Search

The extent to which angina pectoris (AP) predicts secondary cardiovascular events beyond independent of measures of disease severity is unknown. We evaluated the association between AP frequency and secondary events in patients with stable coronary heart disease (CHD). We administered the Seattle Angina Questionnaire to 1,023 participants with stable CHD enrolled from September 2000 to December 2002 and followed for a median of 8.9 years. We used Cox proportional hazards to evaluate the association of AP frequency with death and subsequent hospitalization for AP, revascularization, myocardial infarction (MI), or heart failure. At enrollment, 633 (62%) participants reported no AP, 279 (27%) reported monthly AP, and 111 (11%) reported daily or weekly AP. During follow-up, 396 participants died, 204 were hospitalized for AP, 194 for revascularization, 140 for MI, and 188 for heart failure. Compared with participants without AP, participants with daily or weekly AP were more likely to be hospitalized for AP (hazard ratio [HR] 3.3; 95% confidence interval [CI] 2.3 to 4.7; p <0.001), revascularization (HR 2.0; 95% CI 1.3 to 2.9; p = 0.001), or heart failure (HR 1.6; 95% CI 1.0 to 2.5; p = 0.03) and more likely to die (HR 1.5; 95% CI 1.1 to 2.0; p = 0.01). AP was not independently associated with MI (HR 1.3; 95% CI 0.8 to 2.3; p = 0.29). After adjusting for demographics, co-morbidities, treadmill exercise capacity, ejection fraction, and inducible ischemia, frequency of AP remained independently associated with hospitalization for AP (HR 2.4; 95% CI 1.6 to 3.6; p <0.001), revascularization (HR 1.7; 95% CI 1.1 to 2.7; p = 0.02), and death (HR 1.4; 95% CI 1.0 to 2.0; p = 0.045). In conclusion, in outpatients with stable CHD, AP frequency predicts higher rates of secondary cardiovascular events and death, independent of objective measures of disease severity. [ABSTRACT FROM AUTHOR]

Many patients undergo elective coronary angiography without preprocedural stress testing that may be suitable if performed in patients with more angina pectoris or more frequently identified obstructive coronary artery disease (CAD). Patients in the National Cardiovascular Data Registry CathPCI Registry undergoing elective coronary angiography from July 2009 to April 2013 were assessed for differences in angina (Canadian Cardiovascular Society [CCS] class) and severity of obstructive CAD in those with and without preprocedural stress testing, stratified by CAD history. Given the large sample size, differences were considered clinically meaningful if the standardized difference (SD) was >10%. Of 790,601 patients without CAD history, 36.9% did not undergo preprocedural stress testing. Compared with patients with preprocedural stress testing, patients without preprocedural stress testing were more frequently angina free (CCS class 0; 28.2% with stress test vs 38.5% without, SD = 14.8%) and had similar rates of obstructive CAD (40.1% with stress test vs 35.7% without, SD = 9.0). Of 449,579 patients with CAD history, 44.2% did not undergo preprocedural stress testing. Patients without preprocedural stress testing reported more angina (CCS class III/IV angina: 17.8% vs 13.4%; SD = 11.3%) but were not more likely to have obstructive CAD (78.7% vs 81.1%; SD = 5.8%) than patients with preprocedural stress testing. In conclusion, approximately 40% of patients undergoing elective coronary angiography did not have preprocedural risk stratification with stress testing. For these patients, the clinical decision to proceed directly to invasive evaluation was not driven primarily by severe angina and did not result in higher detection rates for obstructive CAD. [ABSTRACT FROM AUTHOR]

We explored the safety and quality-of-life consequences of treating patients with stable coronary disease and high-risk features initially with optimal medical therapy (OMT) alone compared to OMT plus percutaneous coronary intervention. This was a post hoc analysis of Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial patients. We defined high risk as the onset of Canadian Cardiovascular Society class III angina within 2 months or stabilized acute coronary syndrome within 2 weeks of enrollment. The primary end point was death or myocardial infarction after 4.6 years. Of the 2,287 patients enrolled in the COURAGE trial, 264 (12%) were high risk and had a relative risk of 1.56 for death or myocardial infarction (p = 0.0008) compared to those with non–high-risk features. A total of 35 primary events occurred in the OMT group and 32 in the percutaneous coronary intervention plus OMT group (hazard ratio 1.11, 95% confidence interval 0.69 to 1.79; p = 0.68). No significant difference was found in the prevalence of angina between the 2 groups at 1 year. During the first year of follow-up, 30% of the OMT patients crossed over to the revascularization group. In conclusion, an initial strategy of OMT alone for high-risk patients in the COURAGE trial did not result in increased death or myocardial infarction at 4.6 years or worse angina at 1 year, but it was associated with a high rate of crossover to revascularization. [Copyright &y& Elsevier]

Angina pectoris (AP) is a treatable symptom that is associated with mortality and decreased quality of life. The prevalence and predictors of AP 1 month after a myocardial infarction (MI), a time when additional treatments might be offered, have not been described. We prospectively enrolled 2,094 patients with MI from 19 centers in the United States and evaluated angina symptoms 1 month after discharge with the Seattle Angina Questionnaire. Multivariable logistic regression analysis was performed to identify patient and treatment characteristics associated with 1-month AP. At 1 month, 571 patients (27.3%) had AP. Women (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.09 to 1.74), younger patients (OR 1.33 per 10-year increment, 95% CI 1.20 to 1.47), those with previous coronary artery bypass (OR 1.47, 95% CI 1.05 to 2.05), smokers (OR 1.35, 95% CI 1.09 to 1.77), and those who developed postinfarct AP during the index hospitalization (OR 1.85, 95% CI 1.20 to 2.65) were more likely to have AP at follow-up. In contrast, patients who were treated with coronary artery bypass surgery during their index admission were less likely to have AP at 1 month (OR 0.5, 95% CI 0.33 to 0.77). The strongest correlate was the frequency of AP before patients’ MI. Compared with those without AP before MI, those with AP <1 time per week (OR 1.86, 95% CI 1.45 to 2.41), weekly (OR 4.24, 95% CI 3.09 to 5.82), and daily (OR 6.12, 95% CI 3.62 to 10.3) were more likely to have AP 1 month later. In conclusion, >1 in 4 patients reported AP 1 month after an MI. [Copyright &y& Elsevier]

Although chronic obstructive pulmonary disease (COPD) is common in patients with myocardial infarction (MI), its association with long-term mortality after MI is controversial and little is known about its influence on patients’ health status (symptoms, function, and quality of life). We prospectively enrolled 2,481 patients presenting with MI at 19 United States centers to examine the relations between COPD and patients’ long-term mortality, rehospitalization rates, and health status after MI. Patients were administered the disease-specific Seattle Angina Questionnaire and the generic Short Form 12 at baseline and 1 year later. COPD was common (15.6% of patients) and was associated with a substantially greater risk of 1-year mortality (15.8% vs 5.7%, p <0.001) and rehospitalization (48.7% vs 38.6%, p <0.001). After extensive adjustment for baseline differences, patients with COPD had a twofold greater 1-year mortality rate (hazard ratio 2.00, 95% confidence interval [CI] 1.44 to 2.79) and higher rehospitalization rates (hazard ratio 1.22, 95% CI 1.01 to 1.48). Similarly, adjusted 1-year health status was worse in patients with COPD, with lower 1-year Seattle Angina Questionnaire quality-of-life score (−2.53 points, 95% CI −0.25 to −4.81) and Short Form 12 physical component score (−1.83 points, 95% CI −0.43 to −3.24). In addition, COPD was associated with a trend toward a greater prevalence of angina at 1 year (risk ratio 1.12, 95% CI 0.89 to 1.41). In conclusion, patients with COPD have greater mortality, higher rehospitalization rates, and poorer health status 1 year after a MI. Although additional research is needed, clinicians should recognize that patients with COPD are at high risk for poor outcomes after MI. [Copyright &y& Elsevier]

This study surveyed all cardiologists in a large coalition of cardiology groups. A 1-page, 25-item anonymous questionnaire containing 3 sections (demographics, medical history, and current medications and supplements) was used. Data from returned questionnaires were analyzed and compared with those in national databases. Eight hundred surveys were sent, and complete data were available for analysis on 471 (59%). The average age of the participants was 48.6 years; 7.1% were women. The average body mass index (BMI) was 25 kg/m2, and 8% were obese (BMI ≥30 kg/m2); 1.3% were active smokers; 89% exercised ≥1 time/week; and 72% had ≥1 alcoholic drink/week. Red wine was the most frequently consumed alcoholic beverage. Associated cardiovascular risks included dyslipidemia (28%), hypertension (14%), and diabetes mellitus (0.6%). Four percent had experienced coronary events. Compared with matched cohorts from the United States (US) population, cardiologists reported lower rates of hypertension, dyslipidemia, and diabetes mellitus, and the rates of smoking and obesity were 1/18 and 1/3 those of the US population, respectively. Aspirin and statins were each taken daily by about 1/3 of the participants. A cardiologist with dyslipidemia was 5 times as likely to be treated and a cardiologist with hypertension was almost twice as likely to be treated as an American adult man with either of these disorders, respectively. In conclusion, cardiologists appear to follow healthier lifestyles than the general adult US population. [Copyright &y& Elsevier]

Deficiency in 25-hydroxyvitamin D (25[OH]D) is a treatable condition that has been associated with coronary artery disease and many of its risk factors. A practical time to assess for 25(OH)D deficiency, and to initiate treatment, is at the time of an acute myocardial infarction. The prevalence of 25(OH)D deficiency and the characteristics associated with it in patients with acute myocardial infarction are unknown. In this study, 25(OH)D was assessed in 239 subjects enrolled in a 20-hospital prospective myocardial infarction registry. Patients enrolled from June 1 to December 31, 2008, had serum samples sent to a centralized laboratory for analysis using the DiaSorin 25(OH)D assay. Normal 25(OH)D levels are ≥30 ng/ml, and patients with levels <30 and >20 ng/ml were classified as insufficient and those with levels ≤20 ng/ml as deficient. Vitamin D levels and other baseline characteristics were analyzed with the linear or Mantel-Haenszel trend test. Of the 239 enrolled patients, 179 (75%) were 25(OH)D deficient and 50 (21%) were insufficient, for a total of 96% of patients with abnormally low 25(OH)D levels. No significant heterogeneity was observed among age or gender subgroups, but 25(OH)D deficiency was more commonly seen in non-Caucasian patients and those with lower social support, no insurance, diabetes, and lower activity levels. Higher parathyroid hormone levels (45.3 vs 32.7 pg/ml, p = 0.029) and body mass indexes (31.2 vs 29.0 kg/m2, p = 0.025) were also observed in 25(OH)D-deficient subjects. In conclusion, vitamin D deficiency is present in almost all patients with acute myocardial infarction in a multicenter United States cohort. [ABSTRACT FROM AUTHOR]

This prospective study assessed whether gender differences in health insurance help explain gender differences in delay in seeking care for patients in the US, with acute myocardial infarction (AMI). We also assessed gender differences in such prehospital delay for AMI in Spain, a country with universal insurance. We used data from 2,951 US and 496 Spanish patients aged 18 to 55 years with AMI. US patients were grouped by insurance status: adequately insured, underinsured, or uninsured. For each country, we assessed the association between gender and prehospital delay (symptom onset to hospital arrival). For the US cohort, we modeled the relation between insurance groups and delay of >12 hours. US women were less likely than men to be uninsured but more likely to be underinsured, and a larger proportion of women than men experienced delays of >12 hours (38% vs 29%). We found no association between insurance status and delays of >12 hours in men or women. Only 17.3% of Spanish patients had delays of >12 hours, and there were no significant gender differences. In conclusion, women were more likely than men to delay, although it was not explained by differences in insurance status. The lack of gender differences in prehospital delays in Spain suggests that these differences may vary by health care system and culture. [ABSTRACT FROM AUTHOR]

The impact of baseline exercise capacity on clinical outcomes in patients with stable ischemic heart disease randomized to an initial strategy of optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) in the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial has not been studied. A post hoc analysis was performed in 1,052 patients of COURAGE (PCI + OMT: n = 527, OMT: n = 525) who underwent exercise treadmill testing at baseline. Patients were categorized into 2 exercise capacity groups based on metabolic equivalents (METs) achieved during baseline exercise treadmill testing (<7 METs: n = 464, ≥7 METs: n = 588) and were followed for a median of 4.6 years. The primary composite end point of death or myocardial infarction was similar in the PCI + OMT group and the OMT group for patients with exercise capacity <7 METs (19.1% vs 16.1%, p = 0.31) and ≥7 METs (13.3% vs 10.3%, p = 0.27). After adjusting for baseline covariates, the hazard ratio (99% confidence interval) for the primary end point for the PCI + OMT group versus the OMT group was 1.42 (0.90 to 2.23, p = 0.05) and for the exercise capacity subgroups of ≥7 METs and <7 METs was 0.75 (0.46 to 1.22, p = 0.13). There was no statistically significant interaction between the original treatment arm allocation (PCI + OMT vs OMT) and baseline exercise capacity. In conclusion, there was no difference in the long-term clinical outcomes in patients with exercise capacity <7 METs compared with ≥7 METs, irrespective of whether they were assigned to initial PCI. Patients with exercise capacity <7 METs did not derive a proportionately greater clinical benefit from PCI + OMT compared with those patients who received OMT alone. [ABSTRACT FROM AUTHOR]

Establishing the validity of appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) in the setting of stable ischemic heart disease can support their adoption for quality improvement. We conducted a post hoc analysis of 2,287 Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial patients with stable ischemic heart disease randomized to PCI with optimal medical therapy (OMT) or OMT alone. Within appropriateness categories, we compared rates of death, myocardial infarction, revascularization subsequent to initial therapy, and angina-specific health status as determined by the Seattle Angina Questionnaire in patients randomized to PCI + OMT to those randomized to OMT alone. A total of 1,987 patients (87.9%) were mapped to the 2012 publication of the AUC, with 1,334 (67.1%) classified as appropriate, 551 (27.7%) uncertain, and 102 (5.1%) as inappropriate. There were no significant differences between PCI and OMT alone in the rate of mortality and myocardial infarction by appropriateness classification. Rates of revascularization were significantly lower in patients initially receiving PCI + OMT who were classified as appropriate (hazard ratio 0.65; 95% confidence interval 0.53 to 0.80; p <0.001) or uncertain (hazard ratio 0.49; 95% confidence interval 0.32 to 0.76; p = 0.001). Furthermore, among patients classified as appropriate by the AUC, Seattle Angina Questionnaire scores at 1 month were better in the PCI-treated group compared with the medical therapy group (80 ± 23 vs 75 ± 24 for angina frequency, 73 ± 24 vs 68 ± 24 for physical limitations, and 68 ± 23 vs 60 ± 24 for quality of life; all p <0.01), with differences generally persisting through 12 months. In contrast, health status scores were similar throughout the first year of follow-up in PCI + OMT patients compared with OMT alone in patients classified as uncertain or inappropriate. In conclusion, these findings support the validity of the AUC in efforts to improve health care quality through optimal use of PCI. [ABSTRACT FROM AUTHOR]

Excess dosing of anticoagulant agents has been linked to increased risk of bleeding after percutaneous coronary intervention (PCI) for women compared with men, but these studies have largely included older patients. We sought to determine the prevalence and gender-based differences of excess dosing of anticoagulants including glycoprotein IIb/IIIa inhibitors, bivalirudin, and unfractionated heparin in young patients with acute myocardial infarction who underwent PCI and to examine its association with bleeding. Of 2,076 patients enrolled in the Variation in Recovery: Role of Gender on Outcomes of Young Acute Myocardial Infarction Patients study who underwent PCI, we abstracted doses of unfractionated heparin, bivalirudin, and glycoprotein IIb/IIIa inhibitors administered during PCI from the medical records. At least 47.2% received at least 1 excess dose of an anticoagulant, which did not differ by gender. We used logistic regression to determine the predictors of excess dosing and the association of excess dosing with bleeding. In multivariable analysis, only lower body weight and younger age were significant predictors of excess dosing. Bleeding was higher in young women who received excess dosing versus those who did not (9.3% vs 6.0%, p = 0.03) but was comparable among men (5.2% vs 5.9%, p = 0.69) in univariate analysis. In multivariable analysis, there was a trend to an association between excess dosing and bleeding (odds ratio 1.33, 95% confidence interval 0.92 to 1.91) although not statistically significant. In conclusion, approximately half of the patients received excess dosing of anticoagulant drugs during PCI, which did not vary based on gender. There was a trend toward an association between excess dosing and increased bleeding, although not statistically significant. [ABSTRACT FROM AUTHOR]

Intensive statin therapy is a central component of secondary prevention after acute myocardial infarction (AMI), particularly among high-risk patients, such as those with diabetes mellitus (DM). However, the frequency and predictors of intensive statin therapy use after AMI among patients withDMhave not been described. We examined patterns of intensive statin therapy use (defined as a statin with expected low-density lipoprotein cholesterol lowering of >50%) at discharge among patientswithAMIwithknownDMenrolled in a 24-siteUSregistry. Predictors of intensive statin therapy use were evaluated using multivariable hierarchical Poisson regression models. Among 1,300 patients with DM after AMI, 22% were prescribed intensive statin therapy at hospital discharge. Inmultivariablemodels, ST-elevationAMI (risk ratio [RR] 1.48, 95% confidence interval [CI] 1.29 to 1.70), insurance for medications (RR 1.28, 95% CI 1.00 to 1.63), and higher low-density lipoprotein cholesterol levels (RR1.05 per 1mg/dl, 95%CI 1.02 to 1.07) were independent predictors of intensive statin therapy, whereas higher Global Registry of Acute Coronary Events scores were associated with lower rates of intensive statin therapy (RR0.94 per 10 points, 95%CI 0.91 to 0.98). In conclusion, only 1 in 5 patients withDM was prescribed intensive statin therapy at discharge after an AMI. Predictors of intensive statin therapy use suggest important opportunities to improve quality of care in this patient population. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) is an important clinical co-morbidity that increases the risk of death and myocardial infarction in patients with coronary artery disease (CAD) even when treated with guideline-directed therapies. It is unknown, however, whether CKD influences the effects of CAD treatments on patients' health status, their symptoms, function, and quality of life. We performed a post hoc analysis of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study to compare health status in patients with stable CAD with and without CKD defined as a glomerular filtration rate of <60 ml/min/1.73 m² randomized to either percutaneous coronary intervention (PCI) and optimal medical therapy (OMT) or OMT alone. Health status was measured at baseline, 1, 3, 6, 12, 24, and 36 months of follow-up with the Seattle Angina Questionnaire in 310 patients with CKD and 1,719 patients without CKD. Linear mixed-effects models were used to analyze Seattle Angina Questionnaire scores longitudinally. Mean scores for angina-related quality of life, angina frequency, and physical limitation domains improved from baseline values in both patients with and without CKD and plateaued. Early improvement (1 to 6 months) was more common in patients treated with PCI plus OMT than with OMT alone in both patients with and without CKD. Treatment satisfaction scores were high at baseline in all groups and did not change significantly over time. In conclusion, although CKD is an important determinant of event-free survival in patients with stable CAD, it neither precludes satisfactory treatment of angina with PCI plus OMT or OMT alone nor is it associated with an unsatisfactory quality of life. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is an independent predictor of mortality after acute myocardial infarction (AMI). We analyzed the relation between biomarkers linked to myocardial stretch (NT-pro-brain natriuretic peptide [NT-proBNP]), myocardial damage (Troponin-T [TnT]), and inflammation (high-sensitivity C-reactive protein [hs-CRP]) and new-onset AF during AMI to identify patients at high risk for AF. In a prospective multicenter registry of AMI patients (from the Translational Research Investigating Underlying disparities in recovery from acute Myocardial infarction: Patients' Health status registry), we measured NT-proBNP, TnT, and hs-CRP in patients without a history of AF (n = 2,370). New-onset AF was defined as AF that occurred during the index hospitalization. Hierarchical multivariate logistic regression models were used to determine the association of biomarkers with new-onset AF, after adjusting for other covariates. New-onset AF was documented in 114 patients with AMI (4.8%; mean age 58 years; 32% women). For each twofold increase in NT-proBNP, there was an 18% increase in the rate of AF (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.03 to 1.35; p <0.02). Similarly, for every twofold increase in hs-CRP, there was a 15% increase in the rate of AF (OR 1.15, 95% CI 1.02 to 1.30; p=0.02). TnT was not independently associated with new-onset AF (OR 0.96, 95% CI 0.85 to 1.07; p = 0.3). NT-proBNP and hs-CRP were independently associated with new in-hospital AF after MI, in both men and women, irrespective of race. Our study suggests that markers of myocardial stretch and inflammation, but not the amount of myocardial necrosis, are important determinants of AF in the setting of AMI. [ABSTRACT FROM AUTHOR]

Frailty is a geriatric syndrome characterized by functional impairments and is associated with poor outcomes; however, the prevalence of frailty and its association with health status in patients treated with percutaneous coronary intervention (PCI) are unknown. To assess the prevalence of frailty and its association with health status in PCI-treated patients, we studied 629 patients ≥65 years old undergoing PCI from October 2005 through September 2008. Frailty was characterized using the Fried criteria: weight loss >10 lbs. in previous 1 year, exhaustion, low physical activity, poor gait speed, and poor grip strength (3 features = frail; 1 feature to 2 features = intermediate frailty; 0 feature = not frail). Health status was assessed using the Short-Form 36 and the Seattle Angina Questionnaire (SAQ). Multivariable linear regression models were used to estimate the independent association between frailty and health status. Complete data on 545 patients demonstrated that 19% (n = 117) were frail, 47% (n = 298) had intermediate frailty, and 21% (n = 130) were not frail. Frail patients had more co-morbidities and more frequent left main coronary artery or multivessel disease after adjusting for age and gender (p <0.05 across groups). Multivariable linear regression demonstrated poorer health status in frail patients compared to nonfrail patients as evidenced by lower Short-Form 36 scores, lower SAQ scores for physical limitation, and lower SAQ scores for quality of life (p <0.001 for each health status domain). In conclusion, 1/5 of older patients are frail at the time of PCI and have greater comorbid burden, angiographic disease severity, and poorer health status than nonfrail adults. [ABSTRACT FROM AUTHOR]

A multisite observational study of sexual activity-related outcomes in patients enrolled in the TRIUMPH registry during hospitalization for an acute myocardial infarction (AMI) was conducted to identify patterns and loss of sexual activity 1 year after hospitalization for AMI. Gender-specific multivariable hierarchical models were used to identify correlates of loss of sexual activity including physician counseling. Main outcome measurements included “loss of sexual activity” (less frequent or no sexual activity 1 year after an AMI in those who were sexually active in the year before the AMI) and 1-year mortality. Mean ages were 61.1 years for women (n = 605) and 58.6 years for men (n = 1,274). Many were sexually active in the year before and 1 year after hospitalization (44% and 40% of women, 74% and 68% of men, respectively). One third of women and 47% of men reported receiving hospital discharge instructions about resuming sex. Those who did not receive instructions were more likely to report loss of sexual activity (women, adjusted relative risk 1.44, 95% confidence interval 1.16 to 1.79; men, adjusted relative risk 1.27, 95% confidence interval 1.11 to 1.46). One year mortality after AMI was similar in those who reported sexual activity in the first month after AMI (2.1%) and those who were sexually inactive (4.1%, p = 0.08). In conclusion, although many patients were sexually active before AMI, only a minority received discharge counseling about resuming sexual activity. Lack of counseling was associated with loss of sexual activity 1 year later. Mortality was not significantly increased in patients who were sexually active soon after their AMI. [Copyright &y& Elsevier]

Hospital-acquired anemia (HAA) is common, often develops in the absence of bleeding, and is associated with poor outcomes in patients with acute myocardial infarction (AMI). It is unknown whether red cell distribution width (RDW) and mean corpuscular volume (MCV), which are routinely available markers of iron deficiency, are associated with development of HAA during AMI. We studied 15,133 patients with AMI without anemia at admission. HAA was defined by nadir hemoglobin levels below age-, gender-, and race-specific thresholds and moderate–severe HAA was defined as nadir hemoglobin ≤11 g/dl. We examined the association between low MCV (<80 fL) and/or increased RDW (>15%) on patients'' initial complete blood cell count and moderate–severe HAA using multivariable modified Poisson regression. Moderate–severe HAA was more common in patients with high RDW and low MCV (45.5%), high RDW and MCV ≥80 fL (33.0%), and normal RDW and low MCV (28.0%) than in those with normal RDW and MCV (18.3%, p <0.001). Compared to patients with normal RDW and MCV, those with increased RDW and low MCV (relative risk 1.72, 95% confidence interval 1.57 to 1.87), increased RDW and MCV ≥80 fL (relative risk 1.28, 95% confidence interval 1.16 to 1.42), or normal RDW and low MCV (relative risk 1.34, 95% confidence interval 1.08 to 1.65) were independently more likely to develop moderate–severe HAA. In conclusion, increased RDW and low MCV were independent predictors of moderate–severe HAA. [Copyright &y& Elsevier]

Omega-3 fatty acids have multiple cardiovascular benefits but may also inhibit platelet aggregation and increase bleeding risk. If this platelet inhibition is clinically meaningful, patients with the highest omega-3 indexes (red blood cell eicosapentaenoic acid plus docosahexaenoic acid), which reflect long-term omega-3 fatty acid intake, should be at the risk for bleeding. In this study, 1,523 patients from 24 United States centers who had their omega-3 indexes assessed at the time of acute myocardial infarction were studied. The rates of serious bleeding (Thrombolysis In Myocardial Infarction [TIMI] major or minor) and mild to moderate bleeding (TIMI minimal) were identified in patients with low (<4%), intermediate (4% to 8%), and high (>8%) omega-3 indices. There were no differences in bleeding across omega-3 index categories. After multivariate adjustment, there remained no association between the omega-3 index and either serious (per 2% increase, relative risk 1.03, 95% confidence interval 0.90 to 1.19) or mild to moderate bleeding (per 2% increase, relative risk 1.02, 95% confidence interval 0.85 to 1.23). In conclusion, no relation was found between the omega-3 index and bleeding in this large, multicenter cohort of patients with acute myocardial infarction, suggesting that concerns about bleeding should not preclude the use of omega-3 supplements or increased fish consumption when clinically indicated. [ABSTRACT FROM AUTHOR]

Warfarin is a complex but highly effective treatment for decreasing thromboembolic risk in atrial fibrillation (AF). We examined contemporary warfarin treatment rates in AF before the expected introduction of newer anticoagulants and extent of practice-level variation in warfarin use. Within the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence program from July 2008 through December 2009, we identified 9,113 outpatients with AF from 20 sites who were at moderate to high risk for stroke (congestive heart failure, hypertension, age, diabetes, stroke score >1) and would be optimally treated with warfarin. Using hierarchical models, the extent of site-level variation was quantified with the median rate ratio, which can be interpreted as the likelihood that 2 random practices would differ in treating “identical” patients with warfarin. Overall rate of warfarin treatment was only 55.1% (5,018 of 9,913). Untreated patients and treated patients had mean congestive heart failure, hypertension, age, diabetes, stroke scores of 2.5 (p = 0.38) and similar rates of heart failure, hypertension, diabetes mellitus, and previous stroke, suggesting an almost “random” pattern of treatment. At the practice level, however, there was substantial variation in treatment ranging from 25% to 80% (interquartile range for practices 50 to 65), with a median rate ratio of 1.31 (1.22 to 1.55, p <0.001). In conclusion, within the Practice Innovation and Clinical Excellence registry, we found that warfarin treatment in AF was suboptimal, with large variations in treatment observed across practices. Our findings suggest important opportunities for practice-level improvement in stroke prevention for outpatients with AF and define a benchmark treatment rate before the introduction of newer anticoagulant agents. [ABSTRACT FROM AUTHOR]

New-onset, hospital-acquired anemia (HAA) during acute myocardial infarction (AMI) is independently associated with poor outcomes. The patterns of recovery from HAA after AMI and their association with mortality and health status are unknown. In the prospective 24-center Translational Research Investigating Underlying disparities in acute myocardial infarction Patients'' Health Status (TRIUMPH) registry, we identified 530 patients with AMI and HAA (defined as normal hemoglobin at admission with the development of anemia by discharge) who had a repeat, protocol-driven hemoglobin measurement at 1 month after discharge. The 1-month measures were used to define persistent (persistent anemia) and transient (anemia resolved) HAA. The patients'' health status was assessed at 1, 6, and 12 months after AMI using the Short-Form 12 Physical Component Summary, and the health status of patients with persistent and transient HAA was compared using multivariate repeated measures regression analysis. Mortality was compared using the log-rank test and proportional hazards regression analysis. Overall, 165 patients (31%) developed persistent HAA. The adjusted mean Short-Form 12 Physical Component Summary scores at the follow-up visit were significantly lower in those with persistent HAA than in those with transient HAA (−2.0 points, 95% confidence interval −3.6 to −0.3; p = 0.02). During a median follow-up of 36 months, the crude mortality (13% vs 5%, p = 0.002) and multivariate-adjusted mortality (hazard ratio 2.08, 95% confidence interval 1.02 to 4.21, p = 0.04) was greater in patients with persistent HAA. In conclusion, HAA persists 1 month after discharge in nearly 1 of 3 patients and is associated with worse health status and greater mortality. Additional investigation is needed to understand whether HAA prevention, recognition, and treatment, particularly among those with persistent HAA, will improve outcomes. [Copyright &y& Elsevier]

Considerable attention has been devoted to the effect of social support on patient outcomes after acute myocardial infarction (AMI). However, little is known about the relation between patient living arrangements and outcomes. Thus, we used data from PREMIER, a registry of patients hospitalized with AMI at 19 United States centers from 2003 through 2004, to assess the association of living alone with outcomes after AMI. Outcome measurements included 4-year mortality, 1-year readmission, and 1-year health status using the Seattle Angina Questionnaire (SAQ) and the Short Form-12 Physical Health Component scales. Patients who lived alone had higher crude 4-year mortality (21.8% vs 14.5%, p <0.001) but comparable rates of 1-year readmission (41.6% vs 38.3%, p = 0.79). Living alone was associated with lower unadjusted quality of life (mean SAQ −2.40, 95% confidence interval [CI] −4.44 to −0.35, p = 0.02) but had no impact on Short Form-12 Physical Health Component (−0.45, 95% CI −1.65 to 0.76, p = 0.47) compared to patients who did not live alone. After multivariable adjustment, patients who lived alone had a comparable risk of mortality (hazard ratio 1.35, 95% CI 0.94 to 1.93) and readmission (hazard ratio 0.99, 95% CI 0.76 to 1.28) as patients who lived with others. Mean quality-of-life scores remained lower in patients who lived alone (SAQ −2.91, 95% CI −5.56 to −0.26, p = 0.03). In conclusion, living alone may be associated with poorer angina-related quality of life 1 year after MI but is not associated with mortality, readmission, or other health status measurements after adjusting for other patient and treatment characteristics. [Copyright &y& Elsevier]

Although fast food is affordable and convenient, it is also high in calories, saturated fat, and sodium. The frequency of fast food intake at the time of and after acute myocardial infarction (AMI) is modifiable. However, patterns of fast food intake and characteristics associated with its consumption in patients with AMI are unknown. The aim of this study was to study fast food consumption at the time of AMI and 6 months later in 2,481 patients from the prospective, 24-center Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients'' Health Status (TRIUMPH) study of patients with AMI. Fast food intake was categorized as frequent (weekly or more often) or infrequent (less than weekly). Multivariate log-binomial regression was used to identify patient characteristics associated with frequent fast food intake 6 months after AMI. At baseline, 884 patients (36%) reported frequent fast food intake, which decreased to 503 (20%) 6 months after discharge (p <0.001). Male gender, white race, lack of college education, current employment, and dyslipidemia were independently associated with frequent fast food intake 6 months after AMI. In contrast, older patients and those who underwent coronary bypass surgery were less likely to eat fast food frequently. Documentation of discharge dietary counseling was not associated with 6-month fast food intake. In conclusion, fast food consumption by patients with AMI decreased 6 months after the index hospitalization, but certain populations, including younger patients, men, those currently working, and less educated patients were more likely to consume fast food, at least weekly, during follow-up. Novel interventions that go beyond traditional dietary counseling may be needed to address continued fast food consumption after AMI in these patients. [Copyright &y& Elsevier]

Worsened renal function (WRF) during heart failure (HF) hospitalization is associated with in-hospital mortality, but there are limited data regarding its relation to long-term outcomes after discharge. The influence of WRF resolution is also unknown. This retrospective study analyzed patients who received care from a large health system and had a primary hospital discharge diagnosis of HF from January 2000 to June 2008. Renal function was estimated from creatinine levels during hospitalization. The first available value was considered baseline. WRF was defined a creatinine increase ≥0.3 mg/dl on any subsequent hospital day compared to baseline. Persistent WRF was defined as having WRF at discharge. Proportional hazards regression, adjusting for baseline renal function and potential confounding factors, was used to assess time to rehospitalization or death. Of 2,465 patients who survived to discharge, 887 (36%) developed WRF. Median follow-up was 2.1 years. In adjusted models, WRF was associated with higher rates of postdischarge death or rehospitalization (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.02 to 1.22). Of those with WRF, 528 (60%) had persistent WRF, whereas 359 (40%) recovered. Persistent WRF was significantly associated with higher postdischarge event rates (HR 1.14, 95% CI 1.02 to 1.27), whereas transient WRF showed only a nonsignificant trend toward risk (HR 1.09, 95% CI 0.96 to 1.24). In conclusion, in patients surviving hospitalization for HF, WRF was associated with increased long-term mortality and rehospitalization, particularly if renal function did not recover by the time of discharge. [ABSTRACT FROM AUTHOR]

Light-to-moderate alcohol consumption has been previously associated with a lower risk of acute myocardial infarction (AMI) and mortality. The association of changes in drinking behavior after an AMI with health status and long-term outcomes is unknown. Using a prospective cohort of patients with AMI evaluated with the World Health Organization''s Alcohol Use Disorders Identification Test, we investigated changes in drinking patterns in 325 patients who reported moderate drinking at the time of their AMI. One-year alcohol consumption, disease-specific (angina pectoris and quality of life) and general (mental and physical) health status and rehospitalization outcomes, and 3-year mortality were assessed. Seattle Angina Questionnaire Angina Frequency and Quality of Life, Short Form-12 Mental and Physical Component Summary Scales were modeled using multivariable hierarchical linear models within site. Of the initial 325 moderate drinkers at baseline, 273 (84%) remained drinking and 52 (16%) quit. In fully adjusted models, Physical Component Scale scores (beta 6.47, 95% confidence interval 3.73 to 9.21, p <0.01) were significantly higher during follow-up in those who remained drinking. Persistent moderate drinkers had a trend toward less angina (relative risk 0.65, 95% confidence interval 0.39 to 1.10, p = 0.11), fewer rehospitalizations (hazard ratio 0.79, 95% confidence interval 0.44 to 1.41, p = 0.42), lower 3-year mortality (relative risk 0.75, 95% confidence interval 0.23 to 2.51, p = 0.64), and better disease-specific quality of life (Seattle Angina Questionnaire Quality of Life, beta 3.88, 95% confidence interval −0.79 to 8.55, p = 0.10) and mental health (Mental Component Scale, beta 0.83, 95% confidence interval −1.62 to 3.27, p = 0.51) than quitters. In conclusion, these data suggest that there are no adverse effects for moderate drinkers to continue consuming alcohol and that they may have better physical functioning compared to those who quit drinking after an AMI. [Copyright &y& Elsevier]

Although medical co-morbidities commonly affect clinical outcomes after acute myocardial infarction (AMI), current performance measures of AMI quality focus exclusively on the management of the AMI itself. However, patients with AMIs frequently present with other co-morbidities, such as diabetes mellitus (DM), that also warrant assessment and management. To date, the quality of DM evaluation in patients presenting with AMIs has not been described. From January 2003 to June 2004, the Prospective Registry Evaluating Myocardial Infarction Patients: Events and Recovery–Quality Improvement (PREMIER-QI) enrolled 3,953 patients with AMIs at 19 centers in the United States. The frequency of glycosylated hemoglobin (HbA1c) assessment, either during the hospitalization or documented in the chart from the preceding 3 months, was prospectively evaluated. Among 1,168 patients with AMIs with preexisting DM, only 47% had recent HbA1c levels available, with marked variability in HbA1c assessment among hospitals (range 7% to 81%). Among those with available HbA1c levels, 39% had good control (HbA1c <7%), 36% had suboptimal control (HbA1c 7% to 9%), and 25% had poor control (HbA1c >9%). Patients with suboptimal and poor control were more likely to have their DM treatment intensified than those without HbA1c assessment (for HbA1c 7% to 9%, rate ratio 1.38, 95% confidence interval 1.03 to 1.85; for HbA1c >9%, rate ratio 2.20, 95% confidence interval 1.68 to 2.88). Similarly, patients with DM who had HbA1c measured were more likely to receive instructions on DM disease management before discharge. In conclusion, the assessment of chronic glycemic control is highly variable among patients with AMIs and DM. Because much of this variability occurs at the hospital level, the evaluation of DM control could represent an additional quality indicator and an opportunity to advance patient-centered AMI care. [Copyright &y& Elsevier]

Chronic kidney disease (CKD) is a risk factor for poor outcomes in patients with coronary artery disease (CAD), but it is unknown whether CKD influences the efficacy of alternative CAD treatment strategies. Thus, we compared outcomes in stable CAD patients with and without CKD randomized to percutaneous coronary intervention (PCI) and optimal medical therapy (OMT) or OMT alone in a post hoc analysis of the 2,287 patient COURAGE study. At baseline, 320 patients (14%) had CKD defined as a glomerular filtration rate of <60 mL/min/1.73 m2, as estimated by the abbreviated 4-variable Modification of Diet in Renal Disease equation. The patients with CKD were older (68 ± 9 vs 61 ± 10 years; p <0.001) and more often had diabetes mellitus (42% vs 33%; p = 0.002), hypertension (81% vs 65%; p <0.03), heart failure (13% vs 3.4%; p <001), and three-vessel CAD (37% vs 29%, p = 0.01). After adjustment for these differences, CKD remained an independent predictor of death or nonfatal myocardial infarction (hazard ratio 1.48, 95% confidence interval 1.15 to 1.90). PCI had no effect on these outcomes. Furthermore, at 36 months, a similar percentage of patients with CKD treated with OMT (70%) and PCI plus OMT (76%) were angina free compared to patients without CKD. In conclusion, CKD is an important determinant of clinical outcomes in patients with stable CAD, regardless of the treatment strategy. Although PCI did not reduce the risk of death or myocardial infarction when added to OMT for patients with CKD, it also was not associated with worse outcomes in this high-risk group. [Copyright &y& Elsevier]

The main results of the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial revealed no significant differences in the primary end point of all-cause mortality or nonfatal myocardial infarction [MI] or major secondary end points (composites of death/MI/stroke; hospitalization for acute coronary syndromes [ACSs]) during a median 4.6-year follow-up in 2,287 patients with stable coronary artery disease randomized to optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI). We sought to assess the impact of PCI when added to OMT on major prespecified tertiary cardiovascular outcomes (time to first event), namely cardiac death and composites of cardiac death/MI, cardiac death/MI/hospitalization for ACS, cardiac death/MI/stroke, MI/stroke, or cardiac death/MI/ACS/stroke, during study follow-up. There were no significant differences between treatment arms for the composite of cardiac death or MI (15% in PCI + OMT group vs 14.2% in OMT group, hazard ratio 1.07, 95% confidence interval 0.86 to 1.33, p = 0.62) or in any of the major prespecified composite cardiovascular events during long-term follow-up, even after excluding periprocedural MI as an outcome of interest. Overall, cause-specific cardiovascular outcomes paralleled closely the primary and secondary composite outcomes of the trial as a whole. In conclusion, compared with an initial management strategy of OMT alone, addition of PCI did not decrease the incidence of major cardiovascular outcomes including cardiac death or the composite of cardiac death/MI/ACS/stroke in patients with stable coronary artery disease. [Copyright &y& Elsevier]

Presence of severe left ventricular (LV) diastolic function has been shown to independently predict risk of heart failure or death after acute myocardial infarction (AMI). We aimed to determine whether common echocardiographic parameters and (LV) diastolic function evaluated during AMI hospitalization can predict the risk of rehospitalization, up to 1 year after AMI. One hundred ninety consecutive patients with AMI, who were prospectively enrolled in a longitudinal post-AMI registry, had survived for 1 year, and had a clinically indicated echocardiogram during the index admission, were included in the study. The independent effect of diastolic dysfunction on 1-year all-cause rehospitalization was assessed using multivariable proportional hazards regression. Average age was 62.5 years, 93% were Caucasian, 66% were men, and mean LV ejection fraction was 46%. At 1 year, 78 patients (41%) had been rehospitalized ≥1 time. In multivariable analysis, presence of severe LV diastolic dysfunction was the only echocardiographic variable that predicted increased risk of rehospitalization 1 year after AMI (hazard ration 3.31, 95% confidence interval 1.26 to 8.69). Seventy-eight percent of patients with severe LV diastolic dysfunction (restrictive diastolic physiology) compared with 30% with normal diastolic function (p = 0.0052) and 37% with nonrestrictive physiology during the index admission were rehospitalized. In conclusion, severe LV diastolic dysfunction is the only echocardiographic predictor of rehospitalization in survivors of AMI and routine assessment of diastolic function during AMI hospitalization can provide additional prognostic risk stratification at dismissal. [Copyright &y& Elsevier]

Drug-eluting stents (DESs) are used in >80% of percutaneous coronary intervention (PCI) procedures; however, up to 2/3 are used for off-label indications. Factors associated with DES use in patients with ST-elevation myocardial infarction (STEMI) are not known in contemporary clinical practice. We analyzed temporal trends, geographic patterns, and sociodemographic factors associated with off-label use of DESs in patients undergoing primary PCI for STEMI from July 2004 to March 2006 in the National Cardiovascular Data Registry (NCDR). The main outcome of this study was receipt of any DES, and the candidate independent variables were sociodemographic, hospital, clinical, and procedural variables. We also analyzed temporal trends and geographic patterns for use of DESs. A total of 30,235 patients with STEMI underwent primary PCI with use of DESs (84%) or bare metal stents (16%). Adoption of DESs was rapid but varied widely as a function of geographic location. After adjusting for clinical and procedural variables, older age was associated with lower use (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.91 to 0.98), whereas white race (OR 1.14, 95% CI 1.03 to 1.27), commercial insurance (OR 1.22, 95% CI 1.11 to 1.34), and the west census region (OR 1.37, 95% CI 1.04 to 1.81) were associated with higher use of DESs. In conclusion, adoption of DESs was rapid in patients with STEMI, but geographic location and sociodemographic and hospital factors were associated with the use DESs. [Copyright &y& Elsevier]

Complementary and alternative medicine (CAM) use is common in patients with cardiovascular disease. Although numerous efforts have sought to understand CAM types and the prevalence of CAM, whether patients preferentially use CAM instead of evidence-based therapies is unknown. Self-reported use of CAM and evidence-based therapies in a prospective registry of hospitalized patients with acute coronary syndrome from March 1, 2001 to October 31, 2002 were examined. Poisson regression models were used to assess whether CAM use was independently associated with lower rates of aspirin, β-blocker, and statin use in 596 patients with established coronary artery disease (CAD). Overall, CAM use was 19% in patients with CAD. Higher proportions of patients who used CAM were non-Caucasian (31% vs 12%), uninsured (12% vs 7%), economically burdened (58% vs 29%), and had depression (13% vs 6%, p <0.05 for all). Patients who used CAM were more likely to use β blockers (64% vs 46%, p = 0.008) and as likely to use aspirin (73% vs 74%, p = 0.90) and statins (71% vs 68%, p = 0.76) as non–CAM users. Adjusting for demographic and clinical factors did not change results (CAM users: RR 1.27, 95% confidence interval [CI] 1.01 to 1.60 for using β blockers, RR 0.97, 95% CI 0.85 to 1.11 for using aspirin, and RR 1.05, 95% CI 0.87 to 1.28 for using statins). In conclusion, although CAM users with established CAD have worse socioeconomic status than nonusers, we found no evidence that they were less compliant with evidence-based therapies. [Copyright &y& Elsevier]

Major improvements in medical therapy and percutaneous coronary intervention for coronary artery disease (CAD) have emerged during the previous 2 decades, but no randomized trial in patients with stable CAD has been powered to compare these 2 strategies for the hard clinical end points of death or myocardial infarction (MI), and previous studies have not evaluated the effect of coronary stents and intensive medical therapy on cardiac events during long-term follow-up. Between 1999 and 2004, 2,287 patients with documented myocardial ischemia and angiographically confirmed CAD were randomized to the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial, with a principal hypothesis that a strategy of percutaneous coronary intervention plus intensive, guideline-driven medical therapy would be superior to a strategy of intensive medical therapy alone. The primary end point was a composite of all-cause mortality or acute MI (time to first event) during a 2.5- to 7-year (median 5) follow-up. Baseline characteristics were a mean age of 62 ± 5 years, 85% men, and 86% Caucasian. Mean duration of angina before randomization was 26 months (average 10 episodes/week), and 29% of patients were smokers, 67% had hypertension, 38% had previous MI, 71% had dyslipidemia, 34% had diabetes, 27% had previous revascularization, and 69% had multivessel CAD. Approximately 55% of patients met established criteria for the metabolic syndrome. In conclusion, baseline characteristics of the COURAGE trial study population indicate a highly symptomatic group of patients with CAD who have a significant duration and frequency of antecedent angina pectoris and a high prevalence of cardiac risk factors. [Copyright &y& Elsevier]

We tested the hypothesis that lower blood omega-3 (ω-3) fatty acids (FAs) and/or higher trans FAs are associated with the risk of an acute coronary syndrome (ACS). Higher levels of ω-3 FA have been associated with decreased risk of sudden cardiac death. However, their association with ACS risk is unclear. Although higher self-reported intakes of trans FAs have been linked to increased coronary risk, the association between blood levels of trans FA and ACS risk is also unknown. We analyzed the FA composition of whole blood from 94 subjects with ACS and 94 age-, gender-, and race-matched controls. Omega-3 and trans FA associations with ACS were assessed using multivariable models after adjusting for smoking status, alcohol use, diabetes, body mass index, serum lipids, and history of myocardial infarction or revascularization. Subjects’ mean age was 47 years, 54% were men, and 80% were Caucasian. Whole blood long-chain ω-3 FA (eicosapentaenoic acid [EPA] plus docosahexaenoic acid [DHA]) content was 29% lower in patients than in controls (1.7 ± 0.9% vs 2.4 ± 1.4%, p <0.001), whereas trans FA content was not different (2.1 ± 0.7% vs 2.0 ± 0.9%, p = NS). The multivariable-adjusted odds for case status was 0.67 (95% confidence interval 0.46 to 0.98) for a 1 SD increase in blood EPA + DHA. The inclusion of trans FAs in the EPA + DHA model did not alter this association. In conclusion, low blood EPA + DHA content is an independent predictor of increased risk for ACS, but higher blood trans FA content is not. Blood EPA + DHA may serve as a new, modifiable risk factor for ACS. [Copyright &y& Elsevier]

We investigated whether myocardial contrast echocardiography (MCE) performed soon after acute myocardial infarction (AMI) improves risk stratification for late mortality. MCE after AMI identifies microvascular “no-reflow” and predicts early outcomes; however, the predictive value of MCE for late mortality is unknown. One hundred sixty-seven patients with anterior AMI and left ventricular dysfunction underwent MCE 2 days after admission, and a perfusion score index (PSI) was calculated. Long-term follow-up (mean 39 months) was available for all patients. Patients with normal and abnormal perfusion had similar baseline characteristics. Myocardial contrast echocardiographic PSI was a predictor of mortality as a continuous variable (odds ratio 3.2 for each 1.0 increase in PSI, 95% confidence interval 1.1 to 9.7, p = 0.04). In a logistic regression model, age (odds ratio 2.6 per decade, 95% confidence interval 1.6 to 4.4, p = 0.0002) and PSI (odds ratio 4.5 for each 1.0 increase in PSI, 95% confidence interval 1.3 to 15.4, p = 0.02) were the only significant predictors of mortality. In a subanalysis comparing patients >70 years old with abnormal PSI with all other patients, Kaplan-Meier estimates showed a marked difference in survival over a mean follow-up of 39 months (24% vs 4% mortality, p = 0.0002). In conclusion, MCE refines risk stratification soon after anterior AMI in patients with left ventricular dysfunction. Patients at very high and very low risk of mortality can be identified, and myocardial contrast echocardiographic data are incrementally useful compared with existing clinical and angiographic variables. [Copyright &y& Elsevier]

Two-year survival rate was assessed among 1,038 patients who had acute coronary syndromes that were classified by discharge hematocrit values as normal (>39%, n = 360, 34.7%), mildly anemic (33.1% to 39%, n = 430, 41.4%), or moderately/severely anemic (≤33%, n = 248, 23.9%). Worsening anemia was associated with a decreased 2-year survival rate (normal 95.8%, mild anemia 91.2%, moderate/severe anemia 81.5%, p &#60; 0.001). In multivariable analyses, adjusted hazard ratios for all-cause mortality were 1.57 (95% confidence interval 0.82 to 2.96) for mild anemia and 2.46 (95% confidence interval 1.25 to 4.85) for moderate/severe anemia. [Copyright &y& Elsevier]

In a prospective cohort study of 142 outpatients with advanced heart failure followed for a mean of 3 years, 29% of subjects with a depression diagnosis at baseline were significantly more likely to experience the combined end point of death or transplantation (hazard ratio 2.54, 95% confidence interval 1.16 to 5.55). After adjustment for a range of sociodemographic and clinical characteristics, patients with depressive disorders were still significantly more likely to reach the combined end point (hazard ratio 2.41, 95% confidence interval 1.24 to 4.68). Depressed patients also had more heart failure related hospitalizations (1.5 ± 1.8 vs 0.6 ± 1.4, p = 0.04) and clinic visits (2.4 ± 1.7 vs 1.7 ± 1.8, p = 0.04) over the first year of follow-up. [Copyright &y& Elsevier]

One-year health status improvements in 62 patients with previous coronary artery bypass grafting (CABG) were compared with those of 628 patients undergoing initial CABG using the Seattle Angina Questionnaire (SAQ). Adjusted analyses revealed that repeat CABG conferred similar 1-year improvements in health status compared with patients undergoing a first CABG (changes in SAQ Physical Limitation score [SAQ-PL: repeat CABG 25 ± 27 vs first CABG 20 ± 27; p = 0.30], Quality of Life score [SAQ-QoL: 34 ± 24 vs 35 ± 5; p = 0.87], and Angina Frequency score (SAQ-AF: 35 ± 40 vs 25 ± 24; p = 0.03]). [Copyright &y& Elsevier]

Information on the relative benefit of coronary artery bypass grafting (CABG) versus stent-assisted percutaneous coronary intervention (PCI) for improvement of cardiac-related health status in women and how it compares with men is limited. The Stent or Surgery trial compared randomly assigned CABG and stent-assisted PCI in 206 women and 782 men with multivessel disease. We examined longitudinal changes at 6 and 12 months from baseline by gender and treatment in 3 subscales of the Seattle Angina Questionnaire (SAQ): physical limitation, angina frequency, and quality of life. At the time of revascularization, women were older, more severely ill, and tended to have lower SAQ scores than men. At 6 months, SAQ scores after both procedures improved significantly in both genders, with greater improvement achieved with CABG. After adjustment for other factors, in men, CABG was associated with a 54.7% greater improvement in physical limitation compared with PCI, 31.3% greater improvement in angina frequency, and 18.3% greater improvement in quality of life. In women, these relative differences were 11.6%, 43.2%, and 39.3%, respectively. At 1 year, men continued to show greater improvement with CABG in all 3 dimensions (50.6%, 19.7%, and 15.3%, respectively), but in women the relative differences decreased substantially (1.6%, 11.1%, and 0.6%, respectively) due to a greater later improvement after PCI (p = 0.049 for the interaction among treatment, gender, and follow-up for the quality of life domain). Although CABG may be superior to PCI in men, in women, at 1 year after intervention, both procedures appear equally effective. [Copyright &y& Elsevier]

We used data from 1,344 patients enrolled in the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery study to examine the adoption of drug-eluting stents (DESs) and the effect of the release of the Food and Drug Administration’s preliminary public health notification, which raised concerns about DES safety. Overall, there was a dramatic increase in the use of DESs over the study period, from 32% in April 2003 to 81% in March 2004. The notification issued on October 29, 2003 was associated with a 26% relative decrease in DES use. By January 2004, DES use had returned to the prenotification rate and continued to increase thereafter. In conclusion, the Food and Drug Administration’s notification had a modest but temporary effect on clinical practice. [Copyright &y& Elsevier]

In a prospective cohort of patients who had acute coronary syndrome, we used a simple fasting plasma glucose to identify previously unrecognized diabetes mellitus. A total of 57% of patients who had acute coronary syndrome had abnormal glucose metabolism; ∼66% of those who met criteria for new diabetes were not diagnosed or treated as such by the physicians who managed them. [Copyright &y& Elsevier]

The COVID-19 pandemic accelerated adaption of a telehealth care model. We studied the impact of telehealth on the management of atrial fibrillation (AF) by electrophysiology providers in a large, multisite clinic. Clinical outcomes, quality metrics, and indicators of clinical activity for patients with AF during the 10-week period of March 22, 2020 to May 30, 2020 were compared with those from the 10-week period of March 24, 2019 to June 1, 2019. There were 1946 unique patient visits for AF (1,040 in 2020 and 906 in 2019). During 120 days after each encounter, there was no difference in hospital admissions (11.7% vs 13.5%, p = 0.25) or emergency department visits (10.4% vs 12.5%, p = 0.15) in 2020 compared with 2019. There was a total of 31 deaths within 120 days, with similar rates in 2020 and 2019 (1.8% vs 1.3%, p = 0.38). There was no significant difference in quality metrics. The following clinical activities occurred less frequently in 2020 than in 2019: offering escalation of rhythm control (16.3% vs 23.3%, p <0.001), ambulatory monitoring (29.7% vs 51.7%, p <0.001), and electrocardiogram review for patients on antiarrhythmic drug therapy (22.1% vs 90.2%, p <0.001). Discussions about risk factor modification were more frequent in 2020 compared with 2019 (87.9% vs 74.8%, p <0.001). In conclusion, the use of telehealth in the outpatient management of AF was associated with similar clinical outcomes and quality metrics but differences in clinical activity compared with traditional ambulatory encounters. Longer-term outcomes warrant further investigation., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Revascularization and medical therapy for chronic coronary disease have both evolved significantly over the last 50 years. A total of 4 contemporary randomized controlled trials- Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation (COURAGE), Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D), Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2 (FAME 2), and International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA)-have assessed the incremental benefit of revascularization when added to secondary prevention with intensive pharmacologic and lifestyle intervention. We reviewed these 4 seminal studies with the objective of marshaling evidence to better frame how these results should apply to clinical decision making. These studies differed in study design, end points, intensity of treatment, and revascularization techniques. Nevertheless, they all demonstrate similar rates of "hard" clinical events with invasive and conservative management, and varying degrees of benefit in angina-related quality of life with revascularization. In conclusion, although controversy persists concerning the role of revascularization because of differing interpretations of the clinical trial evidence, we contend that instead of being competing management strategies, invasive and conservative approaches are complementary., (Published by Elsevier Inc.)

Randomized clinical trials have not demonstrated a survival benefit with percutaneous coronary intervention in stable ischemic heart disease (SIHD). We evaluated the generalizability of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial findings to the broader population of veterans with SIHD. Veterans who underwent coronary angiography between 2005 and 2013 for SIHD were identified from the Veterans Affairs Clinical Assessment, Reporting and Tracking Program (VA CART). Patient-level comparisons were made between patients from VA CART who met the eligibility criteria for COURAGE and veterans enrolled in COURAGE between 1999 and 2004. All-cause mortality over long-term follow-up was assessed using Cox proportional hazards models. COURAGE-eligible patients from VA CART (n = 59,758) were older, had a higher body mass index, a greater prevalence of co-morbidities, but fewer diseased vessels on index coronary angiography, and were less likely to be on optimal medical therapy at baseline and on 1-year follow-up compared with VA COURAGE participants (n = 968). Patients from VA CART (median follow-up 6.5 years) had higher all-cause mortality (adjusted hazard ratio [aHR] 1.98 [1.61 to 2.43]) than participants from VA COURAGE (median follow-up: 4.6 years). Risks of mortality were greater in the 56.4% patients from CART who were medically managed (aHR 1.94 [1.49 to 2.53]) and in the 43.6% who underwent percutaneous coronary intervention (aHR 1.99 [1.45 to 2.74]), compared with their respective VA COURAGE arms. In conclusion, in this noncontemporaneous patient-level analysis, veterans in the randomized COURAGE trial had more favorable outcomes than the population of veterans with SIHD at large., Competing Interests: Disclosures Dr. Smilowitz serves on an advisory board for Abbott Vascular. Dr. Shah serves on an advisory board for Philips Volcano and Terumo Medical. The remaining authors have no conflicts of interest to declare., (Published by Elsevier Inc.)

Data on depression and stress among patients with spontaneous coronary artery dissection (SCAD) are limited. Using data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study, which prospectively enrolled 3,572 acute myocardial infarction (AMI) patients between 18 and 55 years of age, we identified 67 SCAD cases. We compared Patient Health Questionnaire-9 (PHQ-9) and 14-item Perceived Stress Scale (PSS-14) scores obtained at baseline, 1 month, and 12 months between SCAD and AMI of all other causes. Using longitudinal linear mixed-effects analysis, we compared depression and stress scores between SCAD and other AMI, adjusting for time and selected covariates. Patients with SCAD had lower baseline PHQ-9 scores (6.1 ± 6.0 vs 7.7 ± 6.4 for other patients with AMI, p = 0.03), similar 1-month scores, and lower 12-month scores (3.2 ± 4.3 vs 4.9 ± 5.5, p = 0.004). At baseline and 1 month, patients with SCAD had similar PSS-14 scores to those of other patients with AMI. At 12 months, patients with SCAD had lower scores (18.4 ± 8.8 vs 21.5 ± 9.3 for other patients with AMI, p = 0.009). After adjustment for cardiovascular risk factors, co-morbidities, and clinical acuity, no differences in PHQ-9 or PSS-14 scores remained between SCAD and other AMI. Similar results were obtained in a subgroup analysis of only women with SCAD and other AMI. In conclusion, patients with SCAD had a relatively lower burden of depression and perceived stress than other patients with AMI, potentially because of fewer co-morbidities and favorable socioeconomic factors. However, given high depression and stress burden in both SCAD and other patients with AMI, routine screening can help identify and treat these patients., Competing Interests: Disclosures Dr. Bueno receives research funding from the Instituto de Salud Carlos III, Spain (PIE16/00021 and PI17/01799), Sociedad Española de Cardiología, Astra-Zeneca, Bayer, PhaseBio, and Novartis; has received consulting fees from Astra-Zeneca, Novartis, and Organon; speaking fees from Novartis, and is a scientific advisor for MEDSCAPE-the heart.org. In the past 3 years, Dr. Krumholz received expenses and/or personal fees from UnitedHealth, Element Science, Aetna, Reality Labs, Tesseract/4Catalyst, F-Prime, the Siegfried and Jensen Law Firm, Arnold and Porter Law Firm, and Martin/Baughman Law Firm. He is a co-founder of Refactor Health and HugoHealth, and is associated with contracts, through Yale New Haven Hospital, with the Centers for Medicare & Medicaid Services and through Yale University with Johnson & Johnson. The remaining authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The association of invasive versus noninvasive treatment and physical activity level in patients with claudication remains unclear. Participants with claudication were enrolled from US vascular clinics. Treatment was categorized as invasive (surgical or endovascular treatment <3 months of initial visit) versus noninvasive. Self-reported leisure time (LTPA) and work related physical activity (WRPA) (sedentary, mild, moderate/strenuous), and health status (peripheral artery questionnaire summary score [PAQ SS]) was measured at baseline and 12 months. Change in PA was also categorized as increased, decreased, persistent sedentary [reference] and persistent active based on activity status at baseline and 12 months. Multivariable logistic regression assessed the association of treatment with 12-month LTPA and WRPA. Multivariable linear regression examined the association between 12-month change in PA with a 12-month change in PAQ. A total of 196of 656 patients (29.9%) underwent invasive treatment. There was no association between treatment and 12-month LTPA (p = 0.77) or WRPA (p = 0.26). Compared with being persistently sedentary, increased LTPA was associated with increased PAQ SS (OR 11.1 95% CI [4.4 to 17.7], p <0.01). In conclusion, there was no association between invasive treatment and physical activity at follow up despite a greater health status change in the invasive group. As increased physical activity was associated with more health status gains than remaining sedentary, additional ways to improve physical activity levels could potentially improve PAD outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Several risk scores in acute coronary syndromes are available, but few models exist for stable coronary artery disease to guide decision-making and prognosis. A multivariate model was developed using 23 baseline candidate variables from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Therapy EvaluationTrial (n = 2,287 patients). Discrimination of the model was evaluated by the concordance c-index. The procedure was validated using 100 random half samples. We identified 9 independent predictors of death or myocardial infarction (MI) during a 5-year follow-up. The following predictors and points contributing to the risk score were: heart failure (3), number of diseased coronary arteries (1 for each vessel), diabetes (1), age (1 for each 15 years ≥ age 45), previous revascularization (1), current smoking (1), female (1), previous MI (1), and high-density lipoprotein cholesterol (1: 31 to 40 mg/dL; 2: <30 mg/dL). The risk tool had a potential range from 0 to 15, corresponding to 5-year event rates of 5.8% to 56%. C-indices ranged from 0.67 for the full data set to 0.62 for the validating subsamples. Respective observed versus predicted 5-year event rates for 3 predefined risk strata revealed: 30% had a low-risk score of 0 to 3 (9.3% vs 9.3%, or 1.9%/year); 59% had an intermediate-risk score of 4-6 (18.0% vs 18.1%, or 3.6%/year); and 11% had a high-risk score of 7-11 (36% vs 36.5%, or 7.2%/year). This stable coronary artery disease risk score permitted a prognostic assessment of 5-year probability of death or MI with an approximate 4-fold range in event rates from the lowest (9.3%) to the highest (36%) terciles, thus enabling better clinical practice decisions that allow physicians to tailor the intensity of treatment to the level of risk., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Although contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is performed with high success rates, 10% to 13% of patients presenting with CTOs have chronic kidney disease (CKD), and the comparative safety, efficacy, and health status benefit of CTO PCI in these patients, has not been well defined. We examined the association of baseline renal function with periprocedural major adverse cardiovascular and cerebral events and health status outcomes in 957 consecutive patients (mean age 65.3 ± 10.3 years, 19.4% women, 90.3% white, 23.6 CKD [estimated glomerular filtration rate {eGFR} < 60]) in the OPEN-CTO (Outcomes, Patients Health Status, and Efficiency in Chronic Total Occlusions Registry) study. Hierarchical multivariable regression models were used to examine the independent association of baseline eGFR with technical success, periprocedural complications and change in health status, using Seattle Angina Questionnaire (SAQ) over 1 year. Crude rates of acute kidney injury were higher (13.5% vs 4.4%, p <0.001) and technical success lower (81.8% vs 88.4%, p = 0.01) in patients with CKD. There were no significant differences in other periprocedural complications. After adjustment for confounding factors, there was no significant association of baseline eGFR with technical success or periprocedural major adverse cardiovascular and cerebral events (death, myocardial infarction, emergent bypass surgery, stroke, perforation), whereas patients with lower eGFR had higher rates of acute kidney injury. The difference in SAQ summary score, between patients on the 10th and 90th percentile for baseline eGFR distribution was not clinically significant (1 month: -0.91; 1 year: -3.06 points). In conclusion, CTO PCI success, complication rates, and the health status improvement after CTO PCI are similar in patients across a range of baseline eGFRs., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Acute coronary syndrome (ACS) admissions are common and costly. The association between comprehensive ACS care pathways, outcomes, and costs are lacking. From 434,172 low-risk, uncomplicated ACS patients eligible for early discharge (STEMI 35%, UA/NSTEMI 65%) from the Premier database, we identified ACS care pathways, by stratifying low-risk, uncomplicated STEMI and UA/NSTEMI patients by access site for PCI (trans-radial intervention [TRI] vs transfemoral intervention [TFI]) and by length of stay (LOS). Associations with costs and outcomes (death, bleeding, acute kidney injury, and myocardial infarction at 1-year) were tested using hierarchical, mixed-effects regression, and projections of cost savings with change in care pathways were obtained using modeling. In low-risk uncomplicated STEMI patients, compared with TFI and LOS ≥3 days, a strategy of TRI with LOS <3 days and TFI with LOS <3 days were associated with cost savings of $6,206 and $4,802, respectively. Corresponding cost savings for UA/NSTEMI patients were $7,475 and $6,169, respectively. These care-pathways did not show an excess risk of adverse outcomes. We estimated that >$300 million could be saved if prevalence of the TRI with LOS <3 days and TFI with LOS <3 days strategies are modestly increased to 20% and 70%, respectively. In conclusion, we demonstrate the potential opportunity of cost savings by repositioning ACS care pathways in low-risk and uncomplicated ACS patients, toward transradial access and a shorter LOS without an increased risk of adverse outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)