Prognostic significance of anemia in women with suspected ischemia, an insight from the women ischemia syndrome evaluation study (WISE)

Background

Anemia is associated with adverse cardiovascular outcomes in patients with myocardial infarction and congestive heart failure. Anemia is more prevalent in women. We investigated the prognosis of anemia in women with suspected ischemic heart disease.

Purpose

To study if hemoglobin levels at baseline in women with symptoms of ischemia predicts long term all-cause mortality and major adverse cardiac events.

Methods

We studied 885 women enrolled in WISE (1997–2001) undergoing clinically indicated coronary angiography for suspected ischemia. Anemia was defined as hemoglobin (Hb) level <12g/dL. Major adverse cardiovascular event (MACE) included all-cause death, nonfatal myocardial infarction, stroke and heart failure hospitalization. Cox regression models and Kaplan-Meier methods were was used.

Results

Overall, 885 women, mean age 58.4±11.7 years, 21.1% and anemia were followed for 6.8 years. Anemic women had higher creatinine, history of diabetes mellitus, hypertension and CHF (p<0.05), but not obstructive coronary artery disease compared to non-anemia women (p=0.97). Anemic women had higher all-cause mortality and MACE (Figure). In multivariate analysis, anemia was independently associated with increased MACE risk (hazard ratio (HR): 1.5, 95% confidence interval [1.11- 2.01, p=0.007]) but not all-cause mortality (HR: 1.2 [0.84–1.72, p=0.30]).

Conclusions

Among women evaluated for symptoms of ischemia, anemia is associated with and independently predicts MACE. Further research targeting anemia treatment in women to mitigate these adverse outcomes is warranted.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): NIH USA

Sex differences in the rates of incident and recurrent coronary heart disease and all-cause mortality

Background

Women have lower age-specific rates of incident coronary heart disease (CHD) than men. However, it remains unclear whether women maintain the same advantage once they have had a cardiac event.

Purpose

To assess whether sex differences in the rates of cardiac events and all-cause mortality among individuals without a history of CHD persist following a myocardial infarction (MI).

Methods

We identified 171,897 women and 167,993 men <65 years of age with commercial health insurance and ≥66 years of age with government health insurance through Medicare who had a MI hospitalization between 2015 and 2016 in the US. These beneficiaries were matched to 687,588 women and 671,972 men without a history of CHD based on age and calendar year. Beneficiaries were followed until December 2017 for the occurrence of MI, CHD, heart failure, and all-cause mortality (Medicare only).

Results

The age-standardized rates of MI per 1,000 person-years were 4.5 in women and 5.7 in men without a history of CHD (multivariable-adjusted hazard ratio [HR] [95% confidence interval] of female sex: 0.64 [0.62; 0.67]) and 60.2 in women and 59.8 in men with a history of MI (HR: 0.94 [0.92, 0.96]) (Figure 1). Rates of CHD events in women vs. men were 6.3 vs. 10.7 among those without CHD (HR: 0.53 [0.51, 0.54]) and 84.5 vs. 99.3 among those with MI (HR: 0.87 [0.85, 0.89]). Heart failure hospitalization rates in women vs. men were 9.3 vs. 6.6 for those without CHD (HR: 0.93 [0.90, 0.96]) and 114.9 vs. 97.9 among those with MI (HR: 1.02 [1.00, 1.04]). All-cause mortality rates in women vs. men were 63.7 vs. 59.0 among those without CHD (HR: 0.72 [0.71; 0.73]) and 311.6 vs. 284.5 among those with a MI (HR: 0.90 [0.89, 0.92]).

Conclusion

The women advantage against MI, CHD, heart failure and all-cause mortality is considerably attenuated following a MI, suggesting that a prior MI puts women at almost the same high-risk of subsequent events as men.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This work was funded by an industry/academic collaboration between Amgen Inc. and University of Alabama at Birmingham.

Persistent chest pain at 1-year predicts long-term angina hospitalization in women with and without obstructive coronary artery disease: results from Women's Ischemia Syndrome Evaluation (WISE)

Background

There is growing evidence that women with ischemia and no obstructive coronary artery disease (INOCA) have an increased risk of major adverse cardiovascular events (MACE). Half of these women continue to experience persistent chest pain (PChP); however longer-term outcomes are unknown.

Purpose

To investigate the relationships between PChP at 1-year with obstructive and nonobstructive coronary artery disease (CAD) and longer-term all-cause mortality, MACE and angina hospitalization in women with suspected myocardial ischemia.

Methods

We studied 673 women with chest pain undergoing coronary angiography for suspected myocardial ischemia in the National Heart, Lung, and Blood Institute Women's Ischemia Syndrome Evaluation (WISE) study. PChP was defined as self-reported continuing chest pain at 1-year, obstructive CAD as >50 stenosis in any coronary artery and non-obstructive CAD was further divided as <20% stenosis and 20–50% stenosis in any coronary artery. The Kaplan-Meier method was used to estimate cumulative incidence rates of all-cause mortality, MACE, and angina hospitalization. Proportional hazards regression estimated adjusted hazard ratios of mortality, MACE and angina hospitalization in relation to PChP at 1-year in obstructive and nonobstructive CAD.

Results

The median age was 58 years, 45% had PChP, and 39% had obstructive CAD with a median follow-up time of 9 years (range 1 to 11) for mortality and 5 years (range 0 to 9) for MACE and anginal hospitalization. There was no difference in mortality or MACE in women with PChP compared to women without PChP in any of the 3 groups (<20%, 20–50%, or >50% CAD), however differences were noted in long-term angina hospitalization (Figure 1). Notably,angina hospitalization rates in women with PChP and nonobstructive CAD were 2.2 times those of women without PChP, and comparable to those of women with obstructive CAD and no PChP (p<0.0001).

Conclusions

Among women undergoing coronary angiography for suspected myocardial ischemia, women with nonobstructive CAD and PChP have rates of angina hospitalization comparable to patients with obstructive CAD without PChP. Thus, PChP increases the hazard of long term anginal hospitalization regardless of the presence or absence of obstructive CAD. Given the economic burden of angina hospitalization, further studies are needed to determine whether aggressive treatment in women with PChP without obstructive CAD changes outcomes and impact on the health care system.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH)

5191Recurrent coronary heart disease in the year following myocardial infarction among US men and women between 2008 and 2015

Background

Although the risk of recurrent events among adults with coronary heart disease (CHD) has declined considerably from the 1970's in the US and many Western countries, studies from the 2000's show that rates remain high. Women have lower rates of incident CHD but little is known about sex differences in recurrent events in adults with CHD.

Purpose

To examine trends in rates of recurrent myocardial infarction (MI), recurrent CHD, and all-cause mortality following a MI hospitalization between 2008 and 2015 among US men and women. Also, we compared sex differences in event rates among individuals with a MI hospitalization versus their counterparts without a history of CHD.

Methods

Data were used from 1,232,024 (53% women) US adults <65 years of age with commercial health insurance in the MarketScan database and US adults ≥66 years of age with government health insurance through Medicare who had a MI hospitalization between January 1, 2008 and December 31, 2015. For each calendar year, age-standardized sex-specific rates of recurrent MI, recurrent CHD (i.e., recurrent MI or coronary revascularization), and all-cause mortality (in Medicare only) were calculated through 365 days following the hospital discharge date for MI. In a secondary analyses, we assessed the rate of recurrent MI, CHD events and all-cause mortality among women versus men with a history of MI (n=324,283) and without a history of CHD (n=1,297,132) in 2014–2015. For these analyses, adjusted hazard ratios (95% confidence intervals) were calculated using follow-up through December 31, 2016.

Results

From 2008 to 2015, age-standardized rates over 365 days of follow-up for recurrent MI declined by 15%, from 94 to 80 per 1000 person-years, in men and by 14%, from 89 to 77 per 1000 person-years, in women. Age-standardized recurrent CHD rates decreased by 16%, from 163 to 138 per 1000 person-years, in men and by 17%, from 142 to 118 per 1000 person-years, in women. In the Medicare population, age-standardized all-cause mortality rates following MI decreased by 6%, from 446 to 421 per 1000 person-years, in men and by 3%, from 412 to 398 per 1000 person-years, in women. In the secondary analyses, the women-to-men hazard ratios for those with a history of MI and those without prior CHD were 0.97 (0.94–0.99) and 0.67 (0.65–0.69), respectively, for MI, 0.89 (0.87–0.91) and 0.52 (0.51–0.54), respectively, for CHD, and 0.84 (0.83–0.85) and 0.74 (0.73–0.75) respectively, for all-cause mortality.

Conclusion

Reductions in rates of recurrent MI, recurrent CHD, and all-cause mortality within 365 days after hospitalization for MI have been similar for US women and men. The lower risk for events comparing women versus men without prior CHD is attenuated after a MI.

Acknowledgement/Funding

The design and conduct of the study was supported through a research grant from Amgen, Inc.

P5322Oxidized phospholipids on apolipoprotein B-100 among black US adults with and without PCSK9 loss-of-function variants

Background

High oxidized phospholipid-apolipoprotein B-100 (OxPL-apoB) levels are associated with an increased risk for coronary heart disease (CHD). Genetic PCSK9 loss-of-function (LOF) variants result in life-long lower levels of LDL-C and lipoprotein(a) and reduced CHD risk, but the association with OxPL-apoB is unknown.

Purpose

To estimate the association between PCSK9 LOF variants and OxPL-apoB levels among black adults.

Methods

Genotyping for LOF variants (Y142X and C679X) was conducted for 10,196 black Reasons for Geographic And Racial Differences in Stroke study participants. OxPL-apoB was measured using antibody E06 for all participants with LOF variants (n=241) and randomly selected participants, matched at a 1:3 ratio, without LOF variants (n=723). Low OxPL-apoB was defined as the bottom quartile of the population distribution (<1.6 nM). Prevalence ratios (PR) and 95% confidence intervals (CI) were calculated for the association between PCSK9 LOF variants and low OxPL-apoB levels adjusting for age, sex, and estimated glomerular filtration rate.

Results

Adults with versus without PCSK9 LOF variants had lower LDL-C and lipoprotein(a) and were less likely to be taking a statin. (Table) A higher proportion of adults with versus without PCSK9 LOF variants had low OxPL-apoB levels (30.3 vs 23.4, p=0.03). After adjustment for covariates, the PR of low OxPL-apoB was increased for participants with compared to without LOF variants (PR 1.31, 95% CI 1.00, 1.72).

Characteristics of REGARDS participants PCSK9 loss-of-function variant p-value Yes (n=241) No (n=723) Age, years, mean (SD) 63.7 (9.2) 63.8 (8.6) 0.81 Female, % 61.4 60.6 0.82 Diabetes, % 34.4 27.4 0.04 LDL-C, mg/dL, mean (SD) 85 (32) 118 (37) <0.001 Lp(a), nmol/L, median (25th, 75th percentile) 63.2 (30.4, 119.6) 80.4 (39.7, 138.4) 0.02 Statin use, % 13.3 30.4 <0.001 OxPL-apoB <1.6 nM, % 30.3 23.4 0.03 Abbreviations: LDL-C, low-density lipoprotein cholesterol; Lp(a), lipoprotein(a); LOF, loss-of-function; nM, nanomolar; OxPL-apoB, oxidized phospholipids on apolipoprotein B-100; PCSK9, proprotein convertase subtilisin/kexin type-9; REGARDS, REasons for Geographic And Racial Differences in Stroke; SD, standard deviation.

Conclusion

Among black adults, PCSK9 LOF variants were associated with lower OxPL-apoB levels.

Acknowledgement/Funding

Industry/academic collaboration between Amgen Inc., University of Alabama at Birmingham and the Icahn School of Medicine at Mt. Sinai; and U01NS041588

4114Efficacy of alirocumab treatment after acute coronary syndrome according to new ACC/AHA guidelines for lipid-lowering therapy

Background

The 2018 ACC/AHA cholesterol management guidelines recommend additional lipid-lowering therapies for secondary prevention in patients with LDL-C ≥1.8 mmol/L despite maximally tolerated statin therapy who are considered “very high-risk” on the basis of history of multiple ischaemic events or an ischaemic event and multiple high-risk conditions.

Purpose

We examined the frequency of major adverse cardiovascular events (MACE) and efficacy of PCSK9 inhibition with alirocumab to reduce MACE in patients with recent acute coronary syndrome (ACS) categorized as very high-risk or not very high-risk by guideline criteria.

Methods

Patients in ODYSSEY OUTCOMES (n=18,924) with recent ACS and residual dyslipidaemia despite optimal statin therapy were randomized to alirocumab or placebo and followed for median 2.8 years. The primary MACE outcome was a composite of coronary heart disease death, non-fatal myocardial infarction (MI), ischaemic stroke, or hospitalization for unstable angina.

Results

Of 18,924 randomized patients, 11,935 (63.1%) were categorized as very high-risk and 6989 (36.9%) as not very high risk (per ACC/AHA guidelines criteria). In the very high-risk category, 4450 (37.3%) had a prior ischaemic event plus the trial-qualifying index ACS (MI, 3633; stroke, 524; peripheral artery disease, 759); 7485 (62.7%) had no ischaemic event before the index ACS but had ≥2 high-risk conditions (diabetes, 3319; age ≥65 years, 3087; current smoking, 2371; chronic kidney disease, 1583). In the placebo group, the incidence of MACE was higher among those in the very high-risk category (14.4%) vs those not at very high-risk (5.6%). Overall, alirocumab reduced the risk of MACE vs placebo (9.5% vs 11.1%, hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.78–0.93; P=0.003), with consistent relative reductions in both risk categories (very high risk HR 0.84, 95% CI 0.76–0.92; not very high risk HR 0.86, 95% CI 0.70–1.06). However, the absolute reduction in MACE with alirocumab was greater among patients classified as very high-risk (2.1%) vs not very high risk (0.8%), and greater in particular among those classified as very high risk based on multiple ischaemic events (2.4%, Figure).

Conclusions

Application of 2018 ACC/AHA cholesterol guidelines criteria accurately identifies patients with ACS and dyslipidaemia who are at very high risk for recurrent MACE, and who derive a large absolute benefit from alirocumab treatment. Patients categorized as very high-risk based upon multiple ischaemic events derive a particularly large absolute benefit from treatment with alirocumab.

Acknowledgement/Funding

Supported by Sanofi and Regeneron Pharmaceuticals

P6206Death, debility, and destitution following recurrent myocardial infarction in older adults

Background

Most prior research on outcomes among older adults with established cardiovascular diseases focuses on recurrent events and hospitalizations. However, older adults value financial security and functional independence in addition to these disease-focused metrics. Recurrent cardiovascular events may increase risk of long-term nursing home residence and financial strain.

Purpose

To compare the risk for death, debility (long-term residence in a nursing home), and destitution (eligibility for health insurance programs for impoverished individuals) among older adults with recurrent myocardial infarction (MI) and controls.

Methods

We conducted a retrospective cohort study using administrative data from the United States Medicare program, a health insurance program for older adults. Among all patients who experienced a first overnight hospitalization with a discharge diagnosis of MI between 1 January 2007 and 30 June 2016, we identified patients with a recurrent MI hospitalization. Additionally, we selected controls from the same population of patients with MI, matched on calendar year of the initial MI and days since the initial MI. We included 194,481 patients aged 66 years and older with recurrent MI hospitalizations and 777,924 controls. Patients were followed for death, debility, and destitution until 31 December 2016. We used Kaplan-Meier curves and Cox proportional hazards models adjusted for sociodemographic factors, comorbidities, and healthcare utilization to compare patients with recurrent MI and matched controls.

Results

The average age of the population was 80.0 (standard deviation 8.3) years and 56.7% were women. Patients with recurrent MI were more likely to have a history of diabetes, chronic kidney disease, heart failure and peripheral artery disease than controls. The cumulative incidence of death, debility, and destitution were all higher among patients with recurrent MI than their matched controls (Figure). Comparing patients with recurrent MI to controls, the hazard ratios (95% confidence intervals) were 2.11 (2.09–2.13) for death, 0.92 (0.89–0.94) for debility, and 1.34 (1.29–1.39) for destitution after multivariable adjustment.

Death, debility, and destitution

Conclusion

Preventing recurrent MIs has the potential to reduce not only mortality but also destitution.

Acknowledgement/Funding

Amgen, Inc

Psychotropic medication use and risk of adverse cardiovascular events in women with suspected coronary artery disease: outcomes from the Women's Ischemia Syndrome Evaluation (WISE) study

OBJECTIVE

This study investigated the relation between psychotropic medication use and adverse cardiovascular (CV) events in women with symptoms of myocardial ischaemia undergoing coronary angiography.

METHOD

Women enrolled in the Women's Ischemia Syndrome Evaluation (WISE) were classified into one of four groups according to their reported antidepressant and anxiolytic medication usage at study intake: (1) no medication (n = 352); (2) anxiolytics only (n = 67); (3) antidepressants only (n = 58); and (4) combined antidepressant and anxiolytics (n = 39). Participants were followed prospectively for the development of adverse CV events (for example, hospitalisations for non-fatal myocardial infarction, stroke, congestive heart failure and unstable angina) or all-cause mortality over a median of 5.9 years.

RESULTS

Use of antidepressant medication was associated with subsequent CV events (HR 2.16, 95% CI 1.21 to 3.93) and death (HR 2.15, 95% CI 1.16 to 3.98) but baseline anxiolytic use alone did not predict subsequent CV events and death. In a final regression model that included demographics, depression and anxiety symptoms, and risk factors for cardiovascular disease, women in the combined medication group (that is, antidepressants and anxiolytics) had higher risk for CV events (HR 3.98, CI 1.74 to 9.10, p = 0.001 and all-cause mortality (HR 4.70, CI 1.7 to 2.97, p = 0.003) compared to those using neither medication. Kaplan-Meier survival curves indicated that there was a significant difference in mortality among the four medication groups (p = 0.001).

CONCLUSIONS

These data suggest that factors related to psychotropic medication such as depression refractory to treatment, or medication use itself, are associated with adverse CV events in women with suspected myocardial ischaemia.

Beneficial effects of aggressive low-density lipoprotein cholesterol lowering in women with stable coronary heart disease in the Treating to New Targets (TNT) study

OBJECTIVE

To examine by secondary analysis of the Treating to New Targets (TNT) study whether the benefits of intensive versus standard levels of lipid lowering are equally applicable to women.

METHODS

A total of 10 001 patients (1902 women) with stable coronary heart disease (CHD) were randomised to double-blind treatment with atorvastatin 10 or 80 mg/day for a median follow-up of 4.9 years.

RESULTS

In women and men, intensive treatment with atorvastatin 80 mg significantly reduced the rate of major cardiovascular events compared with atorvastatin 10 mg. Among women, the relative and absolute reductions were 27% and 2.7%, respectively (hazard ratio (HR) = 0.73, 95% confidence interval (CI) 0.54 to 1.00, p = 0.049). In men, the corresponding rate reductions were 21% and 2.2% (HR = 0.79, 95% CI 0.69 to 0.91, p = 0.001). The number needed to treat value (to prevent one cardiovascular event over 4.9 years compared with patients treated with atorvastatin 10 mg) for atorvastatin 80 mg was 29 for women and 30 for men. Rates of death of non-cardiovascular origin in the atorvastatin 80 mg and atorvastatin 10 mg were 3.6% and 1.6%, respectively (p = 0.004) among women, and 2.8% and 3.1% (p = 0.47) among men.

CONCLUSION

Intensive lipid-lowering treatment with atorvastatin 80 mg produced significant reductions in relative risk for major cardiovascular events compared with atorvastatin 10 mg in both women and men with stable CHD.

Post-challenge glucose predicts coronary atherosclerotic progression in non-diabetic, post-menopausal women

AIMS

We sought to determine whether fasting or post-challenge glucose were associated with progression of coronary atherosclerosis in non-diabetic women.

METHODS

We performed a post-hoc analysis of 132 non-diabetic women who underwent 75-g oral glucose tolerance testing. The primary outcome of interest was progression of atherosclerosis determined by baseline and follow-up coronary angiography, a mean of 3.1 +/- 0.9 years apart. We analysed the association of change in minimal vessel diameter (DeltaMD) by quartile of fasting and post-challenge glucose using mixed models that included adjustment for age, systolic blood pressure, total : high-density lipoprotein cholesterol ratio, current smoking, lipid-lowering and anti-hypertensive medication use and other covariates.

RESULTS

At baseline, participants had a mean age of 65.7 +/- 6.7 years and a mean body mass index of 27.9 +/- 8.5 kg/m(2). Although there were no significant differences in atherosclerotic progression by fasting glucose category (P for trend across quartiles = 0.99), there was a significant inverse association between post-challenge glucose and DeltaMD (in mm) (Q1 : 0.01 +/- 0.03; Q2 : 0.08 +/- 0.03; Q3 : 0.13 +/- 0.03; Q4 : 0.11 +/- 0.03; P for trend = 0.02).

CONCLUSIONS

In post-menopausal women without diabetes, post-challenge glucose predicts angiographic disease progression. These findings suggest that even modest post-challenge hyperglycaemia influences the pathogenesis of atherosclerotic progression.

Outcomes of patients with chronic renal insufficiency in the bypass angioplasty revascularization investigation

BACKGROUND

Although severe chronic kidney disease (CKD) is an independent predictor of mortality among patients with coronary artery disease, the impact of mild CKD on morbidity and mortality has not been fully defined.

METHODS AND RESULTS

Morbidity and mortality for the 3608 patients with multivessel coronary artery disease enrolled in the Bypass Angioplasty Revascularization Investigation randomized trial and registry were compared on the basis of the presence and absence of CKD, defined as a preprocedure serum creatinine level of >1.5 mg/dL. Seventy-six patients had CKD. Patients with renal insufficiency were older and more likely to have a history of diabetes, hypertension, and other comorbidities. Among patients undergoing PTCA, patients with CKD had a greater frequency of in-hospital death and cardiogenic shock (P<0.05 and 0.01, respectively). There was a trend toward a larger proportion of patients with CKD experiencing angina at 5 years (P=0.079). Patients with CKD had more cardiac admissions (P=0.003 and <0.0001 for patients undergoing PTCA and CABG, respectively) and a shorter time to subsequent CABG after initial revascularization than patients without CKD (P=0.01). CKD was associated with a higher risk of death at 7 years, both of all causes (relative risk 2.2, P<0.001) and of cardiac causes (relative risk 2.8, P<0.001).

CONCLUSIONS

CKD is associated with an increased risk of recurrent hospitalization, subsequent CABG, and mortality. This increased risk of death is independent of and additive to the risk associated with diabetes.

Treatment of dyslipidemia in pre- and postmenopausal women with and without known atherosclerotic cardiovascular disease

Cardiovascular disease is the primary cause of death among women in the United States, in part due to a very high prevalence of dyslipidemia. Clinical trials have shown that low-density lipoprotein cholesterol-lowering therapy can decrease angiographic progression of coronary disease and decrease clinical events among women and men. Although hormone replacement therapy has beneficial effects on the lipoprotein profile, its role in cardiovascular disease prevention remains unclear. The recently released Third Report of the National Cholesterol Education Program Expert Panel provides detailed guidelines for the management of dyslipidemia in women, with a focus on low-density lipoprotein cholesterol and intensity guided by risk of cardiovascular events.

Prevalence of clinical and isolated subclinical cardiovascular disease in older adults with glucose disorders: the Cardiovascular Health Study

OBJECTIVE

Clinical cardiovascular disease (CVD) is highly prevalent among people with diabetes. However, there is little information regarding the prevalence of subclinical CVD and its relation to clinical CVD in diabetes and in the glucose disorders that precede diabetes.

RESEARCH DESIGN AND METHODS

Participants in the Cardiovascular Health Study, aged > or = 65 years (n = 5,888), underwent vascular and metabolic testing. Individuals with known disease in the coronary, cerebral, or peripheral circulations were considered to have clinical disease. Those without any clinical disease in whom CVD was detected by ultrasonography, electrocardiography, or ankle arm index in any of the three vascular beds were considered to have isolated subclinical disease.

RESULTS

Approximately 30% of the cohort had clinical disease, and approximately 60% of the remainder had isolated subclinical disease. In those with normal glucose status, isolated subclinical disease made up most of the total CVD. With increasing glucose severity, the proportion of total CVD that was clinical disease increased; 75% of men and 66% of women with normal fasting glucose status had either clinical or subclinical CVD. Among those with known diabetes, the prevalence was approximately 88% (odds ratio [OR] 2.46 for men and 4.22 for women, P < 0.0001). There were intermediate prevalences and ORs for those with impaired fasting glucose status and newly diagnosed diabetes.

CONCLUSIONS

Isolated subclinical CVD is common among older adults. Glucose disorders are associated with an increased prevalence of total CVD and an increased proportion of clinical disease relative to subclinical disease.

Advance directives in cardiac and pulmonary rehabilitation patients

PURPOSE

Advance directives have been available in parts of the United States for more than 20 years, but research shows that only a small percentage of adults (5-25%) have some form of written advance directive. The purose of this study was to examine the presence of advance directives among persons entering cardiac and pulmonary rehabilitation, and identify characteristics of persons most likely to have advance directives.

METHODS

The sample consisted of 336 cardiac patients and 181 pulmonary patients who enrolled in the University of Alabama at Birmingham's Cardiopulmonary Rehabilitation Program between January 1996 and December 1999. As part of the initial program assessment, patients were asked two questions: (1) Do you have a living will? (2) Do you have any advance directives? For the purposes of this study, the two questions were combined to examine the presence of either a living will or other type of advance directive.

RESULTS

Results indicate that 25% of both subgroups (cardiac and pulmonary patients) report having written advance directives. Logistic regression analysis indicates that among cardiac patients whites and older persons were more likely to have advance directives. Among pulmonary patients, females and whites were more likely to have advance directives.

CONCLUSIONS

These results indicate that only a minority of cardiopulmonary rehabilitation patients have advance directives upon entry into the program, and that the prevalence differs among gender, racial, and age groups. Cardiac and pulmonary rehabilitation programs may be valuable sites for educating patients about advance directives and efforts by rehabilitation personnel may increase the prevalence of advance directives among patients.

Weight cycling and high-density lipoprotein cholesterol in women: evidence of an adverse effect: a report from the NHLBI-sponsored WISE study. Women's Ischemia Syndrome Evaluation Study Group

OBJECTIVES

We undertook an analysis of weight cycling, coronary risk factors and angiographic coronary artery disease (CAD) in women.

BACKGROUND

The effect of weight cycling on cardiovascular mortality and morbidity is controversial, and the impact of weight cycling on cardiovascular risk factors is unclear.

METHODS

This is a cross-sectional population study of 485 women with coronary risk factors undergoing coronary angiography for evaluation of suspected myocardial ischemia enrolled in the Women's Ischemia Syndrome Evaluation (WISE). Reported lifetime weight cycling-defined as voluntary weight loss of at least 10 lbs at least 3 times--coronary risk factors including core laboratory determined blood lipoproteins and CAD, as determined by a core angiographic laboratory, are the main outcome measures.

RESULTS

Overall, 27% of women reported weight cycling--19% cycled 10 to 19 lbs, 6% cycled 20 to 49 lbs, and 2% cycled 50+ lbs. Reported weight cycling was associated with 7% lower high-density lipoprotein cholesterol (HDL-C) levels in women (p = 0.01). The HDL-C effect was directly related to the amount of weight cycled with women who lost > or = 50 lbs/cycle having HDL-C levels 27% lower than noncyclers (p = 0.0025). This finding was independent of other HDL-C modulators, including estrogen status, physical activity level, alcohol intake, body mass index, diabetes, beta-blocker use, cigarette smoking and race. Weight cycling was not associated with an increased prevalence of CAD in this population.

CONCLUSIONS

Weight cycling is associated with lower HDL-C in women of a magnitude that is known to be associated with an increased risk of cardiac events as demonstrated in prior clinical trials.

Physical activity and functional capacity measurement in women: a report from the NHLBI-sponsored WISE study

Physical activity and functional capacity have not been assessed by questionnaire for criterion validity in women. We wished to evaluate the ability of a physical activity and a functional capacity assessment questionnaire to predict functional capacity measured by treadmill exercise stress testing, as well as correlate with cardiac risk factors and angiographic coronary artery disease (CAD) in women. In a National Heart, Lung and Blood Institute (NHLBI)-sponsored cross-sectional population study involving four academic medical centers, 476 women with cardiac risk factors undergoing coronary angiography for evaluation for suspected myocardial ischemia were enrolled in the Women's Ischemia Syndrome Evaluation (WISE). The main outcome measures were functional capacity measured during symptom-limited exercise treadmill testing, cardiac risk factors, and CAD, using core laboratory-determined measures. Physical activity measured by the Postmenopausal Estrogen and Progesterone Intervention physical activity questionnaire (PEPI-Q) and functional capacity measured by the Duke Activity Status Index (DASI) questionnaire, correlated with functional capacity measured in metabolic equivalents (METS), as estimated during symptom-limited exercise treadmill testing (r = 0.27, p = 0.001 and r = 0.31, p = 0. 0002, respectively). The DASI was a significant independent predictor of functional capacity even after adjustment for cardiac risk factors, and the PEPI-Q was not. The DASI and PEPI-Q scores were inversely associated with higher numbers and levels of cardiac risk factors, as well as angiographic CAD. The DASI questionnaire is a reasonable correlate of functional capacity achieved during symptom-limited treadmill exercise testing in women with suspected myocardial ischemia. Lower functional capacity or physical activity measured by the DASI and PEPI-Q, respectively, is associated with more prevalent cardiac risk factors and angiographic CAD. These findings suggest that the DASI and, to a lesser extent, the PEPI-Q have criterion validity for use in health-related research in women.

Impact of community intervention to reduce patient delay time on use of reperfusion therapy for acute myocardial infarction: rapid early action for coronary treatment (REACT) trial. REACT Study Group

BACKGROUND

Reperfusion therapy for acute myocardial infarction (AMI) is a time-dependent intervention that can reduce infarct-related morbidity and mortality. Out-of-hospital patient delay from symptom onset until emergency department (ED) presentation may reduce the expected benefit of reperfusion therapy.

OBJECTIVE

To determine the impact of a community educational intervention to reduce patient delay time on the use of reperfusion therapy for AMI.

METHODS

This was a randomized, controlled community-based trial to enhance patient recognition of AMI symptoms and encourage early ED presentation with resultant increased reperfusion therapy rates for AMI. The study took place in 44 hospitals in 20 pair-matched communities in five U.S. geographic regions. Eligible study subjects were non-institutionalized patients without chest injury (aged > or =30 years) who were admitted to participating hospitals and who received a hospital discharge diagnosis of AMI (ICD 410); n = 4,885. For outcome assessment, patients were excluded if they were without survival data (n = 402), enrolled in thrombolytic trials (n = 61), receiving reperfusion therapy >12 hours after ED arrival (n = 628), or missing symptom onset or reperfusion times (n = 781). The applied intervention was an educational program targeting community organizations and the general public, high-risk patients, and health professionals in target communities. The primary outcome was a change in the proportion of AMI patients receiving early reperfusion therapy (i.e., within one hour of ED arrival or within six hours of symptom onset). Trends in reperfusion therapy rates were determined after adjustment for patient demographics, presenting blood pressure, cardiac history, and insurance status. Four-month baseline was compared with the 18-month intervention period.

RESULTS

Of 3,013 selected AMI patients, 40% received reperfusion therapy. Eighteen percent received therapy within one hour of ED arrival (46% of treated patients), and 32% within six hours of symptom onset (80% of treated patients). No significant difference in the trends in reperfusion therapy rates was attributable to the intervention, although increases in early reperfusion therapy rates were noted during the first six months of the intervention. A significant association of early reperfusion therapy use with ambulance use was identified.

CONCLUSIONS

Community-wide educational efforts to enhance patient response to AMI symptoms may not translate into sustained changes in reperfusion practices. However, an increased odds for early reperfusion therapy use during the initiation of the intervention and the association of early therapy with ambulance use suggest that reperfusion therapy rates can be enhanced.

Age and sex differences in presentation of symptoms among patients with acute coronary disease: the REACT Trial. Rapid Early Action for Coronary Treatment

BACKGROUND

There are few data on possible age and sex differences in presentation of symptoms for patients with acute coronary disease.

OBJECTIVE

To investigate demographic differences in presentation of symptoms at the time of hospital presentation for acute myocardial infarction (AMI) and unstable angina.

METHODS

The medical records of patients who presented with chest pain and who also had diagnoses of AMI (n = 889) or unstable angina (n = 893) on discharge from 43 hospitals were reviewed as part of data collection activities of the Rapid Early Action for Coronary Treatment trial based in 10 pair-matched communities throughout the USA.

RESULTS

Dyspnea (49%), arm pain (46%), sweating (35%), and nausea (33%) were commonly reported by men and women of all ages in addition to the presenting complaint of chest pain. After we had controlled for various characteristics through regression modeling, older persons with AMI were significantly less likely than were younger persons to complain of arm pain and sweating, and men were significantly less likely to report vomiting than were women. Among persons with unstable angina, arm pain and sweating were reported significantly less often by elderly patients. Nausea and back, neck, and jaw pain were more common complaints of women.

CONCLUSIONS

Results of this study suggest that there are differences between symptoms at presentation of men and women, and those in various age groups, hospitalized with acute coronary disease. Clinicians should be aware of these differences when diagnosing and managing patients suspected to have coronary heart disease.

Effects of losartan and captopril on left ventricular volumes in elderly patients with heart failure: results of the ELITE ventricular function substudy

BACKGROUND

The mechanism by which angiotensin-converting enzyme inhibitors reduce mortality rates and disease progression in patients with heart failure is likely mediated in part through prevention of adverse ventricular remodeling. This study examined the effects of the angiotensin-converting enzyme inhibitor captopril and the angiotensin II type 1 receptor antagonist losartan on ventricular volumes and function in elderly patients with heart failure and reduced left ventricular ejection fraction (< or =40%).

METHODS

Patients underwent radionuclide ventriculograms (RVG) at baseline and were randomized to either captopril (n = 16) or losartan (n = 13). After 48 weeks, another RVG was obtained. Therapy was then withdrawn for at least 5 days, and the RVG was repeated while the patient was not receiving the drug.

RESULTS

At 48 weeks both captopril and losartan significantly reduced left ventricular (LV) end-diastolic volume index (135 +/- 26 to 128 +/- 23 mL/m(2) for losartan, P <.05 vs baseline; 142 +/- 25 to 131 +/- 20 mL/m(2) for captopril, P <.01; mean (SD). Captopril also reduced LV end-systolic volume index (98 +/- 24 to 89 +/- 21 mL/m(2), P <.01 vs. baseline), whereas a nonsignificant trend was observed for the losartan group (97 +/- 23 to 90 +/- 16 mL/m(2), P = not significant). The between-group differences in the changes in LV volumes were not statistically significant. After drug withdrawal, LV end-diastolic volume index remained significantly lower than baseline in the captopril group (P <.01).

CONCLUSIONS

Both captopril and losartan prevent LV dilation, representing adverse ventricular remodeling, previously seen with placebo treatment. Reverse remodeling was observed in the captopril group. On the basis of these results, the relative effects on LV remodeling do not provide a rationale for a survival benefit of losartan over captopril.

Effect of coronary angiography on use of lipid-lowering agents in women: a report from the Women's Ischemia Syndrome Evaluation (WISE) study. For the WISE Investigators

We sought to assess the impact of coronary angiography results on use of lipid-lowering agents among women enrolled in the Women's Ischemia Syndrome Evaluation [WISE] study. WISE is a multicenter study designed to evaluate new diagnostic modalities among women undergoing angiography for suspected coronary artery disease (CAD). History of atherosclerosis, risk factors for CAD, and low-density lipoprotein (LDL) cholesterol are determined at baseline. The percentage of women at LDL cholesterol goal, use of lipid-lowering agents, and eligibility for lipid-lowering therapy were determined based on National Cholesterol Education Program II guidelines at baseline and 6-week follow-up. Among the 212 women for whom angiographic data were available, 84 had known atherosclerosis, 80 had no history of atherosclerosis but > or =2 risk factors (high risk), and 48 had no history of atherosclerosis and <2 risk factors (low risk). At baseline, LDL cholesterol goals were met in 24% women with atherosclerosis, in 56% high-risk women, and in 88% low-risk women. Angiography revealed previously undiagnosed CAD in 70% of the high-risk and in 42% of the low-risk women. After angiography results were available, 6 women started lipid-lowering therapy and 2 stopped. Based on National Cholesterol Education Program II guidelines, 63 additional women would have been eligible for pharmacologic lipid-lowering therapy. Intensification of lipid-lowering therapy was not apparent 6 weeks after coronary angiography in women with newly diagnosed CAD or among women whose diagnosis was confirmed.

Correlates of high HDL cholesterol among women with coronary heart disease

BACKGROUND

The National Cholesterol Education Program (NCEP) has designated high-density lipoprotein cholesterol (HDL-C) > or =60 mg/dL a "negative" coronary heart disease (CHD) risk factor, but a substantial proportion of coronary events occur among women despite high HDL-C levels.

METHODS AND RESULTS

The objective of this study was to characterize postmenopausal women with prevalent CHD despite HDL-C > or =60 mg/dL and to identify factors that may attenuate the protective effect of high HDL-C. We analyzed baseline data from a randomized, double-blind study of estrogen/progestin replacement therapy in 2763 postmenopausal women <80 years old with CHD. Demographics, CHD risk factors, medications, anthropometrics, and lipid levels were compared among women with low, normal, and high HDL-C by NCEP criteria with and without stratification by use of lipid-lowering medications. Independent correlates of high HDL-C were determined by logistic regression analysis. HDL-C > or =60 mg/dL was present in 20% of participants. Women with high HDL-C were older, better educated, had fewer CHD risk factors, lower triglyceride levels and total cholesterol/HDL-C ratio, and were more likely to report past estrogen and current calcium antagonist, niacin, and statin use. beta-Blocker, diuretic, and fibrate use was less common. Older age, alcohol consumption, niacin, and calcium antagonist use and prior estrogen use were independently associated with high HDL-C, whereas waist-to-hip ratio, smoking, triglyceride level, and beta-blocker and fibrate use were inversely associated (all P <.05).

CONCLUSIONS

High HDL-C, as defined by the NCEP, occurred in 20% of women with CHD in this cohort without a concomitantly higher prevalence of other CHD risk factors. Redefinition of "high" HDL-C levels for women may be warranted.

Hormone replacement therapy in clinical cardiology

The relationship between coronary heart disease (CHD) and menopause remains controversial, but observational studies of hormone replacement therapy among postmenopausal women have found a lower risk of CHD among women taking postmenopausal estrogens or estrogen/progestin combination therapy. In contrast, the Heart and Estrogen/progestin Replacement Study (HERS) did not show any overall benefit of estrogen/progestin therapy over 4.1 years of follow-up in a sample of women with established CHD, despite the expected favorable changes in the participants' lipid profiles. There appeared to be an initial increase in CHD risk, but benefit with increasing duration of hormone use. More research on the relative benefits and risks of hormone replacement therapy in postmenopausal women is needed. For now, a cautionary approach to hormone replacement therapy appears warranted, at least among postmenopausal women with established coronary artery disease.

Referral patterns to a University-based cardiac rehabilitation program

Referral rates to our cardiac rehabilitation program among patients hospitalized for coronary heart disease were computed over an 18-month period. Only 8.7% of eligible patients were referred, suggesting that more education targeting physicians, patients, and insurers is needed and barriers to participation must be systematically addressed.

Knowledge of heart attack symptoms in a population survey in the United States: The REACT Trial. Rapid Early Action for Coronary Treatment

BACKGROUND

Greater use of thrombolysis for patients with myocardial infarction has been limited by patient delay in seeking care for heart attack symptoms. Deficiencies in knowledge of symptoms may contribute to delay and could be a target for intervention. We sought to characterize symptom knowledge.

METHODS

Rapid Early Action for Coronary Treatment is a community trial designed to reduce this delay. At baseline, a random-digit dialed survey was conducted among 1294 adult respondents in the 20 study communities. Two open-ended questions were asked about heart attack symptom knowledge.

RESULTS

Chest pain or discomfort was reported as a symptom by 89.7% of respondents and was thought to be the most important symptom by 56.6%. Knowledge of arm pain or numbness (67.3%), shortness of breath (50.8%), sweating (21.3%), and other heart attack symptoms was less common. The median number of correct symptoms reported was 3 (of 11). In a multivariable-adjusted model, significantly higher mean numbers of correct symptoms were reported by non-Hispanic whites than by other racial or ethnic groups, by middle-aged persons than by older and younger persons, by persons with higher socioeconomic status than by those with lower, and by persons with previous experience with heart attack than by those without.

CONCLUSIONS

Knowledge of chest pain as an important heart attack symptom is high and relatively uniform; however, knowledge of the complex constellation of heart attack symptoms is deficient in the US population, especially in low socioeconomic and racial or ethnic minority groups. Efforts to reduce delay in seeking medical care among persons with heart attack symptoms should address these deficiencies in knowledge.

[Predictors of readmission in patients with congestive heart failure]

Repeated hospitalizations among patients (pts) with congestive heart failure (CHF) are common.

PURPOSE

This retrospective study was designed to determine predictors of readmission.

METHODS

INCLUSION CRITERIA

admitted to University Hospital with a primary diagnosis of CHF between 10/1/94-9/30/95: lived in Jefferson county.

EXCLUSIONS

cardiac transplant during study period; major comorbidity (e.g. malignancy, advanced renal failure). Predictors of readmission were determined by stepwise logistic regression analysis and predictor of time to readmission with Cox Proportionate Hazards modeling p < 0.05 was considered statistically significant.

RESULTS

Mean age of the 237 pts was 66.5 yrs; 56% women. Mean left ventricular ejection fraction (LVEF) was 29%; 96% were in NYHA class III/IV. Mean length of stay was 5 days; 52 pts (22%) had > 1 admission. CHF etiologies: Ischemic (42%), hypertensive (37%), idiopathic (12%). Demographic characteristics and insurance status did not predict readmission risk. Predictors of readmission in the logistic and Cox models were similar. Increased risk of readmission was associated with myocardial ischemia (logistic OR 42.7), past NYHA Class III and IV (OR 32.8), plasmatic creatinine at discharge (OR 1.9) and continued smoking (OR 3.26). History of CABG was associated with a decreased risk of rehospitalization (OR 0.12). Beta-blocker use was associated with decreased risk, but did not achieve statistical significance. ACE-I use (prescribed in 78% of pts), did not contribute to the model. Diabetes Mellitus and a lower LVEF were more frequent in the readmitted group, but they did not predict readmission.

CONCLUSION

CHF pts who have evidence of ischemia, advanced symptoms, renal dysfunction, and who continue to smoke are at increased risk for hospital readmission. Pts with these characteristics should be identified prior to hospital discharge and considered for intensive outpatient intervention.

Better outcome for women compared with men undergoing coronary revascularization: a report from the bypass angioplasty revascularization investigation (BARI)

BACKGROUND

Numerous studies have shown that women undergoing coronary revascularization procedures do so at a higher risk for an adverse outcome compared with men. However, the impact of advances in technology and improvements in techniques on in-hospital and long-term outcome after revascularization in women is unclear.

METHODS AND RESULTS

We evaluated 1829 patients with symptomatic multivessel coronary disease randomized to CABG or PTCA in the Bypass Angioplasty Revascularization Investigation (BARI), of whom 27% were women. As expected, women were older (64.0 versus 60.5 years), with more congestive heart failure (14% versus 7%), hypertension (68% versus 42%), treated diabetes mellitus (31% versus 15%), and unstable angina (67% versus 61%) than men but had similar preservation of left ventricular function and extent of multivessel disease. Women assigned to surgery received the same number of total grafts but fewer internal mammary artery grafts (72% versus 85%, P<0. 01), and those assigned to angioplasty had more intended lesions (76% versus 71%, P<0.01) successfully dilated than men. At an average of 5.4 years' follow-up, crude mortality rates were similar in women (12.8%) and men (12.0%). The Cox regression model adjusting for baseline differences revealed that women had a significantly lower risk of death (relative risk, 0.60; 95% CI, 0.43 to 0.84; P=0. 003) but not a significantly lower risk of death plus myocardial infarction (relative risk, 0.84; 95% CI, 0.66 to 1.07; P=0.16) than men.

CONCLUSIONS

Although the unadjusted mortality rate suggests that women and men undergoing CABG and PTCA have a similar 5-year mortality, women have higher risk profiles; consequently, contrary to previous reports, female sex is an independent predictor of improved 5-year survival after we control for multiple risk factors.

Statistical design of REACT (Rapid Early Action for Coronary Treatment), a multisite community trial with continual data collection

Unusual problems in statistical design were faced by Rapid Early Action for Coronary Treatment (REACT), a multisite trial testing a community intervention to reduce the delay between onset of symptoms of acute myocardial infarction (MI) and patients' arrival at a hospital emergency department. In 20 pair-matched U.S. communities, hospital staff members recorded delay time throughout a 4-month baseline period and the subsequent 18-month intervention period, during which one randomly selected community of each pair received a campaign of public and professional education. To exploit the continual nature of its data-collection protocol, REACT estimated the trend of delay time separately in each community by linear regression, adjusting for age, sex, and history of MI, and compared the ten adjusted slopes from intervention communities with those from control communities by a paired t-test. Power calculations based on the analytical model showed that with K=600-800 cases per community, REACT would have 80% power to demonstrate a differential reduction of 30 min in mean delay time between intervention and control communities, as well as effects on a variety of secondary outcomes. Sensitivity analysis confirmed that the number of communities was optimal within constraints of funding and that the detectable effect depended weakly on the effectiveness of matching but strongly on K, helping the investigators set operational priorities. The methodologic strategy developed for REACT should prove useful in the design of similar trials in the future.

Coronary artery disease in diabetic and nondiabetic patients with lower extremity arterial disease: A report from the Coronary Artery Surgery Study Registry

OBJECTIVE

Patients with lower extremity arterial disease (LEAD) are at an increased risk of having coronary artery disease (CAD). Diabetics are at especially high risk for having LEAD with concomitant CAD. This study was undertaken (1) to define the clinical and arteriographic features associated with CAD among diabetics and nondiabetics with LEAD and (2) to determine the long-term survival and predictors of mortality of diabetics and nondiabetics with LEAD and CAD.

RESEARCH DESIGN AND METHODS

Two hundred sixty-three diabetics and 1137 nondiabetics from the Coronary Artery Surgery Study who had evidence of LEAD, who were 50 years and older, and who had arteriographically proven CAD were monitored for a mean of 12.8 years.

RESULTS

Among all the subjects with LEAD there was a high prevalence of current and past smoking, history of previous myocardial infarction, systemic hypertension, congestive heart failure, high degrees of angina pectoris and unstable angina pectoris, and use of beta-blockers. On arteriographic evaluation a high prevalence of three-vessel epicardial coronary disease and involvement of multiple coronary segments with > or =50% diameter narrowing was found. Multivariate analysis showed the number of coronary segments with >50% occlusion, the presence of cerebrovascular disease, the use of digitalis, and elevated systolic blood pressure were independently associated with diabetes. On follow-up diabetics had a significantly higher mortality rate (mostly cardiac) than nondiabetics: median survival, 8.1 years and 12.7 years, respectively. At 15 years the mortality rates were 77.1% and 62.0%, respectively. On multivariate analysis, age, number of coronary occlusions, number of significantly narrowed epicardial arteries, diminished myocardial contractility, hypertension, and smoking were significant predictors of mortality in the total group and in each subgroup. Coronary artery bypass grafting surgery was protective. The presence of diabetes was an independent risk factor for mortality.

CONCLUSIONS

The presence of LEAD is associated with multivessel epicardial and multiple coronary segment occlusion. On long-term follow-up there is a high mortality rate. In patients with LEAD and diabetes, CAD is especially severe and prognosis is poor.

Prognostic significance of myocardial ischemia detected by ambulatory electrocardiography, exercise treadmill testing, and electrocardiogram at rest to predict cardiac events by one year (the Asymptomatic Cardiac Ischemia Pilot [ACIP] study)

Myocardial ischemia identified by ambulatory electrocardiography (AECG), exercising treadmill testing, (ETT), or 12-lead electrocardiogram at rest is associated with an adverse prognosis, but the effect of improving these ischemic manifestations by treatment on outcome is unknown. The Asymptomatic Cardiac Ischemia Pilot (ACIP) study was a National Heart, Lung, and Blood Institute funded study to determine the feasibility of conducting a large-scale prognosis study and to assess the effect of 3 treatment strategies (angina-guided strategy, AECG ischemia-guided strategy, and revascularization strategy) in reducing the manifestations of ischemia as indicated by AECG and ETT. The study cohort for this database study consisted of 496 randomized patients who performed the AECG, ETT, and 12-lead electrocardiogram at rest at both the qualifying and week 12 visits. The effect of modifying ischemia by treatment on the incidence of cardiac events (death, myocardial infarction, coronary revascularization procedure, or hospitalization for an ischemic event) at 1 year was examined. In the 2 medical treatment groups (n = 328) there was an association between the number of ambulatory electrocardiographic ischemic episodes at the qualifying visit and combined cardiac events at 1 year (p = 0.003). In the AECG ischemia-guided patients there was a trend associating greater reduction in the number of ambulatory electrocardiographic ischemia episodes with a reduced incidence of combined cardiac events (r = -0.15, p = 0.06). In the revascularization strategy patients this association was absent. In the medical treatment patients the exercise duration on the baseline ETT was inversely associated with an adverse prognosis (p = 0.02). The medical treatment strategies only slightly improved the exercise time and the exercise duration remained of prognostic significance. In the revascularization group strategy patients this association was absent. Thus, myocardial ischemia detected by AECG and an abnormal ETT are each independently associated with an adverse cardiac outcome in patients subsequently treated medically.

Coronary artery disease in diabetic patients with lower-extremity arterial disease: disease characteristics and survival. A report from the Coronary Artery Surgery Study (CASS) registry

OBJECTIVE

Patients who have diabetes and lower-extremity arterial disease (LEAD) are at an increased risk of dying from coronary artery disease (CAD). This study was undertaken to: 1) define the clinical and arteriographic factors associated with LEAD among diabetic patients; 2) determine the long-term survival and predictors of mortality of diabetic patients with LEAD, compared to those without LEAD; and 3) determine if the presence of LEAD is an independent risk factor for mortality among diabetic patients with CAD.

RESEARCH DESIGN AND METHODS

A total of 263 diabetic patients from the Coronary Artery Surgery Study (CASS) registry with LEAD, who were > or = 50 years of age, and who had arteriographically proven CAD, were identified and followed for a mean of 12.8 years. A total of 1,349 comparably aged diabetic patients from the CASS registry with CAD and no evidence of LEAD were followed for an equivalent period of time.

RESULTS

Compared with diabetic patients without LEAD, diabetic patients with LEAD were characterized by the presence of cerebrovascular disease, a high rate of current smoking, elevated systolic blood pressure, high grades of angina pectoris, and digitalis use. Severity of epicardial CAD and extent of CAD were not independent predictors of the presence of LEAD. On follow-up, diabetic patients with LEAD had significantly higher mortality (mostly cardiovascular) than diabetic patients without LEAD, with a median survival of 8.1 and 10.9 years, respectively. On multivariate analysis, age, the number of significantly narrowed coronary arteries, and the presence of left ventricular dysfunction predicted mortality in both subsets of diabetic patients. Among all the diabetic patients with CAD, the presence of LEAD was an independent risk factor for mortality.

CONCLUSIONS

Diabetic patients with LEAD have a higher mortality rate (mostly cardiovascular) than diabetic patients without LEAD, despite no apparent anatomic differences in the severity and extent of CAD. This suggests that factors associated with the presence of LEAD, other than the anatomy of the coronary circulation, may play a role in determining survival among diabetic patients with LEAD and CAD.

Adherence to National Cholesterol Education Program Treatment goals in postmenopausal women with heart disease. The Heart and Estrogen/Progestin Replacement Study (HERS). The HERS Research Group

OBJECTIVES

To determine the proportion of volunteer women with established heart disease who have low-density lipoprotein cholesterol (LDL-C) levels at or below the National Cholesterol Education Program Adult Treatment Panel goals and to determine what factors are associated with levels above goal or not receiving lipid-lowering medication when indicated.

DESIGN

Cross-sectional measurement of lipids and lipoproteins, blood pressure, height, weight, and other demographic and cardiovascular risk factors in 2763 postmenopausal women with heart disease.

SETTING

At 18 centers throughout the United States, participants were recruited by means of lists of women with coronary heart disease from coronary units and catheterization laboratories, direct mail to age-eligible women, and advertisements.

PATIENTS

Mean age of the cohort was 66.7 years (range, 44-79 years) and the distribution by race/ethnicity was 88.7% white, 7.9% African American, 2.0% Hispanic/Latina, 0.8% Asian/Pacific Islander, and 0.7% other.

INTERVENTION

We report cross-sectional analysis of the cohort at baseline.

OUTCOME MEASURES

We measured the frequency of achieving 1988 and 1993 Adult Treatment Panel treatment goals, and of being on a regimen of lipid-lowering medication.

RESULTS

Although 47% of participants were taking a lipid-lowering medication, 63% did not meet the 1988 treatment goal of LDL-C level less than 3.4 mmol/L (130 mg/dL) and 91% did not meet the 1993 goal of LDL-C level less than 2.6 mmol/L (100 mg/dL). Factors independently associated with achieving the earlier goal were use of lipid-lowering medication, marital status, education, body mass index, exercise, hypertension, diabetes, gallbladder disease, and first diagnosis of coronary heart disease after 1990. Failure to use lipid-lowering medication was associated with age, being African American, marital status, body mass index, lack of exercise, alcohol consumption, current smoking, and first diagnosis of coronary heart disease before 1985.

CONCLUSION

The majority of women enrolled in the trial had LDL-C levels that significantly exceeded the treatment goals set by the 1988 and 1993 Adult Treatment Panel guidelines. Better implementation of these guidelines among women with coronary disease would be highly desirable.

Platelet activation and restenosis after coronary stenting: flow cytometric detection of wound-induced platelet activation

BACKGROUND

Platelet activation has been implicated in restenosis after percutaneous transluminal coronary angioplasty (PTCA), but previous studies may have been confounded by factors such as elastic recoil and arterial remodelling. Restenosis after coronary stenting is unlikely to be affected by these factors.

METHODS

Forty-nine patients who had stenting for acute or impending closure after PTCA were included in the study. Patients with restenosis (> or = 50% stenosis by angiography) and without restenosis were selected using a case-control design. Restenosis was determined by the caliper method. Patients were tested for platelet activation 1-4 years after their procedure while taking their usual medications (including aspirin). Reliability testing was conducted with 11 healthy subjects. Platelet activation was measured in blood leaving a bleeding-time wound (wound-induced platelet activation), using flow cytometry. Blood was collected from the wound site 1 and 2 min after the incision. Monoclonal antibodies were used to test for activation of glycoprotein (GP) IIb/IIIa (PAC-1), GPIIb/IIIa ligand binding (anti-ligand-induced binding site 1: anti-LIBS-1), and P-selectin expression (AC1.2).

RESULTS

Short-term intersample reliability was very good to excellent for anti-LIBS-1 and AC1.2 (intraclass correlation coefficients 0.79-0.96), but only fair for PAC-1. Patients with restenosis (n = 25) had greater activation in all measures than patients without restenosis (n = 24); the difference was significant for GPIIb/IIIa ligand binding at 1 min (P = 0.03). The correlation between GPIIb/IIIa ligand binding at 1 min and percent stenosis at follow-up was also significant (P = 0.03). Patients taking nitrates had lower activation; after eliminating these patients, GPIIb/IIIa ligand binding was greater among patients with restenosis at both 1 and 2 min (P = 0.04 for both).

CONCLUSIONS

The results suggest that increased GPIIb/IIIa ligand binding may be associated with restenosis after coronary stenting. The results also suggest that the wound-induced platelet activation method is a reliable and valid measure of platelet activity.

Factors limiting the enrollment of women in a randomized coronary artery disease trial. The Asymptomatic Cardiac Ischemia Pilot Study (ACIP) Investigators

BACKGROUND AND HYPOTHESIS

Although it is recognized that women have been underrepresented in clinical trials of cardiovascular disease, the reasons for their limited enrollment have not been elucidated.

METHODS

A prospective tracking system was established in the Asymptomatic Cardiac Ischemia Pilot study (ACIP) to monitor recruitment and identify protocol issues that interfered with the recruitment of women. Patients with stress test evidence for ischemia during the course of routine clinical care were screened for asymptomatic ischemia with an ambulatory electrocardiogram (ECG).

RESULTS

Those with at least one episode of asymptomatic ischemia and angiographic evidence of coronary artery disease suited for revascularization could be randomized. Women comprised only 17% of the 1,820 patients screened for asymptomatic ischemia, and only 14% of the 558 patients randomized. The limited number of women screened for ischemia was largely due to the limited number of women (25% of all patients) found to have test evidence for ischemia or coronary artery disease suited for revascularization during the course of routine clinical care. Once patients were identified as having ischemia on stress test and ambulatory ECG, the major difference in eligibility was the difference in disqualifying angiograms, occurring 21/2 times as frequently in women as in men (p < 0.001).

CONCLUSION

The percentage of women recruited was lower than the prevalence of ischemic heart disease in the general population because at participating centers (1) women were found to have ischemia less often than men during the course of routine clinical care, and (2) screening tests for ischemia were less predictive of protocol-defined coronary disease in women than in men.