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Intensive lipid management is critical to reduce cardiovascular (CV) risk for patients with diabetes mellitus (DM)., Methods: We performed an observational study of 7628 patients with (n = 2943) and without DM (n = 4685), enrolled in the Provider Assessment of Lipid Management (PALM) registry and treated at 140 outpatient clinics across the United States in 2015. Patient self-estimated CV risk, patient-perceived statin benefit and risk, observed statin therapy use and dosing were assessed., Results: Patients with DM were more likely to believe that their CV risk was elevated compared with patients without DM (39.1% vs 29.3%, P < .001). Patients with DM were more likely to receive a statin (74.2% vs 63.5%, P < .001) but less likely to be treated with guideline-recommended statin intensity (36.5% vs 46.9%, P < .001), driven by the low proportion (16.5%) of high risk (ASCVD risk ≥7.5%) primary prevention DM patients treated with a high intensity statin. Patients with DM treated with guideline-recommended statin intensity were more likely to believe they were at high CV risk (44.9% vs 38.4%, P = .005) and that statins can reduce this risk (41.1% vs 35.6%, P = .02), compared with patients treated with lower than guideline-recommended statin intensity. Compared with patients with an elevated HgbA1c, patients with well-controlled DM were no more likely to be on a statin (77.9% vs 79.3%, P = .43)., Conclusions: In this nationwide study, the majority of patients with DM were treated with lower than guideline-recommended statin intensity. Patient education and engagement may help providers improve lipid therapy for these high-risk patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Adherence to guideline-recommended statin recommendations in the United States is suboptimal. Patients' likelihood to be treated according to guidelines may vary by the practice in which they are treated., Methods: Variation in the use of statin therapy in 5445 patients, with known or at high risk for atherosclerotic cardiovascular disease (ASCVD) and meeting a statin treatment indication, was examined across 74 US Patient and Provider Assessment of Lipid Management (PALM) Registry clinics. Multivariable generalized linear mixed modeling was used to determine the median odds ratio (MOR) for statin use and 2013 American College of Cardiology/American Heart Association guideline-recommended statin intensity by practice. MOR quantifies between-practice variation by comparing the odds of receiving guideline-recommended statin treatment in a patient from a randomly selected practice with a similar patient from another random practice. Risk-adjusted low-density lipoprotein cholesterol (LDL-C) control (<100 and <70 mg/dL) was compared among practice tertiles based on percentage of eligible patients receiving recommended statin intensity., Results: Among 74 practices (43.2% cardiology) comprised of 300 healthcare providers enrolling 5445 patients (56.2% with ASCVD), statin use at the guideline-recommended intensity at practices varied widely (12.7-71.4%; adjusted MOR 1.45, 95% confidence interval [CI] 1.35-1.64). Results were consistent when evaluated for any statin use overall (adjusted MOR 1.75, 95% CI 1.48-1.99) and when stratified by primary versus secondary prevention patients. Relative to practices with lowest or mid-tertile statin use of statins, highest tertile clinics were more frequently cardiology practices (68.0% vs 48.0% vs 12.5%, P < .001). Compared with lowest tertile clinics, patients at highest tertile clinics were more likely to achieve LDL-C <70 mg/dL (adjusted odds ratio [OR] 1.49, 95% CI 1.08-2.04) and <100 mg/dL (adjusted OR 1.78, 95% CI 1.41-2.25)., Conclusions: US clinics varied widely in their adherence to guideline recommendations for statin therapy, which contributed to significant differences in LDL-C levels., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To determine how often unnecessary resting echocardiograms that are "not recommended" by clinical practice guidelines are performed in patients with stable chest pain and normal resting electrocardiograms (ECGs)., Background: There are scant data to indicate how often Class III recommendations are ignored in clinical practice., Patients and Methods: We searched electronically all medical records of referral outpatients seen at Mayo Clinic Rochester from January 1, 2010, through December 31, 2013, to identify patients with stable chest pain and known or suspected coronary artery disease who underwent resting echocardiography and had normal resting ECGs and no other indication for echocardiography., Results: Of the 15,529 referral outpatients who were evaluated at Mayo Clinic Rochester with chest pain, 3976 (25.6%) had resting echocardiograms. Eight hundred seventy of these 3976 patients (21.9%) had normal resting ECGs. Six hundred nineteen of these 870 patients (71.1%) had other indications for echocardiography. The remaining 251 patients (6.3% of all echocardiograms and 1.6% of all patients) had normal resting ECGs and no other indication for echocardiography. Two hundred thirty-nine of these 251 patients (95.2%) had normal echocardiograms. Of the 12 abnormal echocardiograms, only 4 led to any change in clinical management. Sixty-one of these 251 echocardiograms (24.3%) were "preordered" before the provider (physicians, nurses, physician assistants) visit., Conclusion: Echocardiograms were performed in 1 in 4 referral outpatients with chest pain seen at Mayo Clinic Rochester. However, only 1 in 16 of these echocardiograms was performed in violation of the class III recommendation in the American College of Cardiology Foundation/American Heart Association guidelines for the management of stable angina. These unnecessary echocardiograms were almost always normal, and had little impact on clinical management. The rate of unnecessary echocardiograms could be decreased by eliminating preordering., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The latest cholesterol guidelines have shifted focus from achieving low-density lipoprotein cholesterol (LDL-C) targets toward statin use and intensity guided by atherosclerotic cardiovascular disease (ASCVD) risk., Methods: Statin use and intensity were evaluated in 5,905 statin-eligible primary or secondary prevention patients from 138 PALM Registry practices., Results: Overall, 74.7% of eligible adults were on statins; only 42.4% were on guideline-recommended intensity. Relative to primary prevention patients, ASCVD patients were more likely to be on a statin (83.6% vs 63.4%, P<.0001) and guideline-recommended intensity (47.3% vs 36.0%, P<.0001). Men were more likely than women to be prescribed recommended intensity for primary (odds ratio [OR] 1.87, 95% CI 1.49-2.34) and secondary (OR 1.47, 95% CI 1.26-1.70) prevention. In primary prevention, increasing age, diabetes, obesity, hypertension, and lower 10-year ASCVD risk were associated with increased odds of receiving recommended intensity. Among ASCVD patients, those with coronary artery disease were more likely to be on recommended intensity than cerebrovascular or peripheral vascular disease patients (OR 1.71, 95% CI 1.41-2.09), as were those seen by cardiologists (OR 1.43, 95% CI 1.12-1.83). Median LDL-C levels were highest among patients not on statins (124.0 mg/dL) and slightly higher among those on lower-than-recommended intensity compared with recommended-therapy recipients (88.0 and 84.0 mg/dL, respectively; P≤.0001)., Conclusions: In routine contemporary practice, 1 in 4 guideline-eligible patients was not on a statin; less than half were on the recommended statin intensity. Untreated and undertreated patients had significantly higher LDL-C levels than those receiving guideline-directed statin treatment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Patients with atrial fibrillation (AF) have many comorbidities and excess risks of hospitalization and death. Whether the impact of comorbidities on outcomes is greater in AF than the general population is unknown., Methods: One thousand four hundred thirty patients with AF and community controls matched 1:1 on age and sex were obtained from Olmsted County, Minnesota. Andersen-Gill and Cox regression estimated associations of 19 comorbidities with hospitalization and death, respectively., Results: AF cases had a higher prevalence of most comorbidities. Hypertension (25.4%), coronary artery disease (17.7%), and heart failure (13.3%) had the largest attributable risk of AF; these along with obesity and smoking explained 51.4% of AF. Over a mean follow-up of 6.3 years, patients with AF experienced higher rates of hospitalization and death than did population controls. However, the impact of comorbidities on hospitalization and death was generally not greater in patients with AF compared with controls, with the exception of smoking. Ever smokers with AF experienced higher-than-expected risks of hospitalization and death, with observed vs expected (assuming additivity of effects) hazard ratios compared with never smokers without AF of 1.78 (1.56-2.02) vs 1.52 for hospitalization and 2.41 (2.02-2.87) vs 1.84 for death., Conclusions: Patients with AF have a higher prevalence of most comorbidities; however, the impact of comorbidities on hospitalization and death is generally similar in AF and controls. Smoking is a notable exception; ever smokers with AF experienced higher-than-expected risks of hospitalization and death. Thus, interventions targeting modifiable behaviors may benefit patients with AF by reducing their risk of adverse outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Despite improvements in diagnosis and treatment, the prevalence of hyperlipidemia among adults in the United States remains high. Data are limited on treatment patterns and patient perceptions of cardiovascular disease risk since the release of new lipid guidelines., Objectives: The objectives of the PALM registry are to assess contemporary patterns of lipid-lowering therapy use among adults receiving care in a nationally representative cohort of community clinics, determine consistency of treatment with varying lipid guidelines, identify factors affecting use of lipid-lowering therapy including patient-reported statin intolerance, and assess patient and provider knowledge of cardiovascular risk reduction goals., Study Design: The PALM registry will enroll 7,500 patients likely to be considered for lipid-lowering therapy from 175 cardiology, primary care, and endocrinology practices across the United States. In this cross-sectional, observational registry, a novel tablet-based platform will be used to collect patient-reported knowledge, attitudes, and beliefs regarding cardiovascular risk reduction and lipid management. Chart abstraction and core laboratory lipid levels will describe current lipid management. Provider surveys will assess perception of current lipid-lowering goals and barriers to optimal cardiovascular risk reduction., Conclusion: The PALM registry will allow for better understanding of current practice patterns, patient experiences, and patient and provider attitudes toward cholesterol management for cardiovascular disease risk reduction. These data can be used to better understand gaps in care and design targeted interventions to improve uptake of lipid-lowering therapies for cardiovascular risk reduction., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Frailty, an important prognostic indicator in heart failure (HF), may be defined as a biological phenotype or an accumulation of deficits. Each method has strengths and limitations, but their utility has never been evaluated in the same community HF cohort., Methods: Southeastern Minnesota residents with HF were recruited from 2007 to 2011. Frailty according to the biological phenotype was defined as 3 or more of: weak grip strength, physical exhaustion, slowness, low activity and unintentional weight loss >10 lb in 1 year. Intermediate frailty was defined as 1 to 2. The deficit index was defined as the proportion of deficits present out of 32 deficits., Results: Among 223 patients (mean age 71 ± 14, 61% male), 21% were frail and 48% intermediate frail according to the biological phenotype. The deficit index ranged from 0.02-0.75, with a mean (SD) of 0.25 (0.13). Over a mean follow-up of 2.4 years, 63 patients died. After adjustment for age, sex and ejection fraction, patients categorized as frail by the biological phenotype had a 2-fold increased risk of death compared to those with no frailty, whereas a 0.1 unit increase in the deficit index was associated with a 44% increased risk of death. Both measures predicted death equally (C-statistics: 0.687 for biological phenotype and 0.700 for deficit index)., Conclusion: The deficit index and the biological phenotype equally predict mortality. As the biological phenotype is not routinely assessed clinically, the deficit index, which can be ascertained from medical records, is a feasible alternative to ascertain frailty., (© 2013.)

Background: Atrial fibrillation (AF) often complicates myocardial infarction (MI). While AF adversely impacts survival in MI patients, the impact of AF on health care utilization has not been studied., Methods: The risk of hospitalizations, emergency department (ED) visits, and outpatient visits associated with prior, new-onset (<30 days post-MI), and late-onset (≥30 days post-MI) AF was assessed among incident MI patients from the Olmsted County, Minnesota, community., Results: Of 1,502 MI patients, 237 had prior AF, 163 developed new-onset AF, 113 developed late-onset AF, and 989 had no AF. Over a mean follow-up of 3.9 years, 3,661 hospitalizations, 5,559 ED visits, and 80,240 outpatient visits occurred. After adjustment, compared with patients without AF, those with prior and new-onset AF exhibited a 1.6-fold and 1.3-fold increased risk of hospitalization, respectively. In contrast, late-onset AF carried a 2.2-fold increased risk of hospitalization. The hazard ratios were 1.4, 1.2, and 1.8 for ED visits and 1.4, 1.2, and 1.7 for outpatient visits for prior, new-onset, and late-onset AF. Additional adjustment for time-dependent recurrent MI and heart failure attenuated the results slightly for hospitalizations and ED visits; however, patients with late-onset AF still exhibited a >50% increased risk for both utilization measures., Conclusions: In MI patients, the risk of hospitalizations, ED visits, and outpatient visits differed by the timing of AF onset, with the greatest risk conferred by late-onset AF. Atrial fibrillation imparts an adverse prognosis after MI, underscoring the importance of its management in MI patients., (© 2013.)

Background: The goal of heart failure (HF) performance measures is to improve quality of care by assessing the implementation of guidelines in eligible patients. Little is known about the proportion of eligible patients and how performance measures are implemented in the community., Methods: We determined the eligibility for and adherence to performance measures and β-blocker therapy in a community-based cohort of hospitalized HF patients from January 2005 to June 2011., Results: All of the 465 HF inpatients (median age 76 years, 48% men) included in the study received an ejection fraction assessment. Only 164 had an ejection fraction <40% thus were candidates for β-blocker and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) therapy. Considering absolute contraindications, 99 patients were eligible to receive ACE inhibitors/ARB, and 162 to receive β-blockers. Among these, 85% received ACE inhibitors/ARBs and 91% received β-blockers. Among the 261 individuals with atrial fibrillation, 89 were eligible for warfarin and 54% received it. Of 52 current smokers, 69% received cessation counseling during hospitalization., Conclusion: In the community, among eligible hospitalized HF patients, the implementation of performance measures can be improved. However, as most patients are not candidates for current performance measures, other approaches are needed to improve care and outcomes., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: Myocardial infarction (MI) and chronic obstructive pulmonary disease (COPD) are frequent and share common risk factors. Yet, studies on MI patients reported limited and conflicting results on the prevalence of COPD, its impact on outcome, and how these may have changed over time. We examined, in a geographically defined community, the prevalence of COPD in patients with MI, its impact on mortality, and how these associations changed over time., Methods: Residents of Olmsted County, Minnesota, who experienced an MI meeting standardized criteria from 1979 to 2007 were included (3,438, 42% women, mean age 68 +/- 15 years). Chronic obstructive pulmonary disease was ascertained from the medical records., Results: Of 3,438 patients, 415 (12%) had COPD. During the study, COPD prevalence increased from 7% in 1979-1985 to 15% in 2000-2007 (P < .001). Survival was worse in patients with COPD than in those without COPD (5-year survival rate: 46% [95% CI 41%-52%] vs 68% [95% CI 66%-70%], respectively; P < .01). The association between COPD and death was independent of age and risk factors (adjusted hazard ratio 1.30, 95% CI 1.10-1.54, P < .01) and did not change over time., Conclusions: In a large community of patients with MI, the prevalence of COPD increased over time and was associated with a markedly increased risk of death after MI independently of age, risk factors, and comorbidity. This underscores the importance of this condition and the need to optimize care for these high-risk patients., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

Background: Participation rates in cardiac rehabilitation after myocardial infarction (MI) remain low. Studies investigating the predictive value of psychosocial variables are sparse and often qualitative. We aimed to examine the demographic, clinical, and psychosocial predictors of participation in cardiac rehabilitation after MI in the community., Methods: Olmsted County, Minnesota, residents hospitalized with MI between June 2004 and May 2006 were prospectively recruited, and a 46-item questionnaire was administered before hospital dismissal. Associations between variables and cardiac rehabilitation participation were examined using logistic regression., Results: Among 179 survey respondents (mean age 64.8 years, 65.9% male), 115 (64.2%) attended cardiac rehabilitation. The median (25th-75th percentile) number of sessions attended within 90 days of MI was 13 (5-20). Clinical characteristics associated with rehabilitation participation included younger age (odds ratio [OR] 0.95 per 1-year increase), male sex (OR 1.93), lack of diabetes (OR 2.50), ST-elevation MI (OR 2.63), receipt of reperfusion therapy (OR 7.96), in-hospital cardiologist provider (OR 18.82), no prior MI (OR 4.17), no prior cardiac rehabilitation attendance (OR 3.85), and referral to rehabilitation in the hospital (OR 12.16). Psychosocial predictors of participation included placing a high importance on rehabilitation (OR 2.35), feeling that rehabilitation was necessary (OR 10.11), better perceived health before MI (excellent vs poor OR 7.33), the ability to drive (OR 6.25), and post-secondary education (OR 3.32)., Conclusions: Several clinical and psychosocial factors are associated with decreased participation in cardiac rehabilitation programs after MI in the community. As many are modifiable, addressing them may improve participation and outcomes.

Objectives: The aim of this study is to evaluate ventricular function and the occurrence of heart failure (HF) among persons with myocardial infarction (MI) meeting only troponin criteria compared to persons meeting creatine kinase and its MB fraction (CK-MB) criteria., Background: The 2000 American College of Cardiology/European Society of Cardiology MI definition enabled identification of MIs meeting only troponin-based criteria. Data on ventricular function and HF among these are lacking., Methods: Between November 2002 and May 2006, we prospectively identified 835 persons with MI in the community using standardized criteria including cardiac pain, electrocardiogram, and biomarkers. Troponin and CK-MB were prospectively measured in all; each patient was classified according to the criteria met., Results: We performed echocardiograms (median of 1 day post-MI) in 482 patients (age 68+/-15 years; 45% women); 363 patients met CK-MB criteria, whereas 119 met only troponin criteria. The latter had lower wall motion score index (1.3+/-0.4 vs 1.5+/-0.5 for CK-MB; P<.01). Diastolic dysfunction was similar in both groups. After 1 year of follow up, 142 patients developed post-MI HF. Patients meeting only troponin criteria had a lower risk of HF after adjustment for age, sex, comorbidity (hazard ratio 0.56, 95% confidence interval 0.37-0.85, P<.01), which persisted after further adjustments for systolic or diastolic function., Conclusions: In the community, the prospective application of the new MI definition identifies patients meeting only troponin criteria with better systolic function than cases meeting CK-MB criteria. Such MIs have a lower risk of subsequent HF. These findings are important for risk stratification in clinical practice.

Background: The diagnosis of angina is challenging because it relies on symptom descriptions. Natural language processing (NLP) of the electronic medical record (EMR) can provide access to such information contained in free text that may not be fully captured by conventional diagnostic coding., Objective: To test the hypothesis that NLP of the EMR improves angina pectoris ascertainment over diagnostic codes., Methods: Billing records of inpatients and outpatients were searched for International Classification of Diseases, Ninth Revision (ICD-9) codes for angina pectoris, chronic ischemic heart disease, and chest pain. EMR clinical reports were searched electronically for 50 specific nonnegated natural language synonyms to these ICD-9 codes. The 2 methods were compared to a standardized assessment of angina by Rose questionnaire for 3 diagnostic levels: unspecified chest pain, exertional chest pain, and Rose angina., Results: Compared with the Rose questionnaire, the true-positive rate of EMR-NLP for unspecified chest pain was 62% (95% CI 55-67) versus 51% (95% CI 44-58) for diagnostic codes (P < .001). For exertional chest pain, the EMR-NLP true-positive rate was 71% (95% CI 61-80) versus 62% (95% CI 52-73) for diagnostic codes (P = .10). Both approaches had 88% (95% CI 65-100) true-positive rate for Rose angina. The EMR-NLP method consistently identified more patients with exertional chest pain over a 28-month follow-up., Conclusion: EMR-NLP method improves the detection of unspecified and exertional chest pain cases compared to diagnostic codes. These findings have implications for epidemiological and clinical studies of angina pectoris.

Background: Sex-specific data on classic risk factors and their impact after myocardial infarction (MI) in the community are lacking. We evaluated the prevalence and association of classic risk factors with recurrent ischemic events in patients with MI and tested the hypothesis that they differed by sex., Methods: All patients (1104, 45% women) from Olmsted County, Minnesota, hospitalized with an incident MI between 1990 and 1998 were identified using standardized criteria and followed-up (mean 3.7 years) for recurrent ischemic events, defined as recurrent MI, ischemic stroke, or coronary death. Data on hypertension, diabetes, hypercholesterolemia, smoking, and obesity at index hospitalization were analyzed individually and in clusters., Results: Women were older than men (73 vs 64 years, P < .001) and had more risk factors. During follow-up, 423 events occurred. For women, the adjusted risk of recurrent events increased with hypertension, diabetes, and hypercholesterolemia. For men, no increase in risk was detected with any risk factor. The population attributable risk of all risk factors combined was 46% (95% CI 29%-62%) in women and 19% (95% CI 6%-35%) in men. As the number of risk factors increased from 1 to > or = 4, compared with no risk factors, the adjusted hazard ratio in women increased progressively (1.12, 1.82, 2.34, and 2.68, respectively), whereas no trend was detected in men (1.40, 1.27, 1.24, and 1.37, respectively) (P = .01 for effect modification by sex)., Conclusions: Classic risk factors are highly prevalent and often clustered in MI, especially among women. Although their predictive value for recurrent ischemic events is marginal in men, strong associations exist in women, which define secondary prevention opportunities.

Background: Although studies have examined the incidence of stroke in heart failure (HF), their findings are inconsistent and difficult to interpret because of heterogeneity in study design and population. Although HF remains a highly fatal disease, the excess mortality imparted from stroke is unknown., Methods: A random sample of cases of HF from 1979 to 1999 was identified and validated according to Framingham criteria. Strokes were identified by screening medical diagnoses and subsequent physician validation. Stroke risk in HF was compared with the risk in the general population with standardized morbidity ratios. Associations between selected characteristics and stroke were examined using proportional hazards regression., Results: The study cohort included 630 persons with incident HF. During a median of 4.3 years of follow-up, 102 (16%) experienced an ischemic stroke. Heart failure was associated with a 17.4-fold increased risk for stroke compared with the general population in the first 30 days after HF diagnosis and remained elevated during 5 years of follow-up. Older persons with prior stroke or diabetes were more likely to experience stroke after HF diagnosis. Persons with stroke after HF were 2.31 times more likely to die compared with persons without stroke., Conclusions: In the community, persons with HF have a large increase in the risk for ischemic stroke compared with the general population. Stroke results in a >2-fold increase in mortality. Thus, prevention of stroke has the potential to improve survival among patients with HF, particularly among the elderly and those with diabetes or prior stroke.

Background: Although myocardial infarction (MI) severity is declining, the occurrence of ventricular arrhythmia (VA) after MI and its effect on outcome is unknown. This study was undertaken to examine the frequency and timing of VA and the effect of VA on mortality after MI., Methods: Myocardial infarctions recorded between 1979 and 1998 were validated. Baseline characteristics, occurrence of VA, and survival were determined. Ventricular arrhythmias were categorized as primary ventricular fibrillation (VF), nonprimary VF, and ventricular tachycardia (VT). Logistic regression was used to analyze associations between VA and baseline characteristics. Temporal trends were assessed with the Mantel-Haenszel chi2. Survival was analyzed with the Kaplan-Meier method. Proportional hazards regression was used to examine the association between death and occurrence of VA., Results: Among 2317 persons with incident MI, 7.5% experienced VA (3.6% nonprimary VF, 2.1% primary VF, 1.8% VT). Ventricular arrhythmia-associated factors were younger age, female sex, higher Killip class, ST elevation, and atrial fibrillation. Ventricular arrhythmias were associated with increased risk of death at 30 days., Conclusion: Ventricular arrhythmias after MI are relatively common, particularly among persons with more severe MI and no prior history of coronary disease. Over time, the incidence of VF declined, whereas VT did not change. Ventricular arrhythmia after MI was associated with a 6-fold increase in morality. Thus, identification of high-risk MI survivors and prevention of VA could markedly improve outcomes. Further studies are needed to determine the cause of the shift in distribution of VA subtype.

Background: Studies have reported that a large proportion of the cases of congestive heart failure (CHF) with mixed etiologies have preserved left ventricular systolic function. Whether this is the case in subjects with CHF after myocardial infarction (MI) is not known. This study was undertaken to examine the prevalence and characteristics associated with CHF in patients who had preserved ejection fraction (LVEF) after MI., Methods: Clinical characteristics and LVEF were ascertained in a population-based cohort of patients with CHF after incident MI in Olmsted County, Minn. All MIs were validated by use of standardized epidemiological criteria, and all episodes of CHF were validated by use of Framingham criteria., Results: Between 1979 and 1994, 1658 patients had an MI, and 644 of these patients (38%) had CHF during 7.4 +/- 5.4 years of follow-up. Of these patients, 395 (61%) underwent LVEF assessment. Preserved LVEF (ie, > or =50%) was present in 30% of cases, and this proportion did not change with time. The proportion of women with CHF and preserved LVEF (37%) was greater than the proportion of men (23%, P =.002). The positive association between female sex and preserved LVEF remained significant after adjustment (odds ratio 1.97, 95% CI 1.26-3.07, P =.003). The highest tertile of peak creatinine phosphokinase level was negatively associated with preserved LVEF (odds ratio 0.51, 95% CI 0.29-0.89)., Conclusion: A notable proportion of cases of CHF after MI have preserved LVEF. This underscores the burden of CHF with preserved LVEF in a well-defined group of patients with documented coronary disease. CHF with preserved LVEF after MI is associated with female sex and smaller MI size.

Objectives: This study was designed to describe the experience of our center with the safety and feasibility of dobutamine stress echocardiography (DSE) in aortic stenosis (AS), to characterize the hemodynamic response to dobutamine infusion, and to examine the hemodynamic response in relation to the anatomic evaluation of the valve among patients who underwent valve replacement., Background: The diagnosis of the hemodynamic severity of AS can be difficult when the cardiac output is reduced and the gradient is low, but the effective valve area calculates to be small. DSE has been proposed as a means of assessing the severity of AS in this setting., Methods: We reviewed 27 patients (18 men, 9 women; mean age 71 +/- 12 years) with AS who underwent DSE between 1991 and 1996., Results: Fifteen (55%) patients were New York Heart Association class III or IV, 8 (30%) had angina Canadian class III or IV, and 3 (11%) syncope. Dobutamine peak dose was 27 +/- 11 micrograms/kg/min. Sixteen (59%) patients had mild side effects. DSE resulted in a significant increase in the cardiac output from 4.1 +/- 1.2 L/min at rest to 7.3 +/- 1.9 L/min at peak dose, and in heart rate (76 +/- 16 beats/min to 124 +/- 20 beats/min), systolic blood pressure (128 +/- 26 mm Hg to 137 +/- 26 mm Hg), ejection fraction (38% +/- 20% to 42% +/- 20%), and transvalvular mean gradient (28 +/- 10 mm Hg to 39 +/- 9 mm Hg) (P <.05). There was also a significant increase in the valve area from 0.77 +/- 0.14 cm2 at rest to 0.97 +/- 0.21 cm2 (P <.001). Seven patients underwent surgery; all valves were severely calcified, confirming anatomic disease. In this group, an increase in the mean gradient but also a trend toward an increase in the valve area were noted in response to dobutamine: 33 +/- 10 mm Hg to 47 +/- 6 mm Hg and 0.79 +/- 0.11 cm2 to 0.95 +/- 0.19 cm2, respectively., Conclusion: Although more data are needed to fully establish the safety of the test in this indication, this study suggests that patients with AS can safely undergo DSE. Dobutamine results in an increase not only in the mean gradient, but also in the valve area. An increase in valve area with dobutamine was observed in some patients with anatomically confirmed severe AS and thus does not exclude fixed valve disease.

Four hundred seven patients with aortic stenosis who had Doppler echocardiography before surgery were studied to determine the feasibility of Doppler-derived valve resistance calculation and its clinical value. Patients with milder aortic stenosis had lower mean gradient, larger valve area, and lower maximal resistance than those with severe stenosis. Maximal resistance was related strongly to aortic stenosis severity but did not add any information after valve area and gradient were known and was not related to surgical mortality.

This study examined progression of aortic stenosis (AS) as assessed by Doppler echocardiography. One hundred twelve consecutive adult patients had calcific AS and underwent three examinations during a mean 25-month period (range 7 to 54 months). At the time of entry into the study, mean values for initial peak aortic velocity and ejection fraction (EF) were 2.9 +/- 0.7 m/sec and 63 +/- 10%, respectively; 52% of the patients were symptomatic. At the third examination the percentage of symptomatic patients increased to 65% (p = 0.0039 compared to baseline values), and the aortic peak velocity increased to 3.3 +/- 0.8 m/sec (p less than 0.001). Age, sex, and EF were not predictors of progression. Documented coronary artery disease (in 57 patients) did not affect progression, and neither did the aortic peak velocity at the time of entry into the study. Thirty-eight patients reported an increase in symptoms from the first to third examination, and their rate of progression was significantly different from that of the rest of the population: 0.33 +/- 0.50 m/sec/yr compared to 0.18 +/- 0.26 m/sec/yr (p less than 0.03).