The effect of age on clinical outcomes and health status BARI 2D (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes)

Quality of Life in Older Adults With Stable Ischemic Heart Disease and Diabetes Mellitus: A Post Hoc Analysis of the BARI 2D Trial

Studies on the long-term differences in quality-of-life (QoL) metrics after treatment for stable ischemic heart disease (SIHD) in older adults with diabetes mellitus are lacking. Older patients (age ≥65 years) in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial were stratified into those who received intensive medical therapy (IMT) only versus revascularization (percutaneous coronary intervention [PCI] vs coronary artery bypass graft surgery [CABG]) with Optimal Medical Therapy (OMT). Self-health score, Duke activity status index (DASI), energy rating, and health distress rating at 5 years were compared using multivariable linear regression. A total of 929 older adults were included, of whom 469 (50.5%) underwent medical therapy alone, 302 (32.5%) underwent PCI, and 158 (17.0%) had CABG. Patients who underwent CABG were more likely to have proximal left anterior descending coronary artery disease, chronic total occlusion, and higher myocardial jeopardy index. At 5 years of follow-up, no differences in self-health score, DASI, energy rating, and health distress rating were observed between PCI and IMT. There are also no differences in the 4 QoL measures between CABG and IMT alone. However, the DASI was marginally higher with CABG but not statistically significant (mean difference 3.88, 95% confidence interval -0.10 to -7.86, p = 0.057). At 5 years of follow-up, no differences in QoL measures were observed between PCI and CABG with OMT versus OMT alone in older adult patients with diabetes mellitus and SIHD. Future blinded randomized trials are necessary to investigate the impact of SIHD treatment in the older adult population, considering the risks associated with multimorbidity, polypharmacy, frailty, and cognitive impairment.

Chronic Coronary Disease in Older Adults

The number of older adults age ≥75 with chronic coronary disease (CCD) continues to rise. CCD is a major contributor to morbidity, mortality, and disability in older adults. Older adults are underrepresented in randomized controlled trials of CCD, which limits generalizability to older adults living with multiple chronic conditions and geriatric syndromes. This review discusses the presentation of CCD in older adults, reviews the guideline-directed medical and invasive therapies, and recommends a patient-centric approach to making treatment decisions.

Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease: The ISCHEMIA Trial

BACKGROUND

Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown.

OBJECTIVES

The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial.

METHODS

One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure.

RESULTS

Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29).

CONCLUSIONS

Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Management of Stable Angina in the Older Adult Population

As society ages, the number of older adults with stable ischemic heart disease continues to rise. Older adults exhibit the greatest morbidity and mortality from stable angina. Furthermore, they suffer a higher burden of comorbidity and adverse events from treatment than younger patients. Given that older adults were excluded or underrepresented in most randomized controlled trials of stable ischemic heart disease, evidence for management is limited and hinges on subgroup analyses of trials and observational studies. This review aims to elucidate the current definitions of aging, assess the overall burden and clinical presentations of stable ischemic heart disease in older patients, weigh the available evidence for guideline-recommended treatment options including medical therapy and revascularization, and propose a framework for synthesizing complex treatment decisions in older adults with stable angina. Due to evolving goals of care in older patients, it is paramount to readdress the patient's priorities and preferences when deciding on treatment. Ultimately, the management of stable angina in older adults will need to be informed by dedicated studies in representative populations emphasizing patient-centered end points and person-centered decision-making.

Health Status Outcomes in Older Adults Undergoing Chronic Total Occlusion Percutaneous Coronary Intervention

Background Although chronic total occlusions (CTOs) are common in older adults, they are less likely to be offered CTO percutaneous coronary intervention for angina relief than younger adults. The health status impact of CTO percutaneous coronary intervention in adults aged ≥75 years has not been studied. We sought to compare technical success rates and angina-related health status outcomes at 12 months between adults aged ≥75 and <75 years in the OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion) registry. Methods and Results Angina-related health status was assessed with the Seattle Angina Questionnaire (score range 0-100, higher scores denote less angina). Technical success rates were compared using hierarchical modified Poisson regression, and 12-month health status was compared using hierarchical multivariable linear regression between adults aged ≥75 and <75 years. Among 1000 participants, 19.8% were ≥75 years with a mean age of 79.5±4.1 years. Age ≥75 years was associated with a lower likelihood of technical success (adjusted risk ratio=0.92 [95% CI, 0.86-0.99; P=0.02]) and numerically higher rates of in-hospital major adverse cardiovascular events (9.1% versus 5.9%, P=0.10). There was no difference in Seattle Angina Questionnaire Summary Score at 12 months between adults aged ≥75 and <75 years (adjusted difference=0.9 [95% CI, -1.4 to 3.1; P=0.44]). Conclusions Despite modestly lower success rates and higher complication rates, adults aged ≥75 years experienced angina-related health status benefits after CTO-percutaneous coronary intervention that were similar in magnitude to adults aged <75 years. CTO percutaneous coronary intervention should not be withheld based on age alone in otherwise appropriate candidates.

'What the herbal medicine can do for me in a week, the orthodox does in a year': Perceived efficacy of local alternative therapies influences medication adherence in patients with atherosclerotic cardiovascular disease

Background

There is strong evidence that anti‐platelet therapy, ACE inhibitors, beta‐blockers and statins are cost‐effective in reducing subsequent cardiovascular disease (CVD) events in patients with atherosclerotic cardiovascular disease (ACVD). In some settings, only a low proportion of people have access to these medications, and even lower adhere to them. The current study explored and presents data on the causes of poor adherence to orthodox medication and motivations for alternative therapies in patients with established atherosclerotic cardiovascular disease (ACVD).

Methods

The study was conducted among city‐dwelling adults with ACVD in Accra – Ghana's capital city. Eighteen interviews were conducted with patients with established ACVD. A follow‐up focus group discussion was conducted with some of them. The protocol was approved by two ethics review committees based in Ghana and in the United Kingdom. All participants were interviewed after informed consent. Analysis was done with the Nvivo qualitative data analysis software.

Results

We identified motivations for use of alternatives to orthodox therapies. These cover the five dimensions of adherence: social and economic, health‐care system, condition‐related, therapy‐related, and patient‐related dimensions. Perceived inability of an orthodox medication to provide immediate benefit is an important motivator for use of alternative forms of medication.

Conclusions

A multiplicity of factors precipitate non‐adherence to orthodox therapies. Perceived efficacy and easy access to local alternative therapies such as herbal and faith‐based therapies are important motivators.

Optimal cardiac strategy based on the history of myocardial infarction in type 2 diabetic patients with coronary artery disease

The aim of this study was to evaluate the association between the cardiac treatment strategy and cardiac event risk in type 2 diabetic patients with coronary artery disease (CAD) based on the history of myocardial infarction. Using Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial data, a Cox proportional hazard model was used for calculating hazard ratios (HRs) for major cardiac events in patients receiving early revascularization or intensive medical therapy. Patients without (n = 1,557) and with myocardial infarction (n = 736) were separately analyzed. In patients without myocardial infarction, risk of major cardiac events was similar for percutaneous coronary intervention and intensive medical therapy groups, whereas it was significantly lower in the coronary artery bypass grafting group than in the intensive medical therapy group (HR: 0.48, 95% confidence interval [95%CI]: 0.30–0.76, P = 0.002). Conversely, in patients with myocardial infarction, risk of major cardiac events was significantly higher in the early revascularization group than in the intensive medical therapy group (HR: 1.47, 95%CI: 1.03–2.11, P = 0.03). In type 2 diabetic patients with CAD, benefits of early revascularization were observed only in those without previous myocardial infarction. For patients with previous myocardial infarction, intensive medical therapy exerted superior benefits.

Strategies for glycemic control in nonobese and obese type 2 diabetic patients with coronary artery disease

BACKGROUND

This study aimed to assess strategies of insulin-providing (IP) or insulin-sensitizing (IS) therapy for glycemic control in nonobese diabetic patients with coronary artery disease (CAD) with possibly higher cardiovascular risk and lower insulin secretion than obese diabetic patients with CAD.

METHODS

We used data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial to calculate hazard ratio (HR) with 95% confidence interval (95%CI) for outcome events in patients with type 2 diabetes and CAD using Cox proportional hazard models. The comparison between the IP and IS groups was performed using the randomized design of the BARI 2D trial separately for nonobese (n = 1021) and obese (n = 1319) patients. The primary outcome was a composite endpoint including all-cause death, myocardial infarction, and stroke.

RESULTS

During the follow-up, 231 nonobese and 295 obese patients had one confirmed primary outcome event. In nonobese patients, the risk of primary outcome events was significantly higher in the IP group than the IS group (HR: 1.30, 95%CI: 1.00-1.68, P = 0.04), whereas that in obese patients did not differ significantly between the two groups. Moreover, in nonobese patients, the risk of primary outcome events in those without abdominal obesity was significantly higher in the IP group than that in the IS group (HR: 1.51, 95%CI: 1.05-2.19, P = 0.02). There were no significant interactions between the strategy for glycemic control and various subgroups of nonobese patients.

CONCLUSIONS

In nonobese patients with type 2 diabetes and CAD, the IS treatment strategy may be more beneficial than the IP treatment strategy.

Thrombotic/Thrombolytic Balance as a Cardiac Treatment Determinant in Patients With Diabetes Mellitus and Coronary Artery Disease

Background

This study aimed to assess whether the plasminogen activator inhibitor‐1/tissue plasminogen activator (PAI‐1/tPA) ratio as a prothrombotic state is useful for optimizing cardiac treatment strategy.

Methods and Results

Using BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial data, we used a Cox proportional hazard model to calculate hazard ratios with 95% CIs for cardiac events in patients receiving early revascularization (percutaneous coronary intervention or coronary artery bypass grafting) or medical therapy, separately in patients with low (n=1276) and high (n=894) PAI‐1/tPA ratios. The primary outcome was major cardiac events, which was a composite end point including cardiac death and nonfatal myocardial infarction. The mean±SD follow‐up period was 4.1±1.7 years. The risk of major cardiac events in patients with high PAI‐1/tPA ratio was significantly higher when receiving percutaneous coronary intervention (hazard ratio, 1.84; 95% CI, 1.16–2.93; P=0.01) than when receiving medical therapy, whereas that in patients with low PAI‐1/tPA ratio did not differ significantly between the groups (hazard ratio, 0.95; 95% CI, 0.66–1.36; P=0.77); the interaction between the cardiac treatment strategy and PAI‐1/tPA ratio was significant (P=0.02). However, regardless of the PAI‐1/tPA ratio, major cardiac event risk seemed to be lower in patients receiving coronary artery bypass grafting than in those receiving medical therapy.

Conclusions

In patients with type 2 diabetes mellitus and coronary artery disease, this study demonstrated that those with high PAI‐1/tPA ratio were at higher risks of major cardiac events when treated with percutaneous coronary intervention than when treated with intensive medical therapy.

Prevalence and correlations of hepatorenal functions in diabetes and cardiovascular disease among stratified adults

Background: The vulnerability of older adults to diabetes and cardiovascular complications is a global concern. Hepatorenal pathophysiology is implicated in these complications, but has yet to be clearly established, especially from rural low-mid income countries. This study investigates differences in prevalence of diabetes in aging groups and correlations of age with hepatorenal variables. Methods: 203 participants of both sexes above the age of 18 years underwent anthropometric measurements at Catholic Hospital, Abbi, Nigeria. Questionnaires collected demographic information and medical history. Urinalysis as well as routine liver and renal function tests were performed. Data analysis included determination of levels of hepatorenal abnormalities and prevalence of diseases in age groups. Percentage of disease subpopulations made up by each age-group was also determined as well as Pearson’s correlation coefficient between age and hepatorenal variables, and comparison of average age and hepatorenal variables in disease subgroups. Results: Percentage hepatorenal abnormalities are not significantly different between age-groups. There is no significant difference in percentage level of disease between groups, but in age-groups constituting disease sub-populations (p<0.00001). The apparently healthy subpopulation comprises of younger adults compared to older adults constituting diabetes and hypertension (p < 0...). Age shows moderate correlation with renal function parameters, especially urea and chloride (r = 0.42), but relatively insignificant with liver function variables. Conclusion: This report affirms that diabetes cardiovascular co-morbidity comes with aging. It also indicates that renal pathophysiology may be more associated, than liver, functions in the vulnerability of adults. (www.actabiomedica.it)

Evidence-Based Management of Diabetes in Older Adults

The number of older adults with diabetes is rapidly increasing worldwide. A variety of factors contribute to the age-related increase in the incidence of diabetes. The lack of empiric evidence in the field has limited the management guidelines to mostly expert opinion. Given uncertainty over the rate at which to lower blood glucose levels and the optimal method of doing so, the goals of diabetes control in older people must be individualized. If the patient requires insulin therapy, the newer insulins, with their improved pharmacodynamic consistency and reduced risk of hypoglycemia, should be preferred. Several oral agents are preferable for people with sufficient endogenous insulin because they do not cause hypoglycemia when used as monotherapy. Some of these oral agents have been found to have cardioprotective effects. Older people with diabetes also require management of the other risk factors for cardiovascular disease, with antihypertensive drugs, cholesterol-lowering agents and low-dose aspirin. However, the precise targets for blood pressure control and low-density lipoprotein (LDL) cholesterol levels continue to evolve as more data become available. Diabetes care in older adults should focus on enhancing the individual's quality of life rather than trying to normalize blood glucose levels or reach predetermined blood pressure and LDL cholesterol targets.

Pulse pressure for selecting the optimal cardiac strategy in patients with type 2 diabetes and coronary artery disease

BACKGROUND

Pulse pressure may be potentially useful for selecting effective cardiac treatment strategies. This study aimed to assess the association between the cardiac treatment strategies and risk of major adverse cardiovascular events (MACE) in patients with type 2 diabetes and coronary artery disease (CAD), based on low or high levels of pulse pressure.

METHODS

We analyzed data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial and calculated hazard ratios (HRs) for MACE with 95% confidence intervals (95%CIs) using the Cox proportional hazard model. The risk of MACE in patients with type 2 diabetes and CAD was compared between the early revascularization and medical therapy groups separately in patients with pulse pressures < 60 mmHg (n = 1378) and ≥ 60 mmHg (n = 916).

RESULTS

During a maximal follow-up of 6 years, 389 patients experienced MACE. In patients with pulse pressure < 60 mmHg, the risk of MACE was significantly higher in the early revascularization group (HR: 1.37, 95%CI: 1.04-1.81, P = 0.02) and was specifically and significantly higher in the percutaneous coronary intervention group (HR: 1.66, 95%CI: 1.17-2.34, P = 0.004) than in the medical therapy group. In contrast, the risk of MACE in patients with pulse pressure ≥ 60 mmHg was significantly lower in the early revascularization group (HR: 0.72, 95%CI: 0.53-0.96, P = 0.02) and was specifically lower in the coronary artery bypass graft surgery group (HR: 0.49, 95%CI: 0.30-0.82, P = 0.006) than in the medical therapy group.

CONCLUSIONS

Pulse pressure may be used to determine optimal cardiac treatment strategies in patients with type 2 diabetes and CAD.

Insulin and glucose-lowering agents for treating people with diabetes and chronic kidney disease

BACKGROUND

Diabetes is the commonest cause of chronic kidney disease (CKD). Both conditions commonly co-exist. Glucometabolic changes and concurrent dialysis in diabetes and CKD make glucose-lowering challenging, increasing the risk of hypoglycaemia. Glucose-lowering agents have been mainly studied in people with near-normal kidney function. It is important to characterise existing knowledge of glucose-lowering agents in CKD to guide treatment.

OBJECTIVES

To examine the efficacy and safety of insulin and other pharmacological interventions for lowering glucose levels in people with diabetes and CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 February 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs looking at head-to-head comparisons of active regimens of glucose-lowering therapy or active regimen compared with placebo/standard care in people with diabetes and CKD (estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) were eligible.

DATA COLLECTION AND ANALYSIS

Four authors independently assessed study eligibility, risk of bias, and quality of data and performed data extraction. Continuous outcomes were expressed as post-treatment mean differences (MD). Adverse events were expressed as post-treatment absolute risk differences (RD). Dichotomous clinical outcomes were presented as risk ratios (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Forty-four studies (128 records, 13,036 participants) were included. Nine studies compared sodium glucose co-transporter-2 (SGLT2) inhibitors to placebo; 13 studies compared dipeptidyl peptidase-4 (DPP-4) inhibitors to placebo; 2 studies compared glucagon-like peptide-1 (GLP-1) agonists to placebo; 8 studies compared glitazones to no glitazone treatment; 1 study compared glinide to no glinide treatment; and 4 studies compared different types, doses or modes of administration of insulin. In addition, 2 studies compared sitagliptin to glipizide; and 1 study compared each of sitagliptin to insulin, glitazars to pioglitazone, vildagliptin to sitagliptin, linagliptin to voglibose, and albiglutide to sitagliptin. Most studies had a high risk of bias due to funding and attrition bias, and an unclear risk of detection bias.Compared to placebo, SGLT2 inhibitors probably reduce HbA1c (7 studies, 1092 participants: MD -0.29%, -0.38 to -0.19 (-3.2 mmol/mol, -4.2 to -2.2); I2 = 0%), fasting blood glucose (FBG) (5 studies, 855 participants: MD -0.48 mmol/L, -0.78 to -0.19; I2 = 0%), systolic blood pressure (BP) (7 studies, 1198 participants: MD -4.68 mmHg, -6.69 to -2.68; I2 = 40%), diastolic BP (6 studies, 1142 participants: MD -1.72 mmHg, -2.77 to -0.66; I2 = 0%), heart failure (3 studies, 2519 participants: RR 0.59, 0.41 to 0.87; I2 = 0%), and hyperkalaemia (4 studies, 2788 participants: RR 0.58, 0.42 to 0.81; I2 = 0%); but probably increase genital infections (7 studies, 3086 participants: RR 2.50, 1.52 to 4.11; I2 = 0%), and creatinine (4 studies, 848 participants: MD 3.82 μmol/L, 1.45 to 6.19; I2 = 16%) (all effects of moderate certainty evidence). SGLT2 inhibitors may reduce weight (5 studies, 1029 participants: MD -1.41 kg, -1.8 to -1.02; I2 = 28%) and albuminuria (MD -8.14 mg/mmol creatinine, -14.51 to -1.77; I2 = 11%; low certainty evidence). SGLT2 inhibitors may have little or no effect on the risk of cardiovascular death, hypoglycaemia, acute kidney injury (AKI), and urinary tract infection (low certainty evidence). It is uncertain whether SGLT2 inhibitors have any effect on death, end-stage kidney disease (ESKD), hypovolaemia, fractures, diabetic ketoacidosis, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, DPP-4 inhibitors may reduce HbA1c (7 studies, 867 participants: MD -0.62%, -0.85 to -0.39 (-6.8 mmol/mol, -9.3 to -4.3); I2 = 59%) but may have little or no effect on FBG (low certainty evidence). DPP-4 inhibitors probably have little or no effect on cardiovascular death (2 studies, 5897 participants: RR 0.93, 0.77 to 1.11; I2 = 0%) and weight (2 studies, 210 participants: MD 0.16 kg, -0.58 to 0.90; I2 = 29%; moderate certainty evidence). Compared to placebo, DPP-4 inhibitors may have little or no effect on heart failure, upper respiratory tract infections, and liver impairment (low certainty evidence). Compared to placebo, it is uncertain whether DPP-4 inhibitors have any effect on eGFR, hypoglycaemia, pancreatitis, pancreatic cancer, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, GLP-1 agonists probably reduce HbA1c (7 studies, 867 participants: MD -0.53%, -1.01 to -0.06 (-5.8 mmol/mol, -11.0 to -0.7); I2 = 41%; moderate certainty evidence) and may reduce weight (low certainty evidence). GLP-1 agonists may have little or no effect on eGFR, hypoglycaemia, or discontinuation due to adverse effects (low certainty evidence). It is uncertain whether GLP-1 agonists reduce FBG, increase gastrointestinal symptoms, or affect the risk of pancreatitis (very low certainty evidence).Compared to placebo, it is uncertain whether glitazones have any effect on HbA1c, FBG, death, weight, and risk of hypoglycaemia (very low certainty evidence).Compared to glipizide, sitagliptin probably reduces hypoglycaemia (2 studies, 551 participants: RR 0.40, 0.23 to 0.69; I2 = 0%; moderate certainty evidence). Compared to glipizide, sitagliptin may have had little or no effect on HbA1c, FBG, weight, and eGFR (low certainty evidence). Compared to glipizide, it is uncertain if sitagliptin has any effect on death or discontinuation due to adverse effects (very low certainty).For types, dosages or modes of administration of insulin and other head-to-head comparisons only individual studies were available so no conclusions could be made.

AUTHORS' CONCLUSIONS

Evidence concerning the efficacy and safety of glucose-lowering agents in diabetes and CKD is limited. SGLT2 inhibitors and GLP-1 agonists are probably efficacious for glucose-lowering and DPP-4 inhibitors may be efficacious for glucose-lowering. Additionally, SGLT2 inhibitors probably reduce BP, heart failure, and hyperkalaemia but increase genital infections, and slightly increase creatinine. The safety profile for GLP-1 agonists is uncertain. No further conclusions could be made for the other classes of glucose-lowering agents including insulin. More high quality studies are required to help guide therapeutic choice for glucose-lowering in diabetes and CKD.

Modelling of the ICF core sets for chronic ischemic heart disease using the LASSO model in Chinese patients

Background

This study aimed to examine the associations among the International Classification of Functioning, Disability, and Health (ICF) core sets relevant to chronic ischemic heart disease (CIHD) using the least absolute shrinkage and selection operator (LASSO) model based on the ICF core sets scale in Chinese patients.

Methods

This was a prospective study of 120 patients with CIHD selected from January 2013 to June 2014 at the Fada Institute of Forensic Medicine & Science (Beijing, China). Functioning was qualified using the ICF core sets checklist for CIHD (Chinese version). The variables of core set categories of the ICF assessment scale for CIHD were entered into the LASSO model for mining dependencies among those variables. Graphical modeling was applied using LASSO generalized linear models.

Results

“Muscle endurance functions”, “sensations associated with cardiovascular and respiratory functions”, “blood vessel functions”, and “heart functions” were the most injured in CIHD status. “Recreation and leisure” and “intimate relationships” were the most affected in CIHD status. “General social support services, systems, and policies” and “acquaintances, peers, colleagues, neighbors, and community members” were important for the outcome of functional status of the CIHD patient. “Economic self-sufficiency” and “family relationships” of the CIHD patient were not undermined in most cases.

Conclusions

Graphical modeling can be used to describe associations between different areas of functioning in CIHD patients. The results suggest that these associations could be used as basis to improve rehabilitation and provide a deeper understanding of functioning in Chinese CIHD patients.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0957-0) contains supplementary material, which is available to authorized users.

Comparison of 3 Predictive Clinical Risk Scores in 603 Patients with Stable Coronary Artery Disease

No clinical risk score is universally accepted for coronary artery disease. In 603 patients (mean age, 61.2 ± 12.3 yr) with stable coronary artery disease, we investigated the predictive power of clinical risk scores derived from the Framingham, the Long-term Intervention with Pravastatin in Ischemic Disease (LIPID), and the Vienna and Ludwigshafen Coronary Artery Disease (VILCAD) studies. Secondary outcomes were the recurrence of an acute thrombotic event (coronary events, strokes, or transient ischemic attacks), or heart failure or death. The primary outcome was the combination of secondary outcomes. During follow-up (duration, 2.08 ± 0.97 yr), 42 patients had an acute thrombotic event; 22, heart failure or death; and 60, the primary outcome. The Framingham score predicted acute thrombotic events: hazard ratio (HR)=1.05; 95% confidence interval (CI), 1.01-1.08; P=0.03; net reclassification index (NRI, calculated to evaluate improvement in prediction gained by adding different risk scores to models constructed with variables excluded from the calculation of that score)=9.7% (95% CI, 9.6-9.8). The LIPID (HR=1.13; 95% CI, 1.04-1.22; P=0.005) and VILCAD scores (HR=1.99; 95% CI, 1.48-2.67; P <0.001) predicted heart failure or death with NRIs of 5.8% (95% CI, 5.7-5.9) and 18.6% (95% CI, 18.3-18.9), respectively. The primary outcome was predicted by the LIPID (HR=1.1; 95% CI, 1.03-1.17; P=0.005) and VILCAD scores (HR=1.39; 95% CI, 1.13-1.70; P=0.003). The NRIs (95% CIs) were 3.4% (3.3-3.5) and 19.4% (19.3-19.6), respectively. We conclude that the accuracy of these risk scores varies in accordance with the outcome studied.

Effects of β-blockers on all-cause mortality in patients with type 2 diabetes and coronary heart disease

AIMS

To assess whether the use of beta-blockers influences mortality and the incidence of major cardiovascular events in patients with diabetes and coronary heart disease (CHD).

MATERIALS AND METHODS

Using data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial, we performed Cox proportional hazards analysis to assess the effects of β-blockers on all-cause mortality in 2244 patients with type 2 diabetes who had stable CHD with and without a history of myocardial infarction (MI)/heart failure with reduced left ventricular ejection fraction (HFrEF).

RESULTS

All-cause mortality in patients with MI/HFrEF was significantly lower in those receiving β-blockers than in those not receiving β-blockers (adjusted hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.37-0.98; P  = .04), whereas that in patients without MI/HFrEF did not significantly differ (adjusted HR 0.91, 95% CI 0.76-1.32; P  = .64). Among patients with MI/HFrEF, all-cause mortality in those who received intensive medical therapy alone for CHD was significantly lower in those on β-blockers than in those not on β-blockers (adjusted HR 0.45, 95% CI 0.23-0.88; P  = .02); however, mortality in patients who received early revascularization for CHD was not significantly lower in those on β-blockers (adjusted HR 0.81, 95% CI 0.40-1.65; P  = .57). The risk of major cardiovascular events in patients without MI/HFrEF was not significantly different between those on and those not on β-blocker treatment.

CONCLUSIONS

In patients with diabetes and CHD, the use of β-blockers was effective in reducing all-cause mortality in those with MI/HFrEF but not in those without MI/HFrEF.

Management of Atherosclerotic Cardiovascular Disease Risk Factors in the Older Adult Patient With Diabetes

: Older adults with diabetes are at higher risk for atherosclerotic cardiovascular disease (ASCVD) than younger adults with diabetes and older adults without diabetes. The rationale to implement ASCVD risk-lowering therapies in older adults with diabetes is compelling. Recommendations for lifestyle modification, lipid-lowering therapy, blood pressure management, blood glucose control, and aspirin therapy are often based on studies that show their efficacy in younger populations. However, the risks associated with each of these interventions increase with age, and favorable risk-to-benefit ratios demonstrated in younger adults with diabetes are less certain in older populations. The variability in health status among older adults is pertinent. Those with robust health are more likely to tolerate and derive benefit from many therapies when compared with those who have more complex health including frailty. Age- and/or frailty-stratified data to help clarify these relationships are sparse. In this Perspective, current recommendations for modifying ASCVD risk are described with a review of the pertinent literature that guides their application in older adults. A pragmatic approach to the treatment of ASCVD risk factors in older adults with diabetes is presented.

Systematic Review of Therapies for Stable Coronary Artery Disease in Diabetic Patients

Diabetes mellitus is a significant risk modifier for stable coronary artery disease, causing patients to have more extensive and diffuse lesions. Opposing treatment strategies remain a matter of debate. A multiple database search was conducted and outcomes, lesion, and patient characteristics were compared. Overall mortality, cardiac death, major adverse cardiovascular and cerebrovascular events, and need for revascularization were higher with percutaneous coronary intervention than with coronary artery bypass graft surgery. Multivessel disease and high Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) scores were associated with better outcomes for coronary artery bypass graft surgery.

Early and long-term outlook of percutaneous coronary intervention for bifurcation lesions in young patients

BACKGROUND

Coronary artery disease is most common in older patients, but may occur in younger subjects. The outlook of young patients after percutaneous coronary intervention (PCI) of challenging lesion subsets such as coronary bifurcations, is not established. We thus aimed to appraise the early and long-term results of PCI for bifurcations in young patients.

METHODS

A multicenter, retrospective study was conducted enrolling consecutive patients undergoing bifurcation PCI between 2002 and 2006 in 22 Italian centers. Patients were divided in 2 groups: age ≤ 45 years, and age > 45 years. The primary end-point was long-term rate of major adverse cardiac events (MACE).

RESULTS

4,314 patients were included: 195 (4.5%) in the younger group, and 4119 (95.5%) in the older group. 30-day outcomes did not show significant differences in MACE rates, with 1.0% in the ≤ 45 years group and 2.1% in the >45 years group (p=0.439), with death in 0.5% and 1.2% (p=0.388). At long-term follow-up (24.4 ± 15.1 months), younger patients showed similar rates of MACE, (12.8% vs. 16.6%, p=0.161), myocardial infarction (3.1% vs. 3.7%, p=0.633), target lesion revascularization (11.3% vs. 12.5%, p=0.627), or stent thrombosis (1.5% vs. 2.8%, p=0.294), despite an increased risk of death in older patients (1.0% vs. 5.0%, p=0.012). Even at extensive multivariable analysis, younger patients still faced a similar risk of MACE (HR=0.78 [0.48-1.27], p=0.318).

CONCLUSIONS

Despite their low age, young patients undergoing PCI for bifurcation face a significant risk of early and late non-fatal adverse events. Thus, they should not be denied careful medical management and follow-up.

Ten-year outcomes of patients randomized to surgery, angioplasty, or medical treatment for stable multivessel coronary disease: effect of age in the Medicine, Angioplasty, or Surgery Study II trial

OBJECTIVE

With progressive aging, coronary artery disease has been diagnosed at more advanced ages. Although patients aged 65 years or more have been referred to surgical or percutaneous coronary interventions, the best option for coronary artery disease treatment remains uncertain. The current study compared the 3 treatment options for coronary artery disease in patients aged 65 years or more and analyzed the impact of age in treatment options.

METHODS

Patients were separated according to age: 65 years or more (n = 200) and less than 65 years (n = 411). All patients were followed for 10 years. The rates of overall mortality, acute myocardial infarction, and new revascularizations were analyzed.

RESULTS

Of 200 patients aged 65 years or more, 68 were randomized to medical therapy, 68 were randomized to percutaneous coronary intervention, and 64 were randomized to coronary artery bypass grafting. At 10 years, overall survival was 63% (medical therapy), 69% (percutaneous coronary intervention), and 66% (coronary artery bypass grafting) (P = .93). The survival free of combined events was 43% (medical therapy), 38% (percutaneous coronary intervention ), and 66% (coronary artery bypass grafting) (P = .007). The survival free of myocardial infarction was 82% (medical therapy), 77% (percutaneous coronary intervention), and 90% (coronary artery bypass grafting) (P = .17), and survival free of new revascularizations was 59% (medical therapy), 58% (percutaneous coronary intervention ), and 91% (coronary artery bypass grafting) (P = .0003). When the 2 age groups were compared, survival free of myocardial infarction for patients treated by percutaneous coronary intervention was 77% (older patients) and 92% (younger patients) (P = .004).

CONCLUSIONS

In this analysis, treatment options for patients aged 65 years or more who have coronary artery disease yield similar overall survival. However, coronary artery bypass grafting was associated with fewer coronary events, and percutaneous coronary intervention was associated with a higher incidence of myocardial infarction.