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Despite its proven efficacy, low cost, and wide availability, aspirin remains underused. We examined current aspirin use and determined factors that influence its use among outpatients in the United States (US). The REduction of Atherothrombosis for Continued Health (REACH) Registry is an international, prospective, longitudinal study of >68,000 outpatients with established atherothrombosis or ≥3 atherothrombotic risk factors. The rates of aspirin use were compared in various patient subgroups. Multivariate logistic regression models were constructed to determine the factors influencing the baseline use of aspirin and other antithrombotic agents in the US population. Approximately 70% of 25,686 US outpatients were treated with aspirin, with greater use in the Midwest and among men, whites, and those aged <65 years. Among aspirin users, 18% took other antiplatelet agents and 6% took oral anticoagulants. Low-dose aspirin (≤100 mg/day) was used in approximately 2/3 of aspirin users. Of patients not taking aspirin, 1/2 were receiving oral anticoagulants or other antiplatelet agents. However, 15% of patients used no antithrombotic agent at all. Female gender, current smoking, or having diabetes mellitus were predictors of a lack of antithrombotic use; white race, atrial fibrillation or vascular disease, the use of other risk-reducing medications, or treatment by a cardiologist were associated with a greater likelihood of receiving antithrombotic therapy. In conclusion, approximately 1/4 of US patients with vascular disease are not treated with aspirin for secondary prevention, and 15% are not treated with any antithrombotic agent. [Copyright &y& Elsevier]

Severe mitral regurgitation (MR), whether isolated or with coronary disease, was associated with adverse clinical outcomes. However, clinician practice is characterized by different thresholds for treatment. No data exist that described current practice patterns, factors that affected these patterns, or whether physicians followed American College of Cardiology/American Heart Association guidelines in clinical practice for patients with MR. Cardiovascular specialists were surveyed using e-mail, and 1,076 physicians completed the survey (71% response rate), including adult cardiologists (94%) and cardiac surgeons (5%) who practiced in the United States (78%), Canada (5%), and other nations (17%). Wide variations were noted regarding rates of referral of asymptomatic patients with severe MR for mitral valve repair. There was geographic and specialty-dependent heterogeneity in practice. Most physicians (65%) used medications to delay the progression of MR in the absence of guideline recommendations. A minority (28%) of respondents routinely quantitated MR by calculating the effective regurgitant orifice area. In patients undergoing percutaneous coronary intervention, MR severity was not assessed before the procedure by 1 in 4 providers, and the presence of MR frequently did not affect clinical care decisions. In conclusion, considerable variability existed in the clinical management of MR, particularly regarding referral of asymptomatic patients for mitral valve reparative surgery. Medications were frequently used to treat asymptomatic patients with MR in the absence of evidence of pharmacologic efficacy. MR was frequently not considered a relevant factor before treatment of patients with coexistent coronary artery disease. [Copyright &y& Elsevier]

In patients with symptomatic coronary heart disease, skin cholesterol (SC) content is associated with the presence and extent of coronary artery disease; however, its relation to subclinical arterial disease in asymptomatic patients is unknown. The purpose of this study was to determine the relations between SC and carotid intima–media thickness (CIMT) in asymptomatic subjects across a wide range of cardiovascular risk. SC was measured using a noninvasive assay. CIMT and carotid plaque presence were determined by high-resolution B-mode ultrasound. Associations among SC, CIMT, carotid plaque presence, and cardiovascular risk factors were evaluated by multivariable logistic regression analyses. SC and CIMT were measured in 565 asymptomatic subjects (57 ± 10 years of age, 38% women) from 6 sites in North America. The mean Framingham 10-year cardiovascular risk was 8.4 ± 7.2%. A 10-U increase in SC was associated with a 12% increase in the odds of having increased CIMT (p = 0.006) and a 15% increase in carotid plaque presence (p = 0.002). Odds ratios (95% confidence intervals) associated with SC >110 U were 2.19 (1.25 to 3.85, p = 0.006) for increased CIMT and 2.89 (1.61 to 5.19, p <0.001) for carotid plaque presence. In conclusion, SC identified the presence of advanced subclinical atherosclerosis. The relations among increasing SC, increasing CIMT, and carotid plaque presence were consistent across all levels of cardiovascular risk and were independent of cardiovascular risk factors. SC may be a useful test for cardiovascular risk prediction. [Copyright &y& Elsevier]