Effects of verapamil and trandolapril in the treatment of hypertension. Trandolapril Study Group

The combination of an angiotensin converting enzyme inhibitor with a calcium antagonist has become a common way of treating patients with essential hypertension who respond insufficiently to monotherapy. This double-blind, randomized, parallel, placebo-controlled, multicenter, outpatient study evaluated the antihypertensive efficacy and safety of a calcium antagonist (verapamil SR) and an angiotensin converting enzyme inhibitor (trandolapril) in patients with mild-to-moderate (stages I and II) essential hypertension. Six hundred thirty-one patients were enrolled in this 10-week study. After a 4-week single-blind placebo phase, patients received one of the following daily dosage regimens in a double-blind fashion for 6 weeks: placebo, 4 mg of trandolapril, 240 mg of verapamil SR, or a combination of 4 mg of trandolapril and 240 mg of verapamil SR. Trough sitting diastolic blood pressure was lowered by 4.5 mm Hg, 4.3 mm Hg, and 8.1 mm Hg more than placebo in the trandolapril, verapamil SR, and combination groups, respectively. In the combination group, sitting diastolic blood pressure was significantly lowered (P < .01) by 3.6 mm Hg more than in the trandolapril group and by 3.8 mm Hg more than in the verapamil SR group. An analysis of the trough-to-peak ratio for sitting diastolic blood pressure revealed values of 0.75 and 0.67, for the 4-mg trandolapril and the combination groups, respectively, at end point. The overall incidence of adverse reactions was similar for all treatment groups. In this study the combination of an angiotensin converting enzyme inhibitor and calcium antagonist was well tolerated and more effective than either agent administered alone for the treatment of mild-to-moderate essential hypertension.

Thyroid hormone and cardiovascular disease

Thyroid hormone directly affects the heart and peripheral vascular system. The hormone can increase myocardial inotropy and heart rate and dilate peripheral arteries to increase cardiac output. An excessive deficiency of thyroid hormone can cause cardiovascular disease and aggravate many preexisting conditions. In severe systemic illness and after major surgical procedures changes in thyroid function can occur, leading to the "euthyroid sick syndrome." Patients will have normal or decreased levels of T4, decreased free and total T3, and usually normal levels of thyroid stimulating hormone. This syndrome may be an adaptive response to systemic illness that usually will revert to normal without hormone supplementation as the illness subsides. Recently, however, many investigators have explored the benefits of thyroid hormone supplementation in those diseases associated with euthyroid sick syndrome. Thyroid hormone's effects on the cardiovascular system make it an attractive therapy for those patients with impaired hemodynamics and low T3. Thyroid hormone has also been considered a treatment for patients with congestive heart failure, for patients undergoing cardiopulmonary bypass and heart transplantation, and for patients with hyperlipidemia. At present there is no evidence suggesting a favorable treatment outcome using thyroid hormone supplementation for any systemic condition except in those patients with documented hypothyroidism.

Chelation therapy in cardiovascular disease: ethylenediaminetetraacetic acid, deferoxamine, and dexrazoxane

This review was conducted to assess whether there is sufficient evidence for the clinical use of chelation therapy in cardiovascular disease based on original articles and abstracts published in the last 30 years, with emphasis placed on the most recent placebo-controlled studies. Articles postulating the mechanisms of chelation also were included. The majority of the literature focused on three chelators in particular, ethylenediaminetetraacetic acid (EDTA), deferoxamine, and dexrazoxane (ICRF-187). Historically, much has been written on the beneficial effects of EDTA. However, there are few controlled studies, and the mechanism of action of EDTA is poorly understood. Although studies of deferoxamine are more recent, most of the research is limited to animals and ex vivo models. Recently, dexrazoxane was approved, but only for parenteral use for reducing the incidence and severity of cardiomyopathy associated with doxorubicin administration in women with metastatic breast cancer. Given these limitations, it is concluded that more controlled studies are required to determine the efficacy of chelation therapy in cardiovascular disease before it can be used broadly in the clinical setting.

Fenoldopam: a new dopamine agonist for the treatment of hypertensive urgencies and emergencies

Fenoldopam is a selective dopamine agonist that is being considered for the parenteral treatment of systemic hypertension. In both an oral and parenteral form, the drug causes peripheral vasodilation by stimulating dopamine-1 adrenergic receptors. Its pharmaco-dynamics are reviewed in this article, along with the clinical experiences in patients with hypertensive urgencies and emergencies. Intravenous fenoldopam may provide advantages over sodium nitroprusside because it can induce both a diuresis and natriuresis, is not light sensitive, and is not associated with cyanide toxicity. There is no evidence for rebound hypertension after discontinuation of fenoldopam influsion.

Matrix metalloproteinases and coronary artery disease: a novel therapeutic target

Matrix metalloproteinases (MMP) are a family of enzymes that selectively digest individual components of the extracellular matrix. Their function has been studied in both normal physiologic processes and pathologic states. In the blood vessel, MMPs play an important role in maintaining the vessel's integrity by breaking down extracellular matrix while new matrix is being synthesized. This is necessary to avoid weakening from continuous mechanical stresses. However, in certain environments, these MMPs may contribute to cardiovascular pathologic processes. The purpose of this review is to first discuss the role of MMPs in coronary vascular disease. Evidence suggests that MMPs contribute to the development of de novo atherosclerotic plaques and postangioplasty restenotic plaques by allowing smooth muscle cells to migrate from the vascular media to the intima. Evidence also suggests that MMPs contribute to the rupture of these plaques by degrading the fibrous cap that surrounds them. With this increased molecular information that concerns the pathogenesis of coronary vascular disease, new molecular therapies aimed at altering these processes are being investigated. The rationale, mode of delivery, and prospects for success of these therapies will also be discussed here.

Optimization of antihypertensive therapy with a novel, extended-release formulation of diltiazem: results of a practice-based clinical study

Although the effectiveness of diltiazem for the treatment of patients with hypertension has been well demonstrated in numerous placebo-controlled and comparative clinical trials, most physicians have had some concern about its efficacy and have used it predominantly in patients with mild hypertension. Few large-scale studies have evaluated the efficacy and safety of higher dosages of diltiazem for the treatment of patients with hypertension, and few have evaluated the use of diltiazem in patients with more severe hypertension. Tiazac (Forest Pharmaceuticals, Inc., St. Louis, Missouri), a new, extended-release formulation of diltiazem, provides 24-hour blood pressure control with a single daily dose of up to 360 mg. The Study of Titration and Response to Tiazac (START) is an ongoing practice-based, open-label, multicenter study designed to evaluate the efficacy and safety profiles of Tiazac at greater-than-traditional doses in hypertensive patients and to assess the ability of Tiazac to decrease the rate-pressure product, a surrogate marker for cardiac workload. Patients were eligible for study entry whether their hypertension was newly diagnosed or previously treated with a different formulation of diltiazem or any other antihypertensive agent. Normotensive (sitting diastolic blood pressure [SDBP] < 90 mm Hg) subjects and those with mild (SDBP 90 to 99 mm Hg), moderate (SDBP 100 to 109 mm Hg), severe (SDBP 110 to 119 mm Hg), and very severe (SDBP > or = 120 mm Hg) hypertension were assessed at baseline (visit 1), visit 2 (10 to 14 days after visit 1), and visit 3 (25 to 28 days after visit 1). A total of 3082 patients were enrolled, and data from 2802 assessable patients (i.e., those who completed visits 1, 2, and 3) were analyzed. No subjects were lost to follow-up as a result of adverse effects. All subjects received a starting dose of Tiazac 180 mg or 240 mg once daily, and doses were titrated upward to 360 mg once daily as clinically indicated. Blood pressure reduction matched the severity of hypertension in all patients. Subjects who were switched from another diltiazem formulation demonstrated further decreases in SDBP. Antihypertensive monotherapy with Tiazac was well tolerated. This interim START report demonstrates that a daily dose of up to 360 mg of diltiazem is optimal in terms of both control of hypertension and patient compliance. It also provides the practice-based physician with useful clinical information on dose titration and response to a new formulation of an approved drug and supports the efficacy and safety profiles of diltiazem documented in previous well-controlled clinical trials.

Mibefradil: A New Selective T-Channel Calcium Antagonist for Hypertension and Angina Pectoris

Calcium antagonists are an established therapy for patients with hypertension and angina pectoris, but their current usage is often limited by their pharmacologic profilers and side effects. Mibefradil is a recently developed calcium antagonist with a unique chemical structure, site of action, and set of pharmacologic effects. Unlike currently available calcium channels as well as L-type channels. It is further distinguished from the other calcium antagonists in that it is the first member of a new class of calcium antagonists, the tetralol derivatives. With chronic oral dosing, mibefradil attains steady-state plasma concentrations within 3-4 days, has a bioavailability of approximately 90%, and a plasma half-life of 17-25 hours. It has a gradual onset of action and can be administered once daily without regard to food intake. It increases coronary blood flow and lowers peripheral vascular resistance. The vasodilatory effects of mibefradil are associated with a lack of inotropic effect on myocardium, lack of neurohormonal activation, and a reduction in heart rate. In clinical trials it has been demonstrated to be an effective agent in the treatment of patients with hypertension and angina pectoris, with a good safety and tolerability profile regardless of age, gender, or race.

Antianginal and anti-ischemic effects of mibefradil in the treatment of patients with chronic stable angina pectoris

Five placebo-controlled, double-blind, multicenter, parallel-design studies were performed to evaluate the antianginal and anti-ischemic characteristics of the novel T-channel-selective calcium antagonist, mibefradil, in the treatment of patients with chronic stable angina pectoris. Of the 5 studies, 2 were monotherapy dose-finding trials and 3 were conducted in patients receiving background antianginal therapy: either beta blockers (2 studies) or long-acting nitrates (1 study). A total of 865 patients were randomized to 1 of 4 mibefradil dose groups (25, 50, 100, and 150 mg; n = 565) and placebo (n = 300). The antianginal and anti-ischemic effects of mibefradil were assessed across all 5 studies by evaluating exercise tolerance test variables, weekly number of anginal attacks and short-acting nitroglycerin consumption, and in both dose-finding studies, the number and total duration of silent ischemic episodes (48-hour Holter monitoring). A statistically significant increase in exercise duration was achieved in 3 of 5 studies with the 50-mg dose of mibefradil and in 3 of 3 studies with the 100-mg dose of the compound over the effects observed in the placebo groups. A significant delay in time to onset of ischemia during exercise was induced in all studies with the 50- and 100-mg doses of mibefradil. The 25-mg dose of mibefradil was not significantly better than placebo, and the effects of the 150-mg dose of the compound were similar to those observed with the 100-mg dose. Across all studies, a dose-related decrease was observed in the number of weekly anginal attacks and in weekly nitroglycerin consumption. Similarly, a significant dose-related decrease in the number and duration of silent ischemic episodes was observed during Holter monitoring for 48 hours in the 2 dose-finding studies. The antianginal and anti-ischemic effects were associated with a dose-related decrease in heart rate and double product both at rest and at exercise termination. Treatment with the 50- and 100-mg doses of mibefradil was found to be well tolerated and safe compared with placebo, a finding that held true for patients on chronic beta-blocker or long-acting nitrate therapy. Taken together, these studies indicate that mibefradil is an effective and well-tolerated once-daily treatment for chronic stable angina pectoris at doses of 50 and 100 mg, which are the lowest and highest effective doses of the compound, respectively.

The association of vitamin b 12 and folate blood levels with mortality and cardiovascular morbidity incidence in the old old: the Bronx aging study

OBJECTIVE

An elevated homocysteine level in the blood has been identified as an independent risk factor for vascular disease, including coronary atherosclerosis and venoembolic disease. A deficiency of vitamins B ( 6 ), B ( 12 ), or folate in the blood can cause increased blood levels of homocysteine. We set out to determine whether there was a relationship between blood levels of folate and B ( 12 ) and the subsequent development of cardiovascular disease and mortality in old old ambulatory men and women.

DESIGN

Four hundred forty subjects (mean age, 79 years; 64% female) were followed in the Bronx Longitudinal Aging Study, a prospective study of 10 years duration, designed to assess risk factors for cardiovascular and cerebrovascular diseases and dementia in an ambulatory old old cohort.

METHODS

Serum levels of vitamin B ( 12 ) and folate were measured and related to the incidence of total all-cause mortality, stroke, myocardial infarction, coronary heart disease, and cardiovascular disease.

RESULTS

No statistical gender- or age-related differences were found in the mean levels of folate or B ( 12 ). The concentration of folate in the blood was not related to the incidence of mortality, myocardial infarction, stroke, or overall cardiovascular disease. However, by logistical regression and Cox proportional-hazards regression analyses, there was an increased incidence of mortality and coronary heart disease in those subjects having increased vitamin B ( 12 ) levels in the blood. Each 100-pg increase in B ( 12 ) was associated with a 10% increase in mortality and coronary heart disease incidence.

CONCLUSION

These results suggest that in elderly subjects, vitamin B ( 12 ) supplementation should not be routinely provided unless there are clear indications for doing so (a deficiency state), and then only to replace enough B ( 12 ) to correct the deficiency. A suggested treatment paradigm is provided for managing vitamin deficiency states and hyperhomocysteinemia in elderly subjects.

The pharmacologic approach to the treatment of obesity

Obesity is a major risk factor for morbidity and mortality, and a series of pharmacologic approaches are available for helping to manage the problem. Obesity is caused by an imbalance between caloric intake and energy expenditure, which is influenced by both environmental and genetic factors. Pharmacologic treatments include anorexigenic agents, which fall into two broad categories: those that act via brain catecholamine pathways and those that act via serotonin pathways. The most recent oral agents approved are dexfenfluramine, which is currently being marketed, and sibutramine. Both agents inhibit the control reuptake of serotonin but in addition may have effects on thermogenesis. Under investigation are agents that increase energy expenditure: the beta 3-adrenergic receptor agonists and drugs that prevent the intestinal absorption of free fatty acids and cholesterol. In development are innovative approaches to influence leptin and its receptors, various obesity genes, and biologic substances thought to influence satiety (neuropeptide Y, enterostatin, cholecystokinin, bombesin, and amylin). Obesity has now become a major target for drug development not only for affecting obesity per se but also for managing and preventing comorbid conditions such as diabetes and cardiovascular disease.

Use of calcium antagonists in patients with ischemic heart disease and systemic hypertension

Ischemic heart disease (IHD) and systemic hypertension commonly coexist in a large number of patients, and the presence of hypertension is a risk factor for worsening IHD. A monotherapy that would effectively treat both is thus an attractive idea, and calcium antagonists have been evaluated in this role. Calcium antagonists exert therapeutic effects through a combination of actions, including systemic and peripheral vasodilation, negative inotropy, and reduced nodal conduction. In randomized, double-blind clinical trials, verapamil compares favorably with propranolol in the alleviation of angina and hypertension. Both diltiazem and nifedipine, as well as long-acting diltiazem, are also effective in treating the combined condition. In addition, each of these drugs enhances exercise tolerance and favors compliance with calcium antagonist therapy. Recent questions regarding the safety of this class of drug have tempered the enthusiasm for their use as first-line therapy in cardiovascular disease. In particular, short-acting dihydropyridine derivatives, including nifedipine and isradipine, may increase cardiovascular morbidity and mortality because of reflex sympathetic stimulation. The results of appropriately controlled, prospective clinical trials will provide more definitive conclusions. For now, we must be cautious in the use of calcium antagonist monotherapy for combined IHD and hypertension.

Pathophysiology and pharmacological approaches for prevention of coronary artery restenosis following coronary artery balloon angioplasty and related procedures

Percutaneous transluminal coronary angioplasty (PTCA) has become a mainstay in the treatment of ischemic heart disease, with an estimated 300,000 procedures performed annually in the United States. Despite significant advances in reducing the acute complications of percutaneous revascularization procedures with periprocedural medications and better techniques, chronic restenosis of dilated lesions remains a serious and frequent problem, occurring in 30% to 50% of cases. With a peak incidence between 1 and 4 months after PTCA, restenosis has been thought to reflect an exaggerated healing response to balloon injury, in which platelets and other cells secrete mitogens that induce smooth muscle cells from the media to migrate to and proliferate in the intima, compromising the coronary lumen and invoking ischemic symptoms. Several factors, including remodeling with compensatory arterial enlargement, normalization of wall shear stress, and recoil, are also likely to play key roles. Based on these concepts, several pharmacological approaches directed at reducing the incidence of restenosis have been investigated. Although studies frequently report suppression of neointimal proliferation in animal models of balloon vascular injury, few drug approaches have met with clear success in clinical trials. This can be explained in several ways, including mistaken understandings of the pathophysiology of restenosis, gross histopathological dissimilarities between animal vascular injury models and clinical restenosis, and inadequate dosing. This report proposes to extensively review the vast literature on the subject to serve as a guide for clinicians to the pathophysiology of restenosis and the pharmacotherapeutic management of patients after PTCA and coronary atherectomy. Those drug approaches that currently show the most clinical promise and that warrant further investigation will be highlighted.

Recombinant growth hormone: a new cardiovascular drug therapy

GH has an important role in normal cardiovascular physiologic functioning, working indirectly through effects on IGF-1. An excess or deficiency of GH causes an increased rate of cardiovascular disease, including cardiomyopathy. A relative GH deficiency in older subjects may also increase cardiovascular morbidity and mortality risk. In replacement doses, GH can enhance myocardial contractility; can decrease peripheral vascular resistance; and can reduce total cholesterol and LDL-cholesterol values and fibrinogen and PAI levels. These effects of GH, coupled with the ability to improve skeletal muscle function and reduce adiposity, make it an attractive treatment for patients with CHF and a potential maintenance drug for elderly people. Clinical trials, including studies with GHRH that may reduce the adverse effects of GH therapy, such as hyperglycemia and hypertension, are now in progress.

Cardiac involvement in HIV infection

Cardiac involvement in HIV infection was previously believed to be an unusual manifestation of the disease, but is now being described with increasing frequency. It may be a well-characterized cardiac disease occurring coincidentally in an AIDS patient, a complication of AIDS or its treatment, or possibly a direct result of HIV infection of the heart. In this article, the authors describe the emerging patterns of heart and vascular diseases in HIV-infected patients, pathogenic mechanisms, and implications for treatment.

Selective and nonselective dopamine receptor agonists: an innovative approach to cardiovascular disease treatment

Dopamine and a new group of selective and nonselective peripheral dopaminergic receptor effectors are being evaluated for the treatment of various cardiovascular disorders, including shock, CHF, and systemic hypertension. Dopamine, in relatively low intravenous doses, will stimulate both peripheral DA1 receptors, which mediate arterial vasodilation of different vascular beds, and the DA2 receptors, which mediate the inhibition of norepinephrine release. Ibopamine is a new oral, nonspecific peripheral dopaminergic agonist with an active metabolite (epinine) that is being evaluated in patients with CHF. Fenoldopam is a selective peripheral DA1 agonist now being developed as a parenteral treatment for hypertensive emergencies. Dopexamine is a parenteral agent that selectively activates both DA1 and beta 2 adrenergic receptors and is being evaluated in patients with CHF and in individuals with postoperative left ventricular dysfunction. A group of selective DA2 receptor agonists is being evaluated as long-term treatment for systemic hypertension.

Twenty-four-hour ambulatory electrocardiography in elderly subjects: prevalence of various arrhythmias and prognostic implications (report from the Bronx Longitudinal Aging Study)

Functional, ambulatory, community-dwelling subjects (n = 423, aged 75 to 85 years) underwent baseline 24-hour ambulatory electrocardiography (ECG) examinations as part of the Bronx Aging Study, a 10-year prospective cohort study designed to identify risk factors and disease markers for cardiovascular, cerebrovascular, and dementia illnesses in old people. Premature ventricular contractions were the most commonly observed arrhythmia noted (93% of subjects), with a low prevalence of nonsustained ventricular tachycardia (5%), paroxysmal atrial tachycardia (13%), atrial fibrillation (4%), and atrioventricular blocks (4%). A 24-hour sinus rate of < 60 beats/min was noted in 13% of subjects, and 11% of subjects were noted to have transient episodes of severe bradycardia (< 40 beats/min). In a multivariate analysis, nonsustained ventricular tachycardia was an independent predictor of death (p = 0.015; relative risk [RR] 2.8; 95% confidence interval [CI] 1.4 to 5.8) and myocardial infarction (p = 0.031; RR 3.2; CI 1.2 to 9.4). Transient atrioventricular block was an independent predictor of stroke (p - 0.0006; RR 9.7; CI 3.3 to 28.9), as was sinus bradycardia over a 24-hour period (p = 0.033; RR 2.7; CI 1.2 to 6.4). Ventricular tachycardia approached significance as an independent predictor of multiinfarct dementia (p = 0.052; RR 6.3; CI 1.4 to 28.7). Episodes of paroxysmal atrial fibrillation, a trial tachycardia, and severe bradycardia were not associated with adverse outcomes. Some arrhythmias found on the ambulatory ECG in very old subjects can predict an increased risk for subsequent death, myocardial infarction, stroke, and multiinfarct dementia.

Nicorandil: a potassium channel opening drug for treatment of ischemic heart disease

Nicorandil is the first oral potassium channel activating drug to be used for the treatment of symptomatic coronary artery disease. It appears to relax vascular smooth muscle through membrane hyperpolarization via increased transmembrane potassium conductance and, like nitrates, through an increase in intracellular cyclic GMP. In addition, nicorandil, in a nitrate-like manner, dilates normal and stenotic coronary arteries and reduces both ventricular preload and afterload. In contrast to nitrates, however, nicorandil does not appear to cause tolerance with long-term administration. In placebo and comparison clinical trials, nicorandil has demonstrated some efficacy and safety in patients with both stable and vasospastic angina pectoris, and it was found to be a myocardial protective agent in animal studies. The antianginal activity of nicorandil, however, is relatively short lived after dosing, which will necessitate the development of extended-release formulations of the drug.

Comparison of subgroups assigned to medical regimens used to suppress cardiac ischemia (the Asymptomatic Cardiac Ischemia Pilot [ACIP] Study)

This report focuses on the subset of 235 patients from the Asymptomatic Cardiac Ischemia Pilot (ACIP) study receiving randomly assigned medical therapy to treat angina and suppress ischemia detected on ambulatory electrocardiography: 121 patients received the sequence of atenolol and nifedipine, and 114 diltiazem and isosorbide dinitrate. After 12 weeks of therapy, the primary end point (absence of ambulatory electrocardiographic (ECG) ischemia and no clinical events) was reached in 47% of atenolol/nifedipine- versus 31% of diltiazem/isosorbide dinitrate-treated patients (adjusted p = 0.03). A trend to increased exercise time to ST depression was seen in the atenolol and nifedipine versus diltiazem and isosorbide dinitrate regimens (median treadmill duration 5.8 vs 4.8 minutes; p = 0.04). However, when adjusted for baseline imbalances in ambulatory ECG ischemia, the 2 medical combinations were similar in suppression of ambulatory ECG ischemia. In both medication regimens, an association between mean heart rate and ischemia on ambulatory electrocardiography after 12 weeks of treatment was observed so that patients on either regimen with a mean heart rate > 80 beats/min had ischemia detectable almost twice as often as those with a mean heart rate < 70 beats/min (p < 0.001).

Renin inhibition: a novel therapy for cardiovascular disease

The renin-angiotensin system (RAS) is a major contributor in the regulation of blood pressure, and pharmacologic manipulation of this system has resulted in a beneficial class of therapeutic agents, which include angiotensin-converting enzyme (ACE) inhibitors. However, ACE inhibitors are not specific for RAS, and in addition, they can affect bradykinin and prostaglandin, which can also cause changes in vascular tone. Under development are renin inhibitors that are specific for angiotensinogen and act at the initial, rate-determining step of the RAS cascade. The various pharmacologic approaches to renin inhibition include specific renin antibodies, synthetic derivatives of the prosegment of renin precursor, pepstatin analogs, and angiotensinogen analogs. The last approach is the most promising for patient therapy. Multiple studies have shown the effectiveness of the renin inhibitors in both primates and human beings. Further research is now directed toward the development of an agent with good oral bioavailability for patient treatment and as a biologic probe for helping to understand the role of the RAS in control of blood pressure and blood volume.

Left ventricular hypertrophy on electrocardiogram: prognostic implications from a 10-year cohort study of older subjects: a report from the Bronx Longitudinal Aging Study

OBJECTIVE

The objective of this study was to report on the prevalence, incidence and prognosis of left ventricular hypertrophy (LVH) on the electrocardiogram (ECG) in a cohort of ambulatory older men and women.

DESIGN

A prospective, longitudinal study of 10 years duration with ECGs obtained at baseline and on an annual basis.

SETTING AND PATIENTS

A community-based cohort study consisting of 459 subjects (aged 75-85, mean age 79 years).

MEASUREMENTS

Baseline and follow up ECGs were interpreted using the Minnesota Code. Prevalence and incidence of LVH and ECG were determined as well as regression of ECG LVH. Clinical event rates measured were incidence of total mortality, myocardial infarction (MI, fatal and non-fatal), cardiovascular mortality, cardiovascular disease (fatal and non-fatal), stroke (fatal and non-fatal), all-cause dementia, and multi-infarct dementia. Differences in event rates between groups (those subjects with and without LVH) were compared as tests between proportions. A Cox Proportional Hazards Regression Analysis was performed to compare the relative independent predictive values of different competing factors, including age, gender, serum cholesterol, digitalis use, body mass, index, Blessed Dementia Scale, cigarette smoking, LVH at baseline, LVH ar baseline (persisting), new LVH, new LVH (persisting), new LVH (regressed), previous MI by history of ECG, hypertension by history, and cardiomegaly by X-ray (cardiothoracic ratio > or = 50%).

RESULTS

At baseline, 9.2% of subjects (n = 42) had LVH on ECG and a mortality rate of 11.7/100 persons years versus 4.9/100 persons years for subjects without baseline LVH (P < .0001), and MI rate of 7.5/100 persons years with LVH versus 2.6/100 persons years without LVH (P < .0001), and a cardiovascular mortality rate of 7.2/100 persons years without LVH versus 2.7/100 person years without LVH. Subjects who developed new LVH on ECG (n = 39) had a mortality rate of 14.4/100 person-years compared with 4.4/100 person-years for those without LVH (P < .0001), a cardiovascular mortality rate of 11.1/100 person years versus 2.0/100 person years without LVH (P < .0001), and an MI rate of 6.1/100 person years versus 2.0/100 person years without LVH (P < .01). Subjects in whom the ECG LVH pattern disappeared over time had fewer cardiovascular mortal and morbid events than those with persistent LVH. According to the regression analyses, persistent LVH from baseline was an independent predictor of MI, overall cardiovascular disease, and total mortality. Newly developing LVH with subsequent regression was an independent predictor of overall cardiovascular disease and death.

CONCLUSIONS

An increased prevalence and incidence of LVH on ECG, irrespective cause, is associated with a poor prognosis in very old men and women. Regression of ECG LVH in older people, irrespective of cause, may confer improvement in risk for cardiovascular disease.