Search

Background Epidemiological studies demonstrating a relationship between gout and cardiovascular disease are older and predate modern cardiovascular preventive therapy. We assessed the contemporary association between gout and cardiovascular disease in patients with obstructive coronary artery disease. Methods and Results Data were from the Duke Databank for Cardiovascular Diseases, which followed up patients undergoing cardiac catheterization with obstructive coronary artery disease at Duke University Medical Center (1998–2013). We assessed the relationship between gout diagnosis at baseline or during follow‐up and the primary composite outcome of cardiovascular death, myocardial infarction, or stroke, adjusting for differences in baseline clinical factors. Secondary end points included cardiovascular death and all‐cause mortality. New, postbaseline, gout diagnosis was included as a time‐dependent covariate. Among 17 201 patients, 1406 (8.2%) had baseline gout and a high burden of cardiovascular risk factors, but high rates of optimal medical therapy. Over a median follow‐up of 6.4 years, gout diagnosis at time of catheterization was not associated with the primary outcome (hazard ratio [95% confidence interval], 1.05 [0.96–1.15]; P =0.31) or cardiovascular death (hazard ratio [95% confidence interval], 1.10 [0.99–1.22]; P =0.08), but was associated with increased all‐cause mortality (hazard ratio [95% confidence interval], 1.13 [1.05–1.23]; P =0.002). After including new, postbaseline, gout diagnosis, the instantaneous risk of the primary outcome was significantly associated with prior gout diagnosis (hazard ratio [95% confidence interval], 1.15 [1.07–1.25]; P =0.0004). Conclusions A clinical history of gout is associated with worse outcomes in a contemporary population of patients with obstructive coronary artery disease. This increased risk exists despite high levels of optimal baseline cardiovascular disease medical therapy, suggesting that residual cardiovascular risk is not addressed by standard medical therapy.

Background Angina has important implications for patients’ quality of life and healthcare utilization. Angina management after acute myocardial infarction ( MI ) treated with percutaneous coronary intervention (PCI) is unknown. Methods and Results TRANSLATE ‐ ACS (Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) was a longitudinal study of MI patients treated with percutaneous coronary intervention at 233 US hospitals from 2010 to 2012. Among patients with self‐reported angina at 6 weeks post‐ MI , we described patterns of angina and antianginal medication use through 1 year postdischarge. Of 10 870 percutaneous coronary intervention–treated MI patients, 3190 (29.3%) reported angina symptoms at 6 weeks post‐ MI ; of these, 658 (20.6%) had daily/weekly angina while 2532 (79.4%) had monthly angina. Among patients with 6‐week angina, 2936 (92.0%) received β‐blockers during the 1 year post‐ MI , yet only 743 (23.3%) were treated with other antianginal medications. At 1 year, 1056 patients (33.1%) with 6‐week angina reported persistent angina symptoms. Of these, only 31.2% had been prescribed non–β‐blocker antianginal medications at any time in the past year. Among patients undergoing revascularization during follow‐up, only 25.9% were on ≥1 non–β‐blocker anti‐anginal medication at the time of the procedure. Conclusions Angina is present in one third of percutaneous coronary intervention–treated MI patients as early as 6 weeks after discharge, and many of these patients have persistent angina at 1 year. Non–β‐blocker antianginal medications are infrequently used in these patients, even among those with persistent angina and those undergoing revascularization.

Background Patients receiving oral anticoagulation in addition to dual‐antiplatelet therapy are known to be at high risk for bleeding events; thus, the selection of a drug‐eluting stent (DES) versus a bare metal stent (BMS) can have important implications for patients with atrial fibrillation (AF) presenting with acute myocardial infarction (MI). Methods and Results From the National Cardiovascular Data Registry ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry—Get With the Guidelines, we identified 14 427 AF patients presenting with acute MI undergoing percutaneous coronary intervention from 2008 to 2014. Temporal trends and hospital variation in DES use were examined, as were patterns of use by stroke risk (CHA 2 DS 2 ‐VASc) and bleeding risk ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation). Among patients with linked Medicare data (n=2844), multivariable Cox regression modeling was used to compare risks for a composite outcome (all‐cause mortality, readmission for stroke, or MI), readmission for stroke, revascularization, and major bleeding at 1 year. A DES was used in 8414 (58.9%) MI patients with AF, increasing from 47.1% in 2008 to 67.9% in 2014, with wide variation among hospitals. DES placement was more common than BMS placement among patients at high stroke risk (CHA 2 DS 2 ‐VASc ≥2) and high bleeding risk (ATRIA ≥4). Although aspirin and a P2Y 12 inhibitor were prescribed for >95% of all patients regardless of stent type at discharge, warfarin was prescribed less frequently among patients receiving a DES than a BMS (31% versus 39%, P Conclusions Use of DESs among MI patients with AF has increased over time, but substantial hospital‐level variation was observed. Patients with AF meeting indications for anticoagulation are more likely to receive a DES than a BMS, even among those at high predicted risk of both stroke and bleeding.

Background While use of P2Y12 receptor inhibitor is recommended by guidelines, few studies have examined its effectiveness among older non– ST ‐segment elevation myocardial infarction patients who did not undergo coronary revascularization. Methods and Results We included unrevascularized non– ST ‐segment elevation myocardial infarction patients ≥65 years discharged home from 463 ACTION Registry‐ GWTG hospitals from 2007 to 2010. Rates of discharge clopidogrel use were described for patients with no angiography, angiography without obstructive coronary artery disease ( CAD ; ≥50% stenosis in ≥1 vessel), and angiography with obstructive CAD . Two‐year outcomes were ascertained from linked Medicare data and included composite major adverse cardiac events (defined as all‐cause death, myocardial infarction readmission, or revascularization), and individual components. Outcomes associated with clopidogrel use were adjusted using inverse probability‐weighted propensity modeling. Of 14 154 unrevascularized patients, 54.7% (n=7745) did not undergo angiography, 10.6% (n=1494) had angiography without CAD , and 34.7% (n=4915) had angiography with CAD . Discharge clopidogrel was prescribed for 42.2% of all unrevascularized patients: 37.8% without angiography, 34.1% without obstructive CAD at angiography, and 51.6% with obstructive CAD at angiography. Discharge clopidogrel use was not associated with major adverse cardiac events in any group: without angiography (adjusted hazard ratio [95% CI ]: 0.99 [0.93–1.06]), angiography without CAD (1.04 [0.74–1.47]), and angiography with CAD (1.12 [1.00–1.25], P interaction =0.20). Conclusions We found no association between discharge clopidogrel use and long‐term risk of major adverse cardiac events among older, unrevascularized non– ST ‐segment elevation myocardial infarction patients. Clopidogrel use in this population requires further prospective evaluation.

Background Cardiovascular disease and cancer increasingly coexist, yet relationships between cancer and long‐term cardiovascular outcomes post–percutaneous coronary intervention (PCI) are not well studied. Methods and Results We examined stented PCI patients at Duke (1996–2010) using linked data from the Duke Information Systems for Cardiovascular Care and the Duke Tumor Registry (a cancer treatment registry). Our primary outcome was cardiovascular mortality. Secondary outcomes included composite cardiovascular mortality, myocardial infarction, or repeat revascularization and all‐cause mortality. We used adjusted cause‐specific hazard models to examine outcomes among cancer patients (cancer treatment pre‐PCI) versus controls (no cancer treatment pre‐PCI). Cardiovascular mortality was explored in a cancer subgroup with recent (within 1 year pre‐PCI) cancer and in post‐PCI cancer patients using post‐PCI cancer as a time‐dependent variable. Among 15 008 patients, 3.3% (n=496) were cancer patients. Observed rates of 14‐year cardiovascular mortality (31.4% versus 27.7%, P =0.31) and composite cardiovascular death, myocardial infarction, or revascularization (51.1% versus 55.8%, P =0.37) were similar for cancer versus control groups; all‐cause mortality rates were higher (79.7% versus 49.3%, P Conclusions Cancer history was present in a minority of PCI patients but was not associated with worse long‐term cardiovascular outcomes. Further investigation into PCI outcomes in this population is warranted.