risks among therapies using Cox regression adjusted for potential confounders.

RESULTS

Of 29,129 new biologic treatment episodes, 28.7% used abatacept, 15.9% adalimumab, 14.8% rituximab, 12.4% infliximab, 12.2% etanercept, 6.1% tocilizumab, 5.8% certolizumab, and 4.4% golimumab. The proportion of RA patients vaccinated for HZ prior to biologic agent initiation ranged from 0.4% in 2007 to 4.1% in 2011. We identified 423 HZ diagnoses with the highest HZ incidence rate for certolizumab (2.45 per 100 person-years) and the lowest for golimumab (1.61 per 100 person-years). Neither the crude incidence rate nor the adjusted hazard ratio differed significantly among biologic agents. Glucocorticoid use had a significant association with HZ.

CONCLUSION

Among older patients with RA, the HZ risk was similar across biologic agents, including those with different MOAs.

Alcohol and incident heart failure among middle-aged and elderly men: cohort of Swedish men

BACKGROUND

Compared with no alcohol consumption, heavy alcohol intake is associated with a higher rate of heart failure (HF) whereas light-to-moderate intake may be associated with a lower rate. However, several prior studies did not exclude former drinkers, who may have changed alcohol consumption in response to diagnosis. This study aimed to investigate the association between alcohol intake and incident HF.

METHODS AND RESULTS

We conducted a prospective cohort study of 33 760 men aged 45 to 79 years with no HF, diabetes mellitus, or myocardial infarction at baseline participating in the Cohort of Swedish Men Study. We excluded former drinkers. At baseline, participants completed a food frequency questionnaire and reported other characteristics. HF was defined as hospitalization for or death from HF, ascertained by Swedish inpatient and cause-of-death records from January 1, 1998, through December 31, 2011. We constructed Cox proportional hazards models to estimate multivariable-adjusted incidence rate ratios. During follow-up, 2916 men were hospitalized for (n=2139) or died (n=777) of incident HF. There was a U-shaped relationship between total alcohol intake and incident HF (P=0.0004). There was a nadir at light-to-moderate alcohol intake: consuming 7 to <14 standard drinks per week was associated with a 19% lower multivariable-adjusted rate of HF compared with never drinking (incidence rate ratio, 0.81; 95% confidence interval, 0.69-0.96).

CONCLUSIONS

In this cohort of Swedish men, there was a U-shaped relationship between alcohol consumption and HF incidence, with a nadir at light-to-moderate intake. Heavy intake did not seem protective.

Underutilization of high-intensity statin therapy after hospitalization for coronary heart disease

BACKGROUND

National guidelines recommend use of high-intensity statins after hospitalization for coronary heart disease (CHD) events.

OBJECTIVES

This study sought to estimate the proportion of Medicare beneficiaries filling prescriptions for high-intensity statins after hospital discharge for a CHD event and to analyze whether statin intensity before hospitalization is associated with statin intensity after discharge.

METHODS

We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries between 65 and 74 years old. Beneficiaries were included in the analysis if they filled a statin prescription after a CHD event (myocardial infarction or coronary revascularization) in 2007, 2008, or 2009. High-intensity statins included atorvastatin 40 to 80 mg, rosuvastatin 20 to 40 mg, and simvastatin 80 mg.

RESULTS

Among 8,762 Medicare beneficiaries filling a statin prescription after a CHD event, 27% of first post-discharge fills were for a high-intensity statin. The percent filling a high-intensity statin post-discharge was 23.1%, 9.4%, and 80.7%, for beneficiaries not taking statins pre-hospitalization, taking low/moderate-intensity statins, and taking high-intensity statins before their CHD event, respectively. Compared with beneficiaries not on statin therapy pre-hospitalization, multivariable adjusted risk ratios for filling a high-intensity statin were 4.01 (3.58-4.49) and 0.45 (0.40-0.52) for participants taking high-intensity and low/moderate-intensity statins before their CHD event, respectively. Only 11.5% of beneficiaries whose first post-discharge statin fill was for a low/moderate-intensity statin filled a high-intensity statin within 365 days of discharge.

CONCLUSIONS

The majority of Medicare beneficiaries do not fill high-intensity statins after hospitalization for CHD.

Derivation of a tuberculosis screening rule for sub-Saharan African prisons

SETTING

Lusaka Central Prison, Zambia.

OBJECTIVE

To derive screening rules for tuberculosis (TB) using data collected during a prison-wide TB and human immunodeficiency virus (HIV) screening program.

DESIGN

We derived rules with two methodologies: logistic regression and classification and regression trees (C&RT). We evaluated the performance of the derived rules as well as existing World Health Organization (WHO) screening recommendations in our cohort of inmates, as measured by sensitivity, specificity, and positive and negative predictive values.

RESULTS

The C&RT-derived rule recommended diagnostic testing of all inmates who were underweight (defined as body mass index [BMI] < 18.5 kg/m(2)] or HIV-infected; the C&RT-derived rule had 60% sensitivity and 71% specificity. The logistic regression-derived rule recommended diagnostic testing of inmates who were underweight, HIV-infected or had chest pain; the logistic regression-derived rule had 74% sensitivity and 57% specificity. Two of the WHO recommendations had sensitivities that were similar to our logistic regression rule but had poorer specificities, resulting in a greater testing burden.

CONCLUSION

Low BMI and HIV infection were the most robust predictors of TB in our inmates; chest pain was additionally retained in one model. BMI and HIV should be further evaluated as the basis for TB screening rules for inmates, with modification as needed to improve the performance of the rules.

Characteristics and prognosis of acute myocardial infarction by discharge diagnosis: the Reasons for Geographic and Racial Differences in Stroke study

PURPOSE

To compare the characteristics and prognosis of acute myocardial infarctions (AMIs) that were not the primary reason for hospitalization, and thus not primary discharge diagnosis, to AMIs that were the primary reason for hospitalization.

METHODS

Primary discharge diagnoses for Reasons for Geographic and Racial Differences in Stroke study participants (black and white men and women age ≥45 years) with adjudicated AMIs were categorized as "AMI" or "other". Cox models were used to compare mortality up to 5 years post-AMI between primary discharge diagnoses of AMI and other.

RESULTS

Of 871 AMIs, primary discharge diagnosis was not AMI in 550 (63%). When primary discharge diagnosis was not AMI, average troponin elevations were smaller and heart failure was more common. Adjusted for participant and hospitalization characteristics, all-cause, coronary heart disease, and cardiovascular disease mortality after AMI were similar between groups (hazard ratios [95% confidence intervals]: 1.08 [0.80-1.47]; 1.29 [0.76-2.18]; and 0.86 [0.58-1.27], respectively).

CONCLUSIONS

Studies limited to individuals with primary discharge diagnosis of AMI may underestimate the burden of AMI and exclude a group with elevated risk of all-cause, coronary heart disease, and cardiovascular disease mortality.

Statin use following hospitalization among Medicare beneficiaries with a secondary discharge diagnosis of acute myocardial infarction

Background

Patients with coronary heart disease are recommended to use statins following hospital discharge. Acute myocardial infarction (AMI) is a common complication of hospitalization, but the use of statins following discharge among patients who were not initially hospitalized for AMI has not been assessed adequately.

Methods and Results

Using the Medicare 5% national random sample, we determined statin use among beneficiaries who were hospitalized and who had a secondary discharge diagnosis of AMI and among beneficiaries who had a primary discharge diagnosis of AMI, coronary artery bypass grafting, or percutaneous coronary intervention in 2007–2009. Statin use was defined by a pharmacy (Medicare Part D) claim within 90 days following discharge. Of 8175 Medicare beneficiaries who did not take statins prior to hospitalization, 31.2% with AMI as a secondary discharge diagnosis, 60.5% with AMI as the primary discharge diagnosis, 67.6% with coronary artery bypass grafting, and 63.9% with a percutaneous coronary intervention initiated statins. After multivariable adjustment, the risk ratio for statin initiation comparing beneficiaries with a secondary versus primary discharge diagnosis of AMI was 0.59 (95% CI 0.54 to 0.65). Among 5468 Medicare beneficiaries taking statins prior to hospitalization, statin use following discharge was lower for those with AMI as a secondary discharge diagnosis (71.8%) compared with their counterparts with AMI, coronary artery bypass grafting, and percutaneous coronary intervention (84.1%, 83.8%, and 87.3%, respectively) as the primary discharge diagnosis.

Conclusion

Medicare beneficiaries with a secondary hospital discharge diagnosis of AMI were less likely to fill statins compared with those with other coronary heart disease events.

Fruit and vegetable intake and rate of heart failure: a population-based prospective cohort of women

AIMS

Although numerous studies have investigated fruit and vegetable consumption in association with cardiovascular diseases (CVD) such as coronary heart disease and stroke, a limited number of studies have investigated the association with heart failure. The aim of this study was to assess the association between fruit and vegetable intake and the incidence of heart failure among women.

METHODS AND RESULTS

In September 1997, a total of 34,319 women (aged 49-83 years) from the Swedish Mammography Cohort, free of cancer and CVD at baseline, completed a food-frequency questionnaire. Women were followed for incident heart failure (diagnosis as primary or secondary cause) through December 2011 using administrative health registries. Over 12.9 years of follow-up (442,348 person-years), we identified 3051 incident cases of heart failure. Total fruit and vegetable consumption was inversely associated with the rate of heart failure {the multivariable-adjusted rate ratio (RR) in the highest quintile compared with the lowest was 0.80 [95% confidence interval (CI) 0.70-0.90]}. Fruit (mutually adjusted for vegetables) were not significantly associated with rate of heart failure (RR 0.94; 95% CI 0.83-1.07), whereas vegetables showed an inverse association (RR 0.83; 95% CI 0.73-0.95). When investigating the shape of association, we found evidence of a non-linear association (P = 0.01), and the lowest rates of heart failure were observed among women consuming ≥5 servings/day of fruit and vegetables, without further decrease with increasing intake.

CONCLUSIONS

In this population-based prospective cohort study of women, higher total consumption of fruit and vegetables was inversely associated with the incidence of heart failure.

Association between neighborhood disadvantage and hypertension prevalence, awareness, treatment, and control in older adults: results from the University of Alabama at Birmingham Study of Aging

OBJECTIVES

We evaluated the effect of neighborhood disadvantage (ND) on older adults' prevalence, awareness, treatment, and control of hypertension.

METHODS

Data were from the University of Alabama at Birmingham Study of Aging, an observational study of 1000 community-dwelling Black and White Alabamians aged 65 years and older, in 1999 to 2001. We assessed hypertension prevalence, awareness, treatment, and control with blood pressure measurements and self-report data. We assessed ND with US Census data corresponding with participants' census tracts, created tertiles of ND, and fit models with generalized estimating equations via a logit link function with a binomial distribution. Adjusted models included variables assessing personal advantage and disadvantage, place-based factors, sociodemographics, comorbidities, and health behaviors.

RESULTS

Living in mid-ND (adjusted odds ratio [AOR] = 1.6; 95% confidence interval [CI] = 1.2, 2.1) and high-ND tertiles (AOR = 1.8; 95% CI = 1.3, 2.3) was associated with higher hypertension prevalence, and living in high-ND tertiles was associated with lower odds of controlled hypertension (AOR = 0.6; 95% CI = 0.4, 0.6). In adjusted models, ND was not associated with hypertension awareness or treatment.

CONCLUSIONS

These findings show that neighborhood environmental factors matter for hypertension outcomes and suggest the importance of ND for hypertension management in older adults.

Ability of low antihypertensive medication adherence to predict statin discontinuation and low statin adherence in patients initiating treatment after a coronary event

Low statin adherence and discontinuation of statins are common in patients with coronary heart disease. We hypothesized that low antihypertensive medication adherence would be associated with future statin discontinuation and low adherence in patients initiating statins. Using a 5% national sample of Medicare beneficiaries, we conducted a cohort study of Medicare beneficiaries initiating statins after hospitalization for acute myocardial infarction or coronary revascularization in 2007, 2008, and 2009. Antihypertensive medication adherence, defined using the average proportion of days covered across 5 classes during the 365 days before hospitalization, was categorized as ≥80% (high), 50% to <80% (medium), and <50% (low). Statin discontinuation was defined as failure to refill a statin within 365 days of hospital discharge, and low adherence was defined as proportion of days covered for statins <80%. In 2,695 Medicare beneficiaries who initiated statins after hospital discharge, 6.0%, 8.4%, and 14.5% with high, medium, and low antihypertensive medication adherence discontinued statins. After multivariable adjustment, the risk ratios (95% confidence interval) for statin discontinuation were 1.38 (0.98 to 1.95) and 2.41 (1.51 to 3.87) for beneficiaries with medium and low versus high antihypertensive medication adherence, respectively. In beneficiaries who did not discontinue statins, 36.2% had low statin adherence. Compared with high adherence, medium and low antihypertensive medication adherences were associated with multivariable adjusted risk ratios (95% confidence interval) for low statin adherence of 1.33 (1.14 to 1.55) and 1.62 (1.25 to 2.10), respectively. In conclusion, low antihypertensive medication adherence before initiating statins is associated with future statin discontinuation and low statin adherence.

Statin underuse and low prevalence of LDL-C control among U.S. adults at high risk of coronary heart disease

BACKGROUND

Statins reduce the risk of coronary heart disease (CHD) in individuals with a history of CHD or risk equivalents. A 10-year CHD risk >20% is considered a risk equivalent but is frequently not detected. Statin use and low-density lipoprotein cholesterol (LDL-C) control were examined among participants with CHD or risk equivalents in the nationwide Reasons for Geographic and Racial Differences in Stroke study (n = 8812).

METHODS

Participants were categorized into 4 mutually exclusive groups: (1) history of CHD (n = 4025); (2) no history of CHD but with a history of stroke and/or abdominal aortic aneurysm (AAA) (n = 946); (3) no history of CHD or stroke/AAA but with diabetes mellitus (n = 3134); or (4) no history of the conditions in (1) through (3) but with 10-year Framingham CHD risk score (FRS) >20% calculated using the third Adult Treatment Panel point scoring system (n = 707).

RESULTS

Statins were used by 58.4% of those in the CHD group and 41.7%, 40.4% and 20.1% of those in the stroke/AAA, diabetes mellitus and FRS >20% groups, respectively. Among those taking statins, 65.1% had LDL-C <100 mg/dL, with no difference between the CHD, stroke/AAA, or diabetes mellitus groups. However, compared with those in the CHD group, LDL-C <100 mg/dL was less common among participants in the FRS >20% group (multivariable adjusted prevalence ratio: 0.72; 95% confidence interval: 0.62-0.85). Results were similar using the 2013 American College of Cardiology/American Heart Association cholesterol treatment guideline.

CONCLUSIONS

These data suggest that many people with high CHD risk, especially those with an FRS >20%, do not receive guideline-concordant lipid-lowering therapy and do not achieve an LDL-C <100 mg/dL.

Visit-to-visit variability of blood pressure and cardiovascular disease and all-cause mortality: a systematic review and meta-analysis

Visit-to-visit variability of blood pressure (BP) has been associated with cardiovascular disease (CVD) and mortality in some but not all studies. We conducted a systematic review and meta-analysis to examine the association between visit-to-visit variability of BP and CVD and all-cause mortality. Medical databases were searched through June 4, 2014, for studies meeting the following eligibility criteria: adult participants; BP measurements at ≥3 visits; follow-up for CVD, coronary heart disease, stroke, or mortality outcomes; events confirmed via database, death certificate, or event ascertainment committee; and adjustment for confounders. Data were extracted by 2 reviewers and pooled using a random-effects model. Overall, 8870 abstracts were identified of which 37 studies, representing 41 separate cohorts, met inclusion criteria. Across studies, visit-to-visit variability of systolic BP and diastolic BP showed significant associations with outcomes in 181 of 312 (58.0%) and 61 of 188 (32.4%) analyses, respectively. Few studies provided sufficient data for pooling risk estimates. For each 5 mm Hg higher SD of systolic BP, the pooled hazard ratio for stroke across 7 cohorts was 1.17 (95% confidence interval [CI], 1.07-1.28), for coronary heart disease across 4 cohorts was 1.27 (95% CI, 1.07-1.51), for CVD across 5 cohorts was 1.12 (95% CI, 0.98-1.28), for CVD mortality across 5 cohorts was 1.22 (95% CI, 1.09-1.35), and for all-cause mortality across 4 cohorts was 1.20 (95% CI, 1.05-1.36). In summary, modest associations between visit-to-visit variability of BP and CVD and all-cause mortality are present in published studies. However, these findings are limited by the small amount of data available for meta-analysis.

Effect of sustaining lifestyle modifications (nonsmoking, weight reduction, physical activity, and mediterranean diet) after healing of myocardial infarction, percutaneous intervention, or coronary bypass (from the REasons for Geographic and Racial Differences in Stroke Study)

Guidelines recommend lifestyle modification for patients with coronary heart disease (CHD). Few data demonstrate which lifestyle modifications, if sustained, reduce recurrent CHD and mortality risk in cardiac patients after the postacute rehabilitation phase. We determined the association between ideal lifestyle factors and recurrent CHD and all-cause mortality in REasons for Geographic and Racial Differences in Stroke study participants with CHD (n = 4,174). Ideal lifestyle factors (physical activity ≥4 times/week, nonsmoking, highest quartile of Mediterranean diet score, and waist circumference <88 cm for women and <102 cm for men) were assessed through questionnaires and an in-home study visit. There were 447 recurrent CHD events and 745 deaths over a median 4.3 and 4.5 years, respectively. After multivariable adjustment, physical activity ≥4 versus no times/week and non-smoking versus current smoking were associated with reduced hazard ratios (HRs; 95% confidence interval [CI]) for recurrent CHD (HR 0.69, 95% CI 0.54 to 0.89 and HR 0.50, 95% CI 0.39 to 0.64, respectively) and death (HR 0.71, 95% CI 0.59 to 0.86 and HR 0.53, 95% CI 0.44 to 0.65, respectively). The multivariable-adjusted HRs (and 95% CIs) for recurrent CHD and death comparing the highest versus lowest quartile of Mediterranean diet adherence were 0.77 (95% CI 0.55 to 1.06) and 0.84 (95% CI 0.67 to 1.07), respectively. Neither outcome was associated with waist circumference. Comparing participants with 1, 2, and 3 versus 0 ideal lifestyle factors (non-smoking, physical activity ≥4 times/week, and highest quartile of Mediterranean diet score), the HRs (and 95% CIs) were 0.60 (95% CI 0.44 to 0.81), 0.49 (95% CI 0.36 to 0.67), and 0.38 (95% CI 0.21 to 0.67), respectively, for recurrent CHD and 0.65 (95% CI 0.51 to 0.83), 0.57 (95% CI 0.43 to 0.74), and 0.41 (95% CI 0.26 to 0.64), respectively, for death. In conclusion, maintaining smoking cessation, physical activity, and Mediterranean diet adherence is important for secondary CHD prevention.

Procedures for assessing psychological predictors of injuries in circus artists: a pilot prospective study

Background

Research on psychological risk factors for injury has focused on stable traits. Our objective was to test the feasibility of a prospective longitudinal study designed to examine labile psychological states as risk factors of injury.

Methods

We measured psychological traits at baseline (mood, ways of coping and anxiety), and psychological states every day (1-item questions on anxiety, sleep, fatigue, soreness, self-confidence) before performances in Cirque du Soleil artists of the show “O”. Additional questions were added once per week to better assess anxiety (20-item) and mood. Questionnaires were provided in English, French, Russian and Japanese. Injury and exposure data were extracted from electronic records that are kept as part of routine business practices.

Results

The 43.9% (36/82) recruitment rate was more than expected. Most artists completed the baseline questionnaires in 15 min, a weekly questionnaire in <2 min and a daily questionnaire in <1 min. We improved the formatting of some questions during the study, and adapted the wording of other questions to improve clarity. There were no dropouts during the entire study, suggesting the questionnaires were appropriate in content and length. Results for sample size calculations depend on the number of artists followed and the minimal important difference in injury rates, but in general, preclude a purely prospective study with daily data collection because of the long follow-up required. However, a prospective nested case-crossover design with data collection bi-weekly and at the time of injury appears feasible.

Conclusion

A prospective study collecting psychological state data from subjects who train and work regularly together is feasible, but sample size calculations suggest that the optimal study design would use prospective nested case-crossover methodology.

Declines in coronary heart disease incidence and mortality among middle-aged adults with and without diabetes

PURPOSE

The purpose of the study was to investigate secular changes in coronary heart disease (CHD) incidence and mortality among adults with and without diabetes and to determine the effect of increased lipid-lowering medication use and reductions in low-density lipoprotein cholesterol (LDL-C) levels on these changes.

METHODS

We analyzed data on participants aged 45 to 64 years from the Atherosclerosis Risk in Communities Study in 1987-1996 (early period) and the Reasons for Geographic and Racial Differences in Stroke Study in 2003-2009 (late period). Hazard ratios (HRs) for the association of diabetes and period with incident CHD and CHD mortality were obtained after adjustment for sociodemographics cardiovascular risk factors, lipid-lowering medication use, and LDL-C.

RESULTS

After multivariable adjustment, diabetes was associated with an increased CHD risk during the early (HR = 1.99, 95% confidence interval = 1.59-2.49) and late (HR = 2.39, 95% confidence interval = 1.69-3.35) periods. CHD incidence and mortality declined between the early and late periods for individuals with and without diabetes. Increased use of lipid-lowering medication and lower LDL-C explained 33.6% and 27.2% of the decline in CHD incidence and CHD mortality, respectively, for those with diabetes.

CONCLUSIONS

Although rates have declined, diabetes remains associated with an increased risk of CHD incidence and mortality, highlighting the need for continuing diabetes prevention and cardiovascular risk factor management.

Hospital variations in severe sepsis mortality

This study sought to characterize variations in severe sepsis mortality between hospitals in the United States. Hospital discharge data (2012) were used from the University HealthSystem Consortium (UHC), a cooperative of US not-for-profit academic medical centers and affiliated hospitals. Discharge diagnosis codes were used to define severe sepsis as the presence of a serious infection with at least 1 organ dysfunction on hospital presentation. Expected mortality was determined from UHC risk adjustment mortality models. Among the 188 hospitals in the analysis, there were 256 509 patients with severe sepsis on admission. The median number of severe sepsis cases per hospital was 1202 (interquartile range [IQR] = 718-1940). Severe sepsis observed mortality (median = 8.6%; IQR = 6.8%-10.3%; range = 0.9%-18.2%) and observed-to-expected (O:E) mortality ratios (median = 0.91; IQR = 0.77-1.05; range = 0.16-1.95) varied across the hospitals. Variations in institutional severe sepsis observed mortality rates and O:E mortality ratios were observed in this national consortium of major medical centers.

Claims-based algorithms for identifying Medicare beneficiaries at high estimated risk for coronary heart disease events: a cross-sectional study

BACKGROUND

Databases of medical claims can be valuable resources for cardiovascular research, such as comparative effectiveness and pharmacovigilance studies of cardiovascular medications. However, claims data do not include all of the factors used for risk stratification in clinical care. We sought to develop claims-based algorithms to identify individuals at high estimated risk for coronary heart disease (CHD) events, and to identify uncontrolled low-density lipoprotein (LDL) cholesterol among statin users at high risk for CHD events.

METHODS

We conducted a cross-sectional analysis of 6,615 participants ≥66 years old using data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study baseline visit in 2003-2007 linked to Medicare claims data. Using REGARDS data we defined high risk for CHD events as having a history of CHD, at least 1 risk equivalent, or Framingham CHD risk score >20%. Among statin users at high risk for CHD events we defined uncontrolled LDL cholesterol as LDL cholesterol ≥100 mg/dL. Using Medicare claims-based variables for diagnoses, procedures, and healthcare utilization, we developed algorithms for high CHD event risk and uncontrolled LDL cholesterol.

RESULTS

REGARDS data indicated that 49% of participants were at high risk for CHD events. A claims-based algorithm identified high risk for CHD events with a positive predictive value of 87% (95% CI: 85%, 88%), sensitivity of 69% (95% CI: 67%, 70%), and specificity of 90% (95% CI: 89%, 91%). Among statin users at high risk for CHD events, 30% had LDL cholesterol ≥100 mg/dL. A claims-based algorithm identified LDL cholesterol ≥100 mg/dL with a positive predictive value of 43% (95% CI: 38%, 49%), sensitivity of 19% (95% CI: 15%, 22%), and specificity of 89% (95% CI: 86%, 90%).

CONCLUSIONS

Although the sensitivity was low, the high positive predictive value of our algorithm for high risk for CHD events supports the use of claims to identify Medicare beneficiaries at high risk for CHD events.

Effect of chlorthalidone, amlodipine, and lisinopril on visit-to-visit variability of blood pressure: results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial

Few randomized trials have compared visit-to-visit variability (VVV) of systolic blood pressure (SBP) across drug classes. The authors compared VVV of SBP among 24,004 participants randomized to chlorthalidone, amlodipine, or lisinopril in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). VVV of SBP was calculated across 5 to 7 visits occurring 6 to 28 months following randomization. The standard deviation (SD) of SBP was 10.6 (SD=5.0), 10.5 (SD=4.9), and 12.2 (SD=5.8) for participants randomized to chlorthalidone, amlodipine, and lisinopril, respectively. After multivariable adjustment including mean SBP across visits and compared with participants randomized to chlorthalidone, participants randomized to amlodipine had a 0.36 (standard error [SE]: 0.07) lower SD of SBP and participants randomized to lisinopril had a 0.77 (SE=0.08) higher SD of SBP. Results were consistent using other VVV of SBP metrics. These data suggest chlorthalidone and amlodipine are associated with lower VVV of SBP than lisinopril.

Validation of the atherosclerotic cardiovascular disease Pooled Cohort risk equations

IMPORTANCE

The American College of Cardiology/American Heart Association (ACC/AHA) Pooled Cohort risk equations were developed to estimate atherosclerotic cardiovascular disease (CVD) risk and guide statin initiation.

OBJECTIVE

To assess calibration and discrimination of the Pooled Cohort risk equations in a contemporary US population.

DESIGN, SETTING, AND PARTICIPANTS

Adults aged 45 to 79 years enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study between January 2003 and October 2007 and followed up through December 2010. We studied participants for whom atherosclerotic CVD risk may trigger a discussion of statin initiation (those without clinical atherosclerotic CVD or diabetes, low-density lipoprotein cholesterol level between 70 and 189 mg/dL, and not taking statins; n = 10,997).

MAIN OUTCOMES AND MEASURES

Predicted risk and observed adjudicated atherosclerotic CVD incidence (nonfatal myocardial infarction, coronary heart disease [CHD] death, nonfatal or fatal stroke) at 5 years because REGARDS participants have not been followed up for 10 years. Additional analyses, limited to Medicare beneficiaries (n = 3333), added atherosclerotic CVD events identified in Medicare claims data.

RESULTS

There were 338 adjudicated events (192 CHD events, 146 strokes). The observed and predicted 5-year atherosclerotic CVD incidence per 1000 person-years for participants with a 10-year predicted atherosclerotic CVD risk of less than 5% was 1.9 (95% CI, 1.3-2.7) and 1.9, respectively, risk of 5% to less than 7.5% was 4.8 (95% CI, 3.4-6.7) and 4.8, risk of 7.5% to less than 10% was 6.1 (95% CI, 4.4-8.6) and 6.9, and risk of 10% or greater was 12.0 (95% CI, 10.6-13.6) and 15.1 (Hosmer-Lemeshow χ2 = 19.9, P = .01). The C index was 0.72 (95% CI, 0.70-0.75). There were 234 atherosclerotic CVD events (120 CHD events, 114 strokes) among Medicare-linked participants and the observed and predicted 5-year atherosclerotic CVD incidence per 1000 person-years for participants with a predicted risk of less than 7.5% was 5.3 (95% CI, 2.8-10.1) and 4.0, respectively, risk of 7.5% to less than 10% was 7.9 (95% CI, 4.6-13.5) and 6.4, and risk of 10% or greater was 17.4 (95% CI, 15.3-19.8) and 16.4 (Hosmer-Lemeshow χ2 = 5.4, P = .71). The C index was 0.67 (95% CI, 0.64-0.71).

CONCLUSIONS AND RELEVANCE

In this cohort of US adults for whom statin initiation is considered based on the ACC/AHA Pooled Cohort risk equations, observed and predicted 5-year atherosclerotic CVD risks were similar, indicating that these risk equations were well calibrated in the population for which they were designed to be used, and demonstrated moderate to good discrimination.

Risk of hospitalised infection in rheumatoid arthritis patients receiving biologics following a previous infection while on treatment with anti-TNF therapy

BACKGROUND

The risk of subsequent infections in rheumatoid arthritis (RA) patients who receive biologic therapy after a serious infection is unclear.

OBJECTIVE

To compare the subsequent risk of hospitalised infections associated with specific biologic agents among RA patients previously hospitalised for infection while receiving anti-tumour necrosis factor (anti-TNF) therapy.

METHODS

Using 2006-2010 Medicare data for 100% of beneficiaries with RA enrolled in Medicare, we identified patients hospitalised with an infection while on anti-TNF agents. Follow-up began 61 days after hospital discharge and ended at the earliest of: next infection, loss of Medicare coverage or 18 months after start of follow-up. We calculated the incidence rate of subsequent hospitalised infection for each biologic and used Cox regression to control for potential confounders.

RESULTS

10 794 eligible hospitalised infections among 10183 unique RA patients who contributed at least 1 day of biologic exposure during follow-up. We identified 7807 person-years of exposure to selected biologics--333 abatacept, 133 rituximab and 7341 anti-TNFs (1797 etanercept, 1405 adalimumab, 4139 infliximab)--and 2666 associated infections. Mean age across biologic exposure cohorts was 64-69 years. The crude incidence rate of subsequent hospitalised infection ranged from 27.1 to 34.6 per 100 person-years. After multivariable adjustment, abatacept (HR: 0.80, 95% CI 0.64 to 0.99) and etanercept (HR: 0.83, 95% CI 0.72 to 0.96) users had significantly lower risks of subsequent infection compared to infliximab users.

CONCLUSIONS

Among RA patients who experienced a hospitalised infection while on anti-TNF therapy, abatacept and etanercept were associated with the lowest risk of subsequent infection compared to other biologic therapies.

The effect of trauma care on the temporal distribution of homicide mortality in Jefferson County, Alabama

The distribution of time from acute traumatic injury to death has three peaks: immediate (less than or equal to one hour), early (6 to 24 hours), and late (days to weeks). It has been suggested that coordinated trauma care dampens the late peak; however, this research may be more reflective of unintentional than intentional deaths. This study examines whether a coordinated trauma system (TS) alters the temporal distribution for assault-related deaths. Data were obtained from homicides examined by the Jefferson County Coroner's/Medical Examiner's Office from 1987 to 2008. Homicides were categorized-based on year of death-as occurring in the presence of no TS, during TS implementation, in the early years of the TS, or in a mature TS. The temporal distribution of homicide mortality was compared among TS categories using a χ(2) test. A Cox Markov multistate model was used to estimate proportional changes in the temporal distribution of death adjusted for assault mechanism. With a TS, after adjusting for assault mechanism, a lower proportion of homicide victims survived through the first hour (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.54 to 1.03) and from one to six hours (HR, 0.68; 95% CI, 0.49 to 0.96). Additionally, the presence of a TS was associated with a proportional decrease in deaths after 24 hours (P = 0.0005). These results suggest that a trauma system is effective in preventing late homicide deaths; however, other means of preventing death (such as violence prevention programs) are needed to decrease the burden of immediate homicide-related deaths.

Effect of change in systolic blood pressure between clinic visits on estimated 10-year cardiovascular disease risk

Systolic blood pressure (SBP) often varies between clinic visits within individuals, which can affect estimation of cardiovascular disease (CVD) risk. We analyzed data from participants with two clinic visits separated by a median of 17 days in the Third National Health and Nutrition Examination Survey (n = 808). Ten-year CVD risk was calculated with SBP obtained at each visit using the Pooled Cohort Equations. The mean age of participants was 46.1 years, and 47.3% were male. The median SBP difference between the two visits was -1 mm Hg (1st to 99th percentiles: -23 to 32 mm Hg). The median estimated 10-year CVD risk was 2.5% and 2.4% at the first and second visit, respectively (1st to 99th percentiles -5.2% to +7.1%). Meaningful risk reclassification (ie, across the guideline recommended 7.5% threshold for statin initiation) occurred in 12 (11.3%) of 106 participants whose estimated CVD risk was between 5% and 10%, but only in two (0.3%) of 702 participants who had a 10-year estimated CVD risk of <5% or >10%. SBP variability can affect CVD risk estimation, and can influence statin eligibility for individuals with an estimated 10-year CVD risk between 5% and 10%.

The effect of previous traumatic injury on homicide risk

Research has reported that a strong risk factor for traumatic injury is having a previous injury (i.e., recidivism). To date, the only study examining the relationship between recidivism and homicide reported strong associations, but was limited by possible selection bias. The current matched case-control study utilized coroner's data from 2004 to 2008. Subjects were linked to trauma registry data to determine whether the person had a previous traumatic injury. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for the association between homicide and recidivism. Homicide risk was increased for those having a previous traumatic injury (OR 1.81, 95% CI 1.09-2.99) or a previous intentional injury (OR 2.53, 95% CI 1.24-5.17). These results suggest an association between homicide and injury recidivism, and that trauma centers may be an effective setting for screening individuals for secondary prevention efforts of homicide through violence prevention programs.

DASH eating pattern is associated with favorable left ventricular function in the multi-ethnic study of atherosclerosis

OBJECTIVE

Potential associations between consistency with the Dietary Approaches to Stop Hypertension (DASH) diet and preclinical stages of heart failure (HF) in a large multiethnic cohort have not been evaluated. This study sought to determine the cross-sectional relationship between the DASH eating pattern and left ventricular (LV) function in the Multi-Ethnic Study of Atherosclerosis (MESA).

DESIGN

A total of 4506 men and women from four ethnic groups (40% white, 24% African American, 22% Hispanic American, and 14% Chinese American) aged 45-84 years and free of clinical cardiovascular disease (CVD) were studied. Diet was assessed using a validated food-frequency questionnaire. LV functional parameters including end-diastolic volume, stroke volume, and LV ejection fraction were measured by magnetic resonance imaging. Multivariate analyses were conducted to examine the association between LV function and DASH eating pattern (including high consumption of fruits, vegetables, whole grains, poultry, fish, nuts, and low-fat dairy products and low consumption of red meat, sweets, and sugar-sweetened beverages).

RESULTS

A 1-unit increase in DASH eating pattern score was associated with a 0.26 ml increase in end-diastolic volume and increases of 0.10 ml/m(2) in stroke volume, adjusted for key confounders. A 1-unit increase in DASH eating pattern score was also associated with a 0.04% increase in ejection fraction, but the relationship was marginally significant (p = 0.08).

CONCLUSIONS

In this population, greater DASH diet consistency is associated with favorable LV function. DASH dietary patterns could be protective against HF.

Mediterranean and DASH diet scores and mortality in women with heart failure: The Women's Health Initiative

BACKGROUND

Current dietary recommendations for patients with heart failure (HF) are largely based on data from non-HF populations; evidence on associations of dietary patterns with outcomes in HF is limited. We therefore evaluated associations of Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diet scores with mortality among postmenopausal women with HF.

METHODS AND RESULTS

Women's Health Initiative participants were followed up from the date of HF hospitalization through the date of death or last participant contact before August 2009. Mediterranean and DASH diet scores were calculated from food-frequency questionnaires. Cox proportional hazards models adjusted for demographics, health behaviors, and health status were used to calculate hazard ratios and 95% confidence intervals (CI). For a median of 4.6 years of follow-up, 1385 of 3215 (43.1%) participants who experienced a HF hospitalization died. Multivariable-adjusted hazard ratios were 1 (reference), 1.05 (95% CI, 0.89-1.24), 0.97 (95% CI, 0.81-1.17), and 0.85 (95% CI, 0.70-1.02) across quartiles of the Mediterranean diet score (P trend=0.08) and 1 (reference), 1.04 (95% CI, 0.89-1.21), 0.83 (95% CI, 0.70-0.98), and 0.84 (95% CI, 0.70-1.00) across quartiles of the DASH diet score (P trend=0.01). Diet score components, vegetables, nuts, and whole grain intake, were inversely associated with mortality.

CONCLUSIONS

Higher DASH diet scores were associated with modestly lower mortality in women with HF, and there was a nonsignificant trend toward an inverse association with Mediterranean diet scores. These data provide support for the concept that dietary recommendations developed for other cardiovascular conditions or general populations may also be appropriate in patients with HF.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000611.

Association between sleep and breast cancer incidence among postmenopausal women in the Women's Health Initiative

STUDY OBJECTIVES

To determine whether the duration of sleep, sleep quality, insomnia, or sleep disturbance was associated with incident breast cancer in the Women's Health Initiative (WHI).

DESIGN

Prospective cohort study.

SETTING

Women enrolled in one of the Clinical Trial (CT) arms or the Observational Study (OS) from the WHI conducted in the United States.

PARTICIPANTS

This study included 110,011 women age 50 to 79 years with no history of cancer.

MEASUREMENTS AND RESULTS

Typical sleep duration, sleep quality, and other self-reported sleep measures over the past 4 weeks were assessed during the screening visits for both the CT and OS participants. The presence of insomnia and level of sleep disturbance was calculated from an index of the WHI Insomnia Rating Scale. The outcome for this study was primary, invasive breast cancer. A total of 5,149 incident cases of breast cancer were identified in this study. No statistically significant associations were found between sleep duration, sleep quality, insomnia, or level of sleep disturbance with the risk of breast cancer after multivariable adjustment. A positive trend was observed for increasing sleeping duration with the risk of estrogen receptor positive breast cancer, but the association estimates for each sleep duration category were weak and nonsignificant.

CONCLUSIONS

This study does not provide strong support for an association between self-reported sleep duration, sleep quality, insomnia, or sleep disturbance with the risk of breast cancer.

Trends in the prevalence, awareness, treatment and control of high low density lipoprotein-cholesterol among United States adults from 1999-2000 through 2009-2010

Marked increases in the awareness, treatment, and control of high low-density lipoprotein (LDL) cholesterol occurred among United States (US) adults from 1988-1994 to 1999-2004. An update to the Third Adult Treatment Panel guidelines was published in 2004, and it is unknown if these improvements have continued since the publication of these revised treatment recommendations. The aim of this study was to determine trends in the awareness, treatment, and control of high LDL cholesterol among US adults from 1999-2000 to 2009-2010 using nationally representative samples of US adults aged ≥20 years from 6 consecutive National Health and Nutrition Examination Surveys (NHANES) in 1999-2000 (n = 1,659), 2001-2002 (n = 1,897), 2003-2004 (n = 1,698), 2005-2006 (n = 1,692), 2007-2008 (n = 2,044), and 2009-2010 (n = 2,318). LDL cholesterol was measured after an overnight fast, and high LDL cholesterol and controlled LDL cholesterol were defined using the 2004 updated Third Adult Treatment Panel guidelines. Awareness and treatment of high cholesterol were defined using self-report. Among US adults, the prevalence of high LDL cholesterol did not change from 1999-2000 (37.2%) to 2009-2010 (37.8%). Awareness of high LDL cholesterol increased from 48.9% in 1999-2000 to 62.8% in 2003-2004 but did not increase further through 2009-2010 (61.5%). Among those aware of having high LDL cholesterol, treatment increased from 41.3% in 1999-2000 to 72.6% in 2007-2008 and was 70.0% in 2009-2010. Among US adults receiving treatment for high LDL cholesterol, the percentage with controlled LDL cholesterol increased from 45.0% in 1999-2000 to 65.3% in 2005-2006 and had decreased slightly by 2009-2010 (63.6%). In conclusion, high LDL cholesterol remains common among US adults. Additional efforts are needed to prevent high LDL cholesterol and increase the awareness, treatment, and control of high LDL cholesterol among US adults.

Fruit and vegetable intake and the risk of colorectal cancer: results from the Shanghai Men's Health Study

PURPOSE

The observed associations of fruit and vegetable consumption with the risk of colorectal cancer have been inconsistent. Therefore, we aimed to evaluate the association of fruit and vegetable consumption with the risk of colorectal cancer among Chinese men.

METHODS

61,274 male participants aged 40-74 years were included. A validated food frequency questionnaire was administered to collect information on usual dietary intake, including 8 fruits and 38 vegetables commonly consumed by residents of Shanghai. Follow-up for diagnoses of colon or rectal cancer was available through 31 December 2010. Dietary intakes were analyzed both as categorical and continuous variables. Multivariable-adjusted hazard ratios (HRs) and 95 % confidence intervals (95 % CIs) were calculated for colorectal, colon, and rectal cancers using Cox proportional hazards models.

RESULTS

After 390,688 person-years of follow-up, 398 cases of colorectal cancer (236 colon and 162 rectal) were observed in the cohort. Fruit consumption was inversely associated with the risk of colorectal cancer (fifth vs. first quintile HR 0.67; 95 % CI 0.48, 0.95; p trend = 0.03), whereas vegetable intake was not significantly associated with risk. The associations for subgroups of fruits and legumes, but not other vegetable categories, were generally inversely associated with the risk of colon and rectal cancers.

CONCLUSIONS

Fruit intake was generally inversely associated with the risk of colorectal cancer, whereas vegetable consumption was largely unrelated to risk among middle-aged and older Chinese men.

Risk for recurrent coronary heart disease and all-cause mortality among individuals with chronic kidney disease compared with diabetes mellitus, metabolic syndrome, and cigarette smokers

BACKGROUND

Lipid-lowering guidelines endorse a low-density lipoprotein cholesterol goal of <100 mg/dL for people with coronary heart disease (CHD). A more stringent threshold of <70 mg/dL is recommended for those with CHD and "very high-risk" conditions such as diabetes mellitus, metabolic syndrome, or cigarette smoking. Whether chronic kidney disease (CKD) confers a similar risk for recurrent CHD events is unknown.

METHODS AND RESULTS

We evaluated the risk for recurrent CHD events and all-cause mortality among 3,938 participants ≥45 years with CHD in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Chronic kidney disease was defined by estimated glomerular filtration rate <60 mL/min per 1.73 m(2) or urinary albumin to creatinine ratio ≥30 mg/g. Participants were categorized by the presence or absence of CKD and any very high-risk condition. Over a median of 4.1 years, the crude incidence (95% CI) of recurrent CHD events were 12.1 (9.0-15.2), 18.9 (15.5-22.3), 35.0 (25.4-44.6), and 34.2 (28.2-40.3) among those without CKD or high-risk conditions; very high-risk conditions alone; and CKD alone and both CKD and very high-risk conditions. After multivariable adjustment, compared with those without CKD or very high-risk conditions, the hazard ratio (95% CI) for recurrent CHD events was 1.45 (1.02-2.05), 2.24 (1.50-3.34), and 2.10 (1.47-2.98) among those with very high-risk conditions alone, CKD alone, and both CKD and very high-risk conditions, respectively. Results were consistent for all-cause mortality.

CONCLUSIONS

Chronic kidney disease is associated with risk for recurrent CHD events that approximates or is larger than other established very high-risk conditions.

Total antioxidant capacity of diet and risk of heart failure: a population-based prospective cohort of women

BACKGROUND

Few studies have investigated the association between individual antioxidants and risk of heart failure. No previous study has investigated the role of all antioxidants present in diet in relation to heart failure. The aim of this study was to assess the association between total antioxidant capacity of diet, which reflects all of the antioxidant compounds in food and the interactions between them, and the incidence of heart failure among middle-aged and elderly women.

METHODS

In September 1997, 33,713 women (aged 49-83 years) from the Swedish Mammography Cohort completed a food-frequency questionnaire. Estimates of dietary total antioxidant capacity were based on the Oxygen Radical Absorbance Capacity assay measurements of foods. Women were followed for incident heart failure (hospitalization or mortality of heart failure as the primary cause) through December 2009 using administrative health registries. Cox proportional hazard models were used to calculate relative risks and 95% confidence intervals.

RESULTS

During 11.3 years of follow-up (394,059 person-years), we identified 894 incident cases of heart failure. Total antioxidant capacity of diet was inversely associated with heart failure (the multivariable-adjusted relative risk in the highest quintile compared with the lowest was 0.58 [95% confidence interval, 0.47-0.72; P for trend<.001]). The crude incidence rate was 18/10,000 person-years in the highest quintile versus 34/10,000 person-years in the lowest quintile.

CONCLUSIONS

The total antioxidant capacity of diet, an estimate reflecting all antioxidants in diet, was associated with lower risk of heart failure. These results indicate that a healthful diet high in antioxidants may help prevent heart failure.

Development and evaluation of a self-report tool to predict low pharmacy refill adherence in elderly patients with uncontrolled hypertension

OBJECTIVE

To develop and evaluate a short self-report tool to predict low pharmacy refill adherence in older patients with uncontrolled hypertension.

DESIGN

Cross-sectional analysis of survey and administrative data from the Cohort Study of Medication Adherence Among Older Adults (CoSMO).

PARTICIPANTS

A total of 394 adults with uncontrolled blood pressure; mean ± SD age was 76.6 ± 5.6 years, 33.0% were black, 66.0% were women, and 23.4% had a low medication possession ratio (MPR).

MEASUREMENTS AND MAIN RESULTS

We considered 164 self-reported candidate items for development of a prediction rule for low (less than 0.8) versus high (0.8 or more) MPR from pharmacy refill data. Risk prediction models were evaluated by using best subsets analyses, and the final model was chosen based on clinical relevance and model parsimony. Bootstrap simulations assessed internal validity. The performance of the final four-item model was compared to the eight-item Morisky Medication Adherence Scale (MMAS-8) and the nine-item Hill-Bone Compliance Scale. The four-item self-report tool for predicting pharmacy refill adherence showed moderate discrimination (C statistic 0.704, 95% confidence interval [CI], 0.683-0.714) and good model fit (Hosmer-Lemeshow χ² = 1.238, p=0.743). Sensitivity and specificity were 67.4% and 67.8%, respectively. The concordance (C) statistics for MMAS-8 and the Hill-Bone Compliance Scale were lower at 0.665 (95% CI 0.632-0.683) and 0.660 (95% CI 0.622-0.674), respectively.

CONCLUSION

A four-item self-report tool moderately discriminated low from high pharmacy refill adherers, and its test performance was comparable with existing eight- and nine-item adherence scales. Parsimonious self-report tools predicting low pharmacy refill in patients with uncontrolled blood pressure could facilitate hypertension management in the elderly.

Relationships between metrics of visit-to-visit variability of blood pressure

This paper examines relationships between metrics of visit-to-visit variability (VVV) of blood pressure (BP) to determine which metrics should be calculated in studies of the association of VVV with health outcomes. We examined correlation and agreement between quintiles for standard deviation (s.d.), standard deviation independent of the mean (SDIM), coefficient of variation (CV), successive variation (SV), average real variability (ARV), range, maximum, peak size and trough size of systolic BP in the Trial of Preventing Hypertension placebo arm (n=288). The average age of participants was 48 years. Mean systolic BP was 133.5 mm Hg. VVV metrics were all significantly correlated (P<0.001). Correlations between s.d., SDIM, CV and range and between ARV and SV were ≥0.90. Kappa statistics between quintiles of SD, SDIM, CV and range and between ARV and SV were ≥0.80. In studies of the relationship of VVV with health outcomes, we recommend reporting results for one of the metrics of overall variability (s.d., SDIM, CV), one of the metrics of variability between consecutive visits (SV, ARV), and one or more of the metrics of extreme values at a single visit (maximum, peak size, trough size).

Assessment tools for unrecognized myocardial infarction: a cross-sectional analysis of the REasons for Geographic and Racial Differences in Stroke population

Background

Routine electrocardiograms (ECGs) are not recommended for asymptomatic patients because the potential harms are thought to outweigh any benefits. Assessment tools to identify high risk individuals may improve the harm versus benefit profile of screening ECGs. In particular, people with unrecognized myocardial infarction (UMI) have elevated risk for cardiovascular events and death.

Methods

Using logistic regression, we developed a basic assessment tool among 16,653 participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study using demographics, self-reported medical history, blood pressure, and body mass index and an expanded assessment tool using information on 51 potential variables. UMI was defined as electrocardiogram evidence of myocardial infarction without a self-reported history (n = 740).

Results

The basic assessment tool had a c-statistic of 0.638 (95% confidence interval 0.617 - 0.659) and included age, race, smoking status, body mass index, systolic blood pressure, and self-reported history of transient ischemic attack, deep vein thrombosis, falls, diabetes, and hypertension. A predicted probability of UMI > 3% provided a sensitivity of 80% and a specificity of 30%. The expanded assessment tool had a c-statistic of 0.654 (95% confidence interval 0.634-0.674). Because of the poor performance of these assessment tools, external validation was not pursued.

Conclusions

Despite examining a large number of potential correlates of UMI, the assessment tools did not provide a high level of discrimination. These data suggest defining groups with high prevalence of UMI for targeted screening will be difficult.