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The article presents the initial scientific statement of the American Heart Association (AHA) and the American College of Cardiology Foundation (ACCF) relating to secondary prevention of coronary heart disease (CHD) in older patients. Both organizations recognize the benefits of CHD risk reduction in patients with atherosclerotic vascular disease. The diagnosis, risk factors, clinical manifestations, prognosis and treatment of patients with CHD are discussed.

Abstract: Background: Heart failure is a leading cause of hospital admission and readmission in older adults. The new United States healthcare reform law has created provisions for financial penalties for hospitals with higher than expected 30-day all-cause readmission rates for hospitalized Medicare beneficiaries aged ≥65 years with heart failure. We examined the effect of digoxin on 30-day all-cause hospital admission in older patients with heart failure and reduced ejection fraction. Methods: In the main Digitalis Investigation Group trial, 6800 ambulatory patients with chronic heart failure (ejection fraction ≤45%) were randomly assigned to digoxin or placebo. Of these, 3405 were aged ≥65 years (mean age, 72 years; 25% were women; 11% were nonwhite). The main outcome in the current analysis was 30-day all-cause hospital admission. Results: In the first 30 days after randomization, all-cause hospitalization occurred in 5.4% (92/1693) and 8.1% (139/1712) of patients in the digoxin and placebo groups, respectively, (hazard ratio {HR} when digoxin was compared with placebo, 0.66; 95% confidence interval {CI}, 0.51-0.86; P=.002). Digoxin also reduced both 30-day cardiovascular (3.5% vs 6.5%; HR, 0.53; 95% CI, 0.38-0.72; P<.001) and heart failure (1.7 vs 4.2%; HR, 0.40; 95% CI, 0.26-0.62; P<.001) hospitalizations, with similar trends for 30-day all-cause mortality (0.7% vs 1.3%; HR, 0.55; 95% CI, 0.27-1.11; P=.096). Younger patients were at lower risk of events but obtained similar benefits from digoxin. Conclusions: Digoxin reduces 30-day all-cause hospital admission in ambulatory older patients with chronic systolic heart failure. Future studies need to examine its effect on 30-day all-cause hospital readmission in hospitalized patients with acute heart failure. [Copyright &y& Elsevier]

Objectives: The goal of this study was to compare the prognostic efficacy of the 6-min walk (6MW) and cardiopulmonary exercise (CPX) tests in stable outpatients with chronic heart failure (HF). Background: CPX and 6MW tests are commonly applied as prognostic gauges for systolic HF patients, but few direct comparisons have been conducted. Methods: Stable New York Heart Association (NYHA) functional class II and III systolic HF patients (ejection fraction ≤35%) from the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trial were studied. 6MW distance (6MWD) and CPX indices (peak oxygen consumption [VO2] and ventilatory equivalents for exhaled carbon dioxide [VE/VCO2] slope) were compared as predictors of all-cause mortality/hospitalization and all-cause mortality over 2.5 years of mean follow-up. Results: A total of 2,054 HF-ACTION participants underwent both CPX and 6MW tests at baseline (median age 59 years; 71% male; 64% NYHA functional class II and 36% NYHA functional class III/IV). In unadjusted models and in models that included key clinical and demographic covariates, C-indices of 6MWD were 0.58 and 0.65 (unadjusted) and 0.62 and 0.72 (adjusted) in predicting all-cause mortality/hospitalization and all-cause mortality, respectively. C-indices for peak VO2 were 0.61 and 0.68 (unadjusted) and 0.63 and 0.73 (adjusted). C-indices for VE/VCO2 slope were 0.56 and 0.65 (unadjusted) and 0.61 and 0.71 (adjusted); combining peak VO2 and VE/VCO2 slope did not improve the C-indices. Overlapping 95% confidence intervals and modest integrated discrimination improvement values confirmed similar prognostic discrimination by 6MWD and CPX indices within adjusted models. Conclusions: In systolic HF outpatients, 6MWD and CPX indices demonstrated similar utility as univariate predictors for all-cause hospitalization/mortality and all-cause mortality. However, 6MWD or CPX indices added only modest prognostic discrimination to models that included important demographic and clinical covariates. [Copyright &y& Elsevier]

Increasing life expectancy in industrialized societies has resulted in a huge population of older adults with cardiovascular disease. Despite advances in device therapy and surgery, the mainstay of treatment for these disorders remains pharmacological. Hypertension affects two-thirds of older adults and remains a potent risk factor for coronary artery disease, chronic heart failure, atrial fibrillation, and stroke in this age group. Numerous trials have demonstrated reduction in these adverse outcomes with antihypertensive drugs. After acute myocardial infarction, β-adrenergic blockers reduce mortality regardless of patient age. Statins and antiplatelet drugs have proven beneficial in both primary and, especially, secondary prevention of coronary events in older adults. In elders with chronic heart failure, loop diuretics must be used cautiously, owing to their higher potential for adverse effects, whereas angiotensin-converting-enzyme inhibitors and β-blockers reduce symptoms and prolong survival. The high risk of stroke in elderly patients with atrial fibrillation is markedly reduced with warfarin, although bleeding risk is increased. The high prevalence of polypharmacy among older adults with cardiovascular disease, coupled with age-associated physiological changes and comorbidities, provides major challenges in adherence and avoidance of drug-related adverse events. [ABSTRACT FROM AUTHOR]

Objectives: This secondary analysis from the SANDS (Stop Atherosclerosis in Native Diabetics Study) trial examines the effects of lowering low-density lipoprotein cholesterol (LDL-C) with statins alone versus statins plus ezetimibe on common carotid artery intima-media thickness (CIMT) in patients with type 2 diabetes and no prior cardiovascular event. Background: It is unknown whether the addition of ezetimibe to statin therapy affects subclinical atherosclerosis. Methods: Within an aggressive group (target LDL-C ≤70 mg/dl; non–high-density lipoprotein cholesterol ≤100 mg/dl; systolic blood pressure ≤115 mm Hg), change in CIMT over 36 months was compared in diabetic individuals >40 years of age receiving statins plus ezetimibe versus statins alone. The CIMT changes in both aggressive subgroups were compared with changes in the standard subgroups (target LDL-C ≤100 mg/dl; non–high-density lipoprotein cholesterol ≤130 mg/dl; systolic blood pressure ≤130 mm Hg). Results: Mean (95% confidence intervals) LDL-C was reduced by 31 (23 to 37) mg/dl and 32 (27 to 38) mg/dl in the aggressive group receiving statins plus ezetimibe and statins alone, respectively, compared with changes of 1 (−3 to 6) mg/dl in the standard group (p < 0.0001) versus both aggressive subgroups. Within the aggressive group, mean CIMT at 36 months regressed from baseline similarly in the ezetimibe (−0.025 [−0.05 to 0.003] mm) and nonezetimibe subgroups (−0.012 [−0.03 to 0.008] mm) but progressed in the standard treatment arm (0.039 [0.02 to 0.06] mm), intergroup p < 0.0001. Conclusions: Reducing LDL-C to aggressive targets resulted in similar regression of CIMT in patients who attained equivalent LDL-C reductions from a statin alone or statin plus ezetimibe. Common carotid artery IMT increased in those achieving standard targets. (Stop Atherosclerosis in Native Diabetics Study [SANDS]; NCT00047424) [Copyright &y& Elsevier]

Objectives: The purpose of this study was to characterize how aging impacts the left ventricular (LV) functional reserve. Background: Early diastolic LV filling slows markedly with advancing age, but the effects of β-adrenergic stimulation on filling, and its major determinant, relaxation, have not been investigated in an aging population. Although the responses of contractility and heart rate to catecholamines reportedly diminish with age, the effect of age on the responses to steady-state dobutamine infusions is unclear. Methods: Groups of younger (40 ± 10 years, n = 26) and older (68 ± 11 years, n = 24) normal adult patients were studied at baseline and at three progressive dobutamine infusion dosages (5, 10, and 20 μg/kg/min). The LV function was evaluated by two-dimensional and Doppler echocardiography. Myocardial relaxation was evaluated from cardiovascular magnetic resonance (CMR)-based ρ, a preload-independent surrogate for τ . Effective LV pump-function index (PFi), defined as systolic blood pressure/end-systolic LV diameter, was measured. Results: Both groups showed expected dose-dependent increases in heart rate and LV systolic function, diastolic function, and relaxation. Early LV filling reserve was much greater in younger than older patients (E-wave increase from baseline to highest dose, 24.0 vs. 9.5 cm/s, p < 0.004), although the dose responses of ρ were indistinguishable (0.18% vs. 0.19%/ms, p = 0.22). Whereas dobutamine caused a significantly greater increase of PFi in younger than older patients (30.1 vs. 15.6 mm Hg/cm, p < 0.0001), there was no difference in heart rate augmentation (37 vs. 38 beats/min, p = 0.94). Conclusions: Aging is accompanied by a blunted inotropic but preserved chronotropic response to steady-state dobutamine infusion. Although LV filling reserve declines with age, relaxation reserve does not. [Copyright &y& Elsevier]

Increased thickness and stiffness of large arteries may contribute to why aging is the most important risk for cardiovascular diseases. Arterial stiffness, intimal medial thickness, and alcohol intake were measured in 563 subjects. A U-shaped relation was found between alcohol intake and a stiffness index, with the lowest index in moderate drinkers, which may partially explain the relation between alcohol and cardiovascular disease. [Copyright &y& Elsevier]

MRI and echocardiographic assessment of the diastolic dysfunction of normal aging: altered LV pressure decline or load? Am J Physiol Heart Circ Physiol 286: H782–H788, 2004. First published October 9, 2003; 10.1152/ajpheart.01092.2002.—Changes in diastolic indexes during normal aging, including reduced early filling velocity (E), lengthened E deceleration time (DT), augmented late filling (A), and prolonged isovolumic relaxation time (IVRT), have been attributed to slower left ventricular (LV) pressure (LVP) decay. Indeed, this constellation of findings is often referred to as the ‘abnormal relaxation’ pattern. However, LV filling is determined by the atrioventricular pressure gradient, which depends on both LVP decline and left atrial (LA) pressure (LAP). To assess the relative influence of LVP decline and LAP, we studied 122 normal subjects aged 21–92 yr by Doppler echocardiography and MRI. LVP decline was assessed by color M-mode (Vp) and the LV untwisting rate. Early diastolic LAP was evaluated using pulmonary vein flow systolic fraction, pulmonary vein flow diastolic DT, color M-mode (E/Vp), and tissue Doppler (E/Em). Linear regression showed the expected reduction of E, increase in A, and prolongation of IVRT and DT with advancing age. There was no relation of age to parameters reflecting the rate of LVP decline. However, older age was associated with reduced E/Vp (P = 0.008) and increased pulmonary vein systolic fraction (P < 0.001), pulmonary vein DT (P = 0.0026), and E/Em (P < 0.0001), all suggesting reduced early LAP. Therefore, reduced early filling in older adults may be more closely related to a reduced early diastolic LAP than to slower LVP decline. This effect also explains the prolonged IVRT. We postulate that changes in LA active or passive properties may contribute to development of the abnormal relaxation pattern during the aging process. [ABSTRACT FROM AUTHOR]

: BackgroundWe examined secular trends in leisure-time physical activities (LTPA) in health-conscious men (n = 1359) from 1958 to 1998 and in women (n = 839) from 1978 to 1998, who were participants of the Baltimore Longitudinal Study of Aging (BLSA).: MethodsLTPA was the self-reported time spent performing 97 activities, and was converted to metabolic equivalent of oxygen uptake (MET) minutes per day. Evaluations of LTPA were averaged for each decade. The prevalence of a sedentary lifestyle in each decade was assessed based on compliance with widely publicized recommendations for participation in physical activity. All analyses were adjusted for age, education, and race differences across decades.: ResultsMedian high-intensity LTPA, defined as activities ≥6 METs, increased from 30 to 80 MET min/day from the 1960s to the 1990s for men (P < 0.01) but did not change between the 1970s and the 1990s in women. Moderate-intensity LTPA, defined as 4–5.9 METs, did not change significantly over these periods in either sex. The percentage of sedentary men, defined as those performing <40 MET min/day of high-intensity LTPA, declined across the four decades, whereas for women it did not change significantly.: ConclusionsIn a health-conscious sample across a broad age range, national recommendations appear to have made modest progress in decreasing the proportion of sedentary adults. [Copyright &y& Elsevier]

The present investigation was designed to evaluate the acute effect of aerobic exercise on oxidative stress and the flow properties of the blood. Fourteen clinically healthy subjects (7 men and 7 women aged 56 5 ± 19 yr) underwent maximal treadmill exercise with blood samples drawn prior to and immediately after exercise. Post-exercise significant increases were observed in plasma lipid hydroperoxides from 6.5 5 ± 2.0 μM to 7.9 ± 1.9 μM (p < 0.0001) and the relative concentration of plasma fluorescent products associated with red cell peroxidation from 138 ± 28 RF to 220 ± 92 RF (p < 0.005). After exercise there was a rise in the hematocrit from 41.4 ± 3.7% to 44.4 ± 4.1% (p < 0.0001), increases in whole blood viscosity at shear rates of 22.5/sec to 450/sec (p < 0.0005), an increase in plasma viscosity from 1.27 ± 0.12 cP to 1.36 ± 0.11 cP (p < 0.01), an increase in red cell rigidity from 2.44 ± 0.48 cP to 2.62 ± 0.42 cP (p < 0.001) and a decrease in erythrocyte sedimentation rate from 26.9 ± 18.6 mm/h to 22.5 ± 15.9 mm/h (p < 0.01). The findings suggest that acute aerobic exercise induces oxidative damage to red blood cells and adversely affects rheological properties of the peripheral blood. [ABSTRACT FROM AUTHOR]

Echocardiographic left ventricular (LV) wall thickness increases with age, suggesting LV hypertrophy. However, autopsy studies have shown no change, or even a decrease, in LV mass with age. With many pathologies, LV remodeling results in changes in ventricular shape. Age-associated LV shape change might explain this discrepancy, although this has not been studied. Magnetic resonance imaging (MRI) was used in 336 healthy, normotensive adults (mean age 56 ± 18 years; 200 women, 136 men) to measure LV mass, end-diastolic LV wall thickness, length, diameter, and shape. Echocardiographic LV mass was measured in a subset of 86 subjects by a standard algorithm. In women, LV wall thickness increased by 14% (r = 0.19, p <0.02), whereas LV length decreased by 9% (r = −0.26, p = 0.0006); LV diameter was unchanged. Thus, LV mass did not vary with age (r −0.04, p = 0.06) and the sphericity index decreased (r = −0.165, p <0.05). In men, LV wall thickness and diameter were unrelated to age, but there was an 11% decrease in LV length (r = −0.29, p = 0.003); therefore, there was an 11% decrease in LV mass (r = −0.20, p = 0.019) and a decrease in the sphericity index (r = −0.218, p <0.04). No change occurred in echocardiographic LV mass with age in either gender, although echocardiographic LV wall thickness increased in both. The left ventricle becomes more spherical with age in normal adults due to reduced LV length. In women, increased LV wall thickness offsets the decreasing LV length, whereas in men, LV wall thickness fails to compensate, resulting in decreased LV mass with age. [Copyright &y& Elsevier]

Background: Previous studies have documented the prognostic value of low body weight in patients with COPD and also in general populations. However, it is not clear whether low body weight is a risk factor for COPD or a consequence of established disease. Study objective: To determine whether asymptomatic subjects with low initial body mass were at a greater risk of having COPD develop during subsequent follow-up. Design and subjects: Observational retrospective study of 458 male and 192 female participants (age range, 40 to 73 years) in the Baltimore Longitudinal Study of Aging. At baseline, the participants did not have COPD. After mean follow-up periods of 10.2 years for the men and 6.4 years for the women, 40 men and 7 women received a diagnosis of COPD. Methods: Cox proportional-hazards regression models were used to assess the relationship between COPD diagnosis and baseline body mass index (BMI) in men. Results: The risk of COPD developing in men varied inversely with baseline BMI, even after adjusting for other risk factors, including cigarette smoking, age, FEV[sub 1] percent predicted, abdominal obesity, and educational status. In men, the relative risk of COPD developing for the lowest BMI tertile relative to the highest tertile was 2.76 (95% confidence interval, 1.15 to 6.59). The small number of women who had COPD did not allow us to draw conclusions regarding BMI as a risk factor for COPD. Conclusion: After controlling for confounding variables, men with low BMI are at increased risk for getting COPD. [ABSTRACT FROM AUTHOR]

A major issue in evaluating the success of educational programs intended to improve public participation in physical activity is how to classify the intensity of activities performed. Currently, there are at least two approaches to estimating intensity of leisure time physical activity (LTPA), based on relative and absolute scales. We examined the impact of using relative versus absolute criteria on reaching physical activity goals set by the American College of Sports Medicine (ACSM; 2000) and the Surgeon General (United States Department of Health and Human Services, USDHHS, 1996). Subjects were healthy men (n = 619) and women (n = 497) aged 18-95 who were participants in the Baltimore Longitudinal Study of Aging. The percentage of subjects meeting the Surgeon General's recommendations for moderate and high intensity LTPA declined with age under the absolute classification system but increased with age when a relative intensity scale was used. Using ACSM recommendations, aging was associated with a decline in high absolute intensity LTPA. However, when a relative classification system was used, high relative intensity LTPA appeared to increase with age, inverting the relationship between high-intensity LTPA and cardiorespiratory fitness. The use of relative intensity LTPA criteria suggests that older subjects are meeting national standards for physical activity, raising questions about the appropriateness of such a scale to motivate older adults to improve their fitness. [ABSTRACT FROM AUTHOR]

Determines whether older men who have undergone intensive endurance training over many years demonstrate less age-related impairment of early diastolic left ventricular filling performance than sedentary men. Methods; Results; Comment.

Discusses the management of heart failure patients with normal systolic function in the United States. Determination of patterns of laboratory utilization and therapeutic interventions; Comparison of patient management among family practitioners, general internists, geriatricians and cardiologists.

Studies the prevalence of exercise-induced silent myocardial ischemia in athletes. Conduction of surveys on the family history of premature coronary artery disease; Risk factors for silent ischemia in men; Comparison of exercise tests in athletes and untrained men.

The article presents the abstract of "Secondary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults: A Scientific Statement From the American Heart Association," published in this journal.

BACKGROUND In the US,. around 30% of deaths from myocardial infarction occur in patients aged over 85 years, but individuals in this age group are often excluded from clinical trials. Thus, there are uncertainties about the optimum management of elderly patients with cardiac disease and their suitability for therapies that have been developed in younger individuals. OBJECTIVE To compare the baseline characteristics, treatment, and outcomes of 'older elderly' (aged ≥90 years) and 'younger elderly' (aged 75-89 years) patients with non-ST-segment elevation acute coronary syndromes (non-STE ACS). DESIGN The cohort for this retrospective, observational study was derived from the CRUSADE National Quality Improvement Initiative, which is an ongoing registry of patients admitted to hospital with non-STE ACS within 24h of symptom onset. All participants have elevated cardiac biomarkers, transient ST-segment elevation, ST-segment depression, or another high-risk characteristic for non-STE ACS. The patients included in this analysis were aged 75 years or older and registered in the CRUSADE database between 1 January 2001 and 30 June 2005. OUTCOME MEASURES The outcome measures were in-hospital mortality and in-hospital adverse events. RESULTS This analysis included 51,827 patients--46,270 in the 'younger elderly' group and 5,557 in the 'older elderly' group. There were more female patients in the older than in the younger age-group (67.4% vs 50.1%). 'Older elderly' patients had a lower incidence of traditional coronary risk factors, higher levels of HDL cholesterol, and were less likely to have undergone a previous coronary intervention or to have been cared for by a cardiologist than were those in the younger group. 'Older elderly' patients had more contraindications to guideline-based therapies than did their younger counterparts. Contraindications to cardiac catheterization were cited as being 'advanced age' in 40.6% of patients and 'do-not-resuscitate' status in 29.3%. Nevertheless, even in the absence of contraindications, 'older elderly' patients were less likely to receive guideline-based therapies than the 'younger elderly' (clopidogrel 35.5% vs 40.1%; statins 30.4% vs 45.7%; glycoprotein IIb/IIIa inhibitors 12.0% vs 29.2%; percutaneous coronary intervention 6.5% vs 20.2%; CABG surgery 1.1 % vs 9.4%; P<0.001 for all). Patients in the older age-group were more likely to die or experience adverse cardiac outcomes while in hospital than were younger patients (12.0% vs 7.8% and 26.8% vs 21.3%, respectively; P<0.001 for both). In both groups, adherence to guidelinebased therapies was associated with decreased mortality (P<0.001 for trend). Treatment with cardiac catheterization within 48h of hospital admission (odds ratio [OR] 0.70), β-blockers (OR 0.67), and aspirin (OR 0.65) produced the most pronounced reductions in mortality. CONCLUSIONS Patients with non-STE ACS aged 90 years or older are more likely to die or suffer adverse cardiac events in hospital and less likely to receive guideline-based therapies than are younger patients. Adherence to therapy in the older elderly is, however, associated with lower mortality. [ABSTRACT FROM AUTHOR]

Background: Physical activity (PA) prevents disease and promotes longevity; yet, few older adults meet the recommended daily guidelines. Wearable PA and heart rate monitors provide the opportunity to define age-related differences in the absolute and relative intensity of daily activities, and provide insight into the underlying factors influencing PA in older adults.Methods: Participants in the Baltimore Longitudinal Study of Aging (n = 440, 52% male, aged 31 to 88 years) completed a clinical assessment and wore an Actiheart monitor in the free-living environment. The association between age and minutes per day in sedentary, light, moderate, and vigorous PA was assessed using relative intensity, as defined by heart rate reserve, and absolute intensity using activity count thresholds.Results: In cross-sectional analyses, time spent in sedentary and light activities as defined by relative intensity did not differ across age (p > 0.05), whereas time spent in moderate and vigorous relative PA was higher for each 1 year increase in age (p < .01). Using absolute intensity PA thresholds, older adults registered fewer activity counts per day with more sedentary time and lesser amounts of light, moderate, and vigorous PA (p < .05). Persons with higher relative and lower absolute PA intensity had poorer functional performance and higher subclinical disease indicators.Conclusions: These findings suggest that time spent in moderate or higher intensity activities may not be lower with age after considering changes in physiology, functional ability, and subclinical disease burden and highlight the need for more age- and ability-specific PA research to inform future interventions and public health guidelines. [ABSTRACT FROM AUTHOR]

Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure; its prevalence is increasing, and outcomes are worsening. Affected patients often experience severe exertional dyspnea and debilitating fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Until recently, most pharmacological intervention trials for HFpEF yielded neutral primary outcomes. In contrast, trials of exercise-based interventions have consistently demonstrated large, significant, clinically meaningful improvements in symptoms, objectively determined exercise capacity, and usually quality of life. This success may be attributed, at least in part, to the pleiotropic effects of exercise, which may favorably affect the full range of abnormalities—peripheral vascular, skeletal muscle, and cardiovascular—that contribute to exercise intolerance in HFpEF. Accordingly, this scientific statement critically examines the currently available literature on the effects of exercise-based therapies for chronic stable HFpEF, potential mechanisms for improvement of exercise capacity and symptoms, and how these data compare with exercise therapy for other cardiovascular conditions. Specifically, data reviewed herein demonstrate a comparable or larger magnitude of improvement in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with heart failure with reduced ejection fraction, although Medicare reimbursement is available only for the latter group. Finally, critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise setting, training modalities, combinations with other strategies such as diet and medications, long-term adherence, incorporation of innovative and more accessible delivery methods, and management of recently hospitalized patients are highlighted to provide guidance for future research. [ABSTRACT FROM AUTHOR]

Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure; its prevalence is increasing, and outcomes are worsening. Affected patients often experience severe exertional dyspnea and debilitating fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Until recently, most pharmacological intervention trials for HFpEF yielded neutral primary outcomes. In contrast, trials of exercise-based interventions have consistently demonstrated large, significant, clinically meaningful improvements in symptoms, objectively determined exercise capacity, and usually quality of life. This success may be attributed, at least in part, to the pleiotropic effects of exercise, which may favorably affect the full range of abnormalities—peripheral vascular, skeletal muscle, and cardiovascular—that contribute to exercise intolerance in HFpEF. Accordingly, this scientific statement critically examines the currently available literature on the effects of exercise-based therapies for chronic stable HFpEF, potential mechanisms for improvement of exercise capacity and symptoms, and how these data compare with exercise therapy for other cardiovascular conditions. Specifically, data reviewed herein demonstrate a comparable or larger magnitude of improvement in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with heart failure with reduced ejection fraction, although Medicare reimbursement is available only for the latter group. Finally, critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise setting, training modalities, combinations with other strategies such as diet and medications, long-term adherence, incorporation of innovative and more accessible delivery methods, and management of recently hospitalized patients are highlighted to provide guidance for future research. [ABSTRACT FROM AUTHOR]

Background and aims Previous results of the AIM-HIGH trial showed that baseline levels of the conventional lipid parameters were not predictive of future cardiovascular (CV) outcomes. The aims of this secondary analysis were to examine the levels of cholesterol in high density lipoprotein (HDL) subclasses (HDL2-C and HDL3-C), small dense low density lipoprotein (sdLDL-C), and LDL triglyceride (LDL-TG) at baseline, as well as the relationship between these levels and CV outcomes. Methods Individuals with CV disease and low baseline HDL-C levels were randomized to simvastatin plus placebo or simvastatin plus extended release niacin (ERN), 1500 to 2000 mg/day, with ezetimibe added as needed in both groups to maintain an on-treatment LDL-C in the range of 40–80 mg/dL. The primary composite endpoint was death from coronary disease, nonfatal myocardial infarction, ischemic stroke, hospitalization for acute coronary syndrome, or symptom-driven coronary or cerebrovascular revascularization. HDL-C, HDL3-C, sdLDL-C and LDL-TG were measured at baseline by detergent-based homogeneous assays. HDL2-C was computed by the difference between HDL-C and HDL3-C. Analyses were performed on 3094 study participants who were already on statin therapy prior to enrollment in the trial. Independent contributions of lipoprotein fractions to CV events were determined by Cox proportional hazards modeling. Results Baseline HDL3-C was protective against CV events (HR: 0.84, p = 0.043) while HDL-C, HDL2-C, sdLDL-C and LDL-TG were not event-related (HR: 0.96, p = 0.369; HR: 1.07, p = 0.373; HR: 1.05, p = 0.492; HR: 1.03, p = 0.554, respectively). Conclusions The results of this secondary analysis of the AIM-HIGH Study indicate that levels of HDL3-C, but not other lipoprotein fractions, are predictive of CV events, suggesting that the HDL3 subclass may be primarily responsible for the inverse association of HDL-C and CV disease. [ABSTRACT FROM AUTHOR]

Black women are disproportionately affected by cardiovascular disease with an excess burden of cardiovascular morbidity and mortality. In addition, the racialized structure of the United States shapes cardiovascular disease research and health care delivery for Black women. Given the indisputable evidence of the disparities in health care delivery, research, and cardiovascular outcomes, there is an urgent need to develop and implement effective and sustainable solutions to advance cardiovascular health equity for Black women while considering their ethnic diversity, regions of origin, and acculturation. Innovative and culturally tailored strategies that consider the differential impact of social determinants of health and the unique challenges that shape their health-seeking behaviors should be implemented. A patient-centered framework that involves collaboration among clinicians, health care systems, professional societies, and government agencies is required to improve cardiovascular outcomes for Black women. The time is "now" to achieve health equity for all Black women. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to two articles about the survival rate of patients with heart failure in the 2006 issue.

Presents a letter to the editor in response to the articles ' Potential Complications of High-Dose Epinephrine Therapy in Patients Resuscitated From Cardiac Arrest,' by Michael Callaham, et al and 'The Effect of Standard- and High-Dose Epinephrine on Coronary Perfusion Pressure During Prolonged Cardiopulmonary Resuscitation,' by Norman A. Paradis et al, both in the 1991 issue.

Presents a response by Jerome L. Fleg to a letter to the editor about his article on treadmill exercise testing in hypertensive persons, in a 1990 issue of the 'Journal of the American Medical Association.'

A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found to have ischemia with no obstructive coronary artery disease (INOCA). Based on current evidence, these patients are at increased risk of adverse cardiovascular events, even though they have no obstructive CAD. Importantly, INOCA is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced health-related quality of life, and high healthcare costs. Underlying coronary microvascular dysfunction (CMD), through endothelium-dependent and independent mechanisms contribute to these adverse outcomes in INOCA. While non-invasive and invasive diagnostic testing has typically focused on identification of obstructive CAD in symptomatic patients, functional testing to detect coronary epicardial and microvascular dysfunction should be considered in those with INOCA who have persistent angina. Current diagnostic methods to clarify functional abnormalities and treatment strategies for epicardial and/or microvascular dysfunction in INOCA are reviewed. • Patients with myocardial ischemia and no obstructive coronary arteries (INOCA) are at risk of major cardiovascular events. • Coronary vascular dysfunction may contribute to abnormal coronary blood flow and ischemia. • Stress testing can detect low vasodilatory reserve, but invasive testing is needed to assess coronary endothelial dysfunction. • Invasive functional coronary angiography can provide a diagnosis and guide therapeutic management. • Anti-anginal and anti-atherosclerotic medications are used to manage INOCA, while large trials of outcomes are underway. [ABSTRACT FROM AUTHOR]

Purpose: Aerobic exercise training has been used in patients with stable heart failure (HF) to reduce the risk of clinical events. However, due to patient heterogeneity, some patients may experience a decrease in functional capacity due to such training. The purpose of this study was to estimate the proportion of HF patients participating in a training program who had negative responses to such therapy and to compare them with a concurrent control group. Methods: Baseline and 3-month peak VO2 measurements were obtained on 1870 HF subjects who were randomized to receive either an exercise training program or a control program of usual care without exercise training. The exercise program consisted of supervised walking or stationary cycling 3 d•wk−1 for 12 wk as well as a 2-d•wk−1 home exercise program after completing 18 supervised sessions. A negative response was defined as a baseline-to-3-month decrease in peak VO2 of at least 5 mL•kg−1•min−1 which was two times the SD of the control group's change in peak VO2. Results: The mean ± SD change in peak VO2 in the exercise group and control group was 0.8 ± 2.5 mL•kg−1 and 0.2 ± 2.5 mL•kg−1•min−1 respectively (P < 0.001). The percentage of negative responders in the exercise and control groups was 0.9% and 2.3% (P = 0.02). Conclusions: The low negative response rate in the exercise group combined with the slightly higher rate in the control group and equal variability in the exercise and control groups suggests that few if any subjects had training-related negative peak VO2 responses. These findings support current exercise recommendations for HF patients. [ABSTRACT FROM AUTHOR]

• An obesity paradox was not seen in the ISCHEMIA-CKD cohort. • Obesity may increase death and myocardial infarction risk in advanced chronic kidney disease and chronic coronary disease. • Obesity is associated with greater dyspnea in advanced chronic kidney disease and chronic coronary disease. • There was no body mass index by treatment assignment interaction for the primary outcome in the ISCHEMIA-CKD trial. This study aimed to assess whether an obesity paradox (lower event rates with higher body mass index [BMI]) exists in participants with advanced chronic kidney disease (CKD) and chronic coronary disease in the International Study of Comparative Health Effectiveness of Medical and Invasive Approaches (ISCHEMIA)-CKD, and whether BMI modified the effect of initial treatment strategy. Baseline BMI was analyzed as both a continuous and categorical variable (< 25, ≥ 25 to < 30, ≥ 30 kg/m2). Associations between BMI and the primary outcome of all-cause death or myocardial infarction (D/MI), and all-cause death, cardiovascular death, and MI individually were estimated. Associations with health status were also evaluated using the Seattle Angina Questionnaire-7, the Rose Dyspnea Scale, and the EuroQol-5D Visual Analog Scale. Body mass index ≥ 30 kg/m2 vs < 25 kg/m2 demonstrated increased risk for MI (hazard ratio [HR] [95% confidence interval] = 1.81 [1.12-2.92]) and for D/MI (HR 1.45 [1.06-1.96]) with a HR for MI of 1.22 (1.05-1.40) per 5 kg/m2 increase in BMI in unadjusted analysis. In multivariate analyses, a BMI ≥ 30 kg/m2 was marginally associated with D/MI (HR 1.43 [1.00-2.04]) and greater dyspnea throughout follow-up (P <.05 at all time points). Heterogeneity of treatment effect between baseline BMI was not evident for any outcome. In the ISCHEMIA-CKD trial, an obesity paradox was not detected. Higher BMI was associated with worse dyspnea, and a trend toward increased D/MI and MI risk. Larger studies to validate these findings are warranted. [ABSTRACT FROM AUTHOR]

Socioeconomic disparities in cardiovascular risk factors and outcomes exist among women, particularly those of minority racial or ethnic backgrounds. Barriers to optimal cardiovascular health begin early in life-with inadequate access to effective contraception, postpartum follow-up, and maternity leave-and result in excess rates of myocardial infarction, stroke, and cardiovascular death in at-risk populations. Contributing factors include reduced access to care, low levels of income and social support, and lack of diversity among cardiology clinicians and within clinical trials. These barriers can be mitigated by optimizing care access via policy change and improving physical access to care in women with geographic or transportation limitations. Addressing structural racism through policy change and bolstering structured community support systems will be key to reducing adverse cardiovascular outcomes among women of racial and ethnic minorities. Diversification of the cardiology workforce to more closely represent the patients we serve will be beneficial to all women. [ABSTRACT FROM AUTHOR]

An increased rate of cardiac symptoms at combat theater hospitals brings concerns about the predeployment health of Army National Guard (ARNG) soldiers on the basis of older age, lower fitness level, and sedentary lifestyle than active duty troops. The purpose of this study was to examine the association of physical fitness, reported physical activity (PA), and coronary risk factors to calculated 10-year hard coronary heart disease (CHD) risk in 136 ARNG soldiers, aged 18-53 years, who failed the 2-mile run of the Army Physical Fitness Test (APET). The APFT score, derived from a composite of 2-mile run time, sit-ups, and push-ups, related inversely to 10-year CHD risk (r = -0.23, p < 0.01 ) but no relationship with CHD risk was observed for PA. APPT scores were positively associated with high-density lipoprotein (HDL) cholesterol and inversely with triglycerides, total cholesterol:HDL ratio, diastolic blood pressure, and body mass index (BMI). No relationship existed between PA and any of the CHD risk factors. We conclude that a higher APFT score is associated with a healthier CHD risk factor profile and is a predictor of better predeployment cardiovascular health. [ABSTRACT FROM AUTHOR]

Abstract: Background : Higher levels of leisure time physical activity (LTPA) are associated with reduced mortality. However it is unclear how changes in LTPA over time impact all-cause mortality in men and women. Methods : From 1958 to 1996 for men (n =1316) and 1978 to 1996 for women (n =776), participants aged 19–90+ years from the Baltimore Longitudinal Study of Aging (Baltimore, MD) were assessed for LTPA at baseline and at ∼2-year intervals over a mean follow-up of 21.2±9.4 years for men and 10.2±5.6 years for women. Death occurred in 538 men and 90 women. LTPA was derived from self-reports of time spent in 97 activities converted into MET-min per 24 h and was further grouped into high-, moderate- and low-intensity LTPA. The longitudinal data was analyzed using mixed effects models to determine the rate of change in LTPA at each assessment. Proportional hazard models were used to assess the associations between LTPA at baseline and rate of change in LTPA with all-cause mortality. Results : In younger (<70 years) men, those who reported increases or negligible declines in total and high-intensity LTPA had lower all-cause mortality compared to those with greater declines in LTPA. In older (≥70 years) men, the association between rate of change in high-intensity LTPA and mortality was similar to that seen in younger men. For women, longitudinal analyses showed neither rates of change in total, high-, moderate- nor low-intensity LTPA were predictive of mortality. Conclusions : In this health-conscious population, greater longitudinal declines in total and high-intensity LTPA are independent predictors of all-cause mortality in men. [Copyright &y& Elsevier]

Objectives: To determine criterion validity of the 400-m walk component of the Long Distance Corridor Walk (LDCW) and develop equations for estimating peak oxygen consumption (VO2) from 400-m time and factors intrinsic to test performance (e.g., heart rate (HR) and systolic blood pressure (SBP) response) in older adults. Design: Cross-sectional validation study. Setting: Gerontology Research Center, National Institute on Aging, Baltimore, Maryland. Participants: Healthy volunteers (56 men and 46 women) aged 60 to 91 participating in the Baltimore Longitudinal Study of Aging between August 1999 and July 2000. Measurements: The LDCW, consisting of a 2-minute walk followed immediately by a 400-m walk “done as quickly as possible” over a 20-m course was administered the day after maximal treadmill testing. HR and SBP were measured before testing and at the end of the 400-m walk. Weight, height, activity level, perceived effort, and stride length were also acquired. Results: Peak VO2 ranged from 12.2 to 31.1 mL oxygen/kg per minute, and 400-m time ranged from 2 minutes 52 seconds to 6 minutes 18 seconds. Correlation between 400-m time and peak VO2 was −0.79. The estimating equation from linear regression included 400-m time (partial coefficient of determination ( R2)=0.625), long versus short stride (partial R2=0.090), ending SBP (partial R2=0.019), and a correction factor for fast 400-m time (<240 seconds; partial R2=0.020) and explained 75.5% of the variance in peak VO2 (correlation coefficient =0.87). Conclusion: A 400-m walk performed as part of the LDCW provides a valid estimate of peak VO2 in older adults. Incorporating low-cost, safe assessments of fitness in clinical and research settings can identify early evidence of physical decline and individuals who may benefit from therapeutic interventions. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- Under the auspices of the National Institutes of Health, American Diabetes Association, and World Health Organization, expert committees lowered the fasting plasma glucose (FPG) concentration diagnostic for diabetes from 7.8 to 7.0 mmol/l and defined 6.1-6.9 mmol/l as impaired fasting glucose (IFG) and <6.1 mmol/l as normal fasting glucose. In 2003, IFG was lowered to 5.6-6.9 mmol/l and normal fasting glucose to <5.6 mmol/l. Reports of the relationship between glucose concentration and all-cause mortality have been inconsistent. It is not known if the 2-h plasma glucose (2hPG) concentration from an oral glucose tolerance test (OGTT) adds to the predictive power of FPG. RESEARCH DESIGN AND METHODS -- We followed 1,236 men for an average of 13.4 years to determine the relationship between both FPG and 2hPG and all-cause mortality. RESULTS -- Risk for mortality did not increase until the FPG exceeded 6.1 mmol/l. Risk increased by ∼40% in the 6.1-6.9 mmol/l range and doubled when FPG ranged from 7.0 to 7.7 mmol/l. A combination of the 2hPG and FPG allowed better estimation of risk than the FPG alone. Within any category of FPG, risk generally increased as the 2hPG increased, and within any category of 2hPG, risk generally increased as the FPG increased. CONCLUSIONS -- These data support the decision to lower the FPG diagnostic for diabetes from 7.8 to 7.0 mmol/l, show that both IFG and impaired glucose tolerance have risks between the normal and diabetic ranges, and show that the OGTT adds predictive power to that of FPG alone and should not be abandoned. The lowering of IFG to 5.6 mmol/l from 6.1 mmol/l, at least for mortality, is, however, not supported by our results. Diabetes Care 28:2626-2632, 2005 [ABSTRACT FROM AUTHOR]

OBJECTIVES: To compare the longitudinal changes in maximal aerobic capacity (VO2 max) in healthy middle aged and older athletes and sedentary men. DESIGN: A cohort study with mean follow-up of 8.7 years (range 4.0–12.8). SETTING: Outpatient research at a tertiary hospital. PARTICIPANTS: Forty-two healthy, middle aged, and older athletes (initial age 64 ± 1 year) and 47 healthy sedentary men of comparable age recruited for research studies. MEASUREMENTS: VO2 max during a maximal treadmill test. RESULTS: At baseline, the cross-sectional rates of decline in VO2 max with age (slope) were virtually identical in the athletes and sedentary men (-0.42 versus -0.43 mL·kg-1 · min-1 ·year-1 ). At follow-up, the VO2 max had declined by 11.9 ± 1.1 mL·kg-1 ·min-1 (22%) in the athletes, a crude average rate of -1.4 ± 0.14 mL·kg-1 ·min-1 ·year-1 . By comparison, the VO2 max declined by 4.4 ± 0.6 mL·kg-1 · min-1 (14%) in the sedentary men, a crude average rate of change of -0.48 ± 0.07 mL·kg-1 ·min-1 ·year-1 . Therefore, the observed absolute rate of longitudinal decline in VO2 max in the athletes was triple that of the sedentary men (P = .001) and significantly greater than the decline predicted by their baseline cross-sectional data (P = .001). Post hoc analyses of the longitudinal data in the athletes based on the training regimens over the follow-up period demonstrated that the seven individuals who continued to train vigorously (“high training”) had no significant decline in VO2 max (0.28% change in VO2 max per year). By contrast, the VO2 max declined by 2.6% per year in the “moderate training” group (N = 21),... [ABSTRACT FROM AUTHOR]

Background: Patients with chronic kidney disease (CKD) and coronary artery disease frequently undergo preemptive revascularization before kidney transplant listing.Objectives: In this post hoc analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness of Medical and Invasive Approaches-Chronic Kidney Disease), we compared outcomes of patients not listed versus those listed according to management strategy.Methods: In the ISCHEMIA-CKD trial (n = 777), 194 patients (25%) with chronic coronary syndromes and at least moderate ischemia were listed for transplant. The primary (all-cause mortality or nonfatal myocardial infarction) and secondary (death, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure, resuscitated cardiac arrest, or stroke) outcomes were analyzed using Cox multivariable modeling. Heterogeneity of randomized treatment effect between listed versus not listed groups was assessed.Results: Compared with those not listed, listed patients were younger (60 years vs 65 years), were less likely to be of Asian race (15% vs 29%), were more likely to be on dialysis (83% vs 44%), had fewer anginal symptoms, and were more likely to have coronary angiography and coronary revascularization irrespective of treatment assignment. Among patients assigned to an invasive strategy versus conservative strategy, the adjusted hazard ratios for the primary outcome were 0.91 (95% confidence interval [CI]: 0.54-1.54) and 1.03 (95% CI: 0.78-1.37) for those listed and not listed, respectively (pinteraction= 0.68). Adjusted hazard ratios for secondary outcomes were 0.89 (95% CI: 0.55-1.46) in listed and 1.17 (95% CI: 0.89-1.53) in those not listed (pinteraction = 0.35).Conclusions: In ISCHEMIA-CKD, an invasive strategy in kidney transplant candidates did not improve outcomes compared with conservative management. These data do not support routine coronary angiography or revascularization in patients with advanced CKD and chronic coronary syndromes listed for transplant. (ISCHEMIA-Chronic Kidney Disease Trial [ISCHEMIA-CKD]; NCT01985360). [ABSTRACT FROM AUTHOR]

Background: High-sensitivity cardiac troponin (hs-cTn) assays have different analytic characteristics.Objectives: The goal of this study was to quantify differences between assays for common analytical benchmarks and to determine whether they may result in differences in the management of patients with suspected acute coronary syndrome (ACS).Methods: The authors included patients with suspected ACS enrolled in the ROMICAT (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography) I and II trials, with blood samples taken at emergency department presentation (ROMICAT-I and -II) or at 2 and 4 h thereafter (ROMICAT-II). hs-cTn concentrations were measured using 3 assays (Roche Diagnostics, Elecsys 2010 platform; Abbott Diagnostics, ARCHITECT i2000SR; Siemens Diagnostics, HsVista). Per blood sample, we determined concordance across analytic benchmarks (99th percentile). Per-patient, the authors determined concordance of management recommendations (rule-out/observe/rule-in) per the 0/2-h algorithm, and their association with diagnostic test findings (coronary artery stenosis >50% on coronary computed tomography angiography or inducible ischemia on perfusion imaging) and ACS.Results: Among 1,027 samples from 624 patients (52.8 ± 10.0 years; 39.4% women), samples were classified as 99th percentile (7.2% vs. 6.0% vs. 6.2%) by Roche, Abbott, and Siemens, respectively. A total of 37.4% (n = 384 of 1,027) of blood samples were classified into the same analytical benchmark category, with low concordance across benchmarks (99th percentile 43.6%). Serial samples were available in 242 patients (40.1% women; mean age: 52.8 ± 8.0 years). The concordance of management recommendations across assays was 74.8% (n = 181 of 242) considering serial hs-cTn measurements. Of patients who were recommended to discharge, 19.6% to 21.1% had positive diagnostic test findings and 2.8% to 4.3% had ACS at presentation.Conclusions: Caregivers should be aware that there are significant differences between hs-cTn assays in stratifying individual samples and patients with intermediate likelihood of ACS according to analytical benchmarks that may result in different management recommendations. (Rule Out Myocardial Infarction by Computer Assisted Tomography [ROMICAT]; NCT00990262) (Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239). [ABSTRACT FROM AUTHOR]

Background: Treatment of heart failure with preserved ejection fraction (HFpEF) with spironolactone is associated with lower risk of heart failure hospitalization (HFH) but increased risk of worsening renal function (WRF). The prognostic implications of spironolactone-associated WRF in HFpEF patients are not well understood.Objectives: The purpose of this study was to investigate the association between WRF, spironolactone treatment, and clinical outcomes in patients with HFpEF.Methods: In 1,767 patients randomized to spironolactone or placebo in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial)-Americas study, we examined the incidence of WRF (doubling of serum creatinine) by treatment assignment. Associations between incident WRF and subsequent risk for the primary study endpoint of cardiovascular (CV) death, HFH, or aborted cardiac arrest and key secondary outcomes, including CV death, HFH, and all-cause mortality according to treatment assignment, were examined in time-updated Cox proportional hazards models with an interaction term.Results: WRF developed in 260 (14.7%) patients with higher rates in those assigned to spironolactone compared to placebo (17.8% vs. 11.6%; odds ratio: 1.66; 95% confidence interval: 1.27 to 2.17; p < 0.001). Regardless of treatment, incident WRF was associated with increased risk for the primary endpoint (hazard ratio: 2.04; 95% confidence interval: 1.52 to 2.72; p < 0.001) after multivariable adjustment. Although there was no statistical interaction between treatment assignment and WRF regarding the primary endpoint (interaction p = 0.11), spironolactone-associated WRF was associated with lower risk of CV death (interaction p = 0.003) and all-cause mortality (interaction p = 0.001) compared with placebo-associated WRF.Conclusions: Among HFpEF patients enrolled in TOPCAT-Americas, spironolactone increased risk of WRF compared with placebo. Rates of CV death were lower with spironolactone in both patients with and without WRF. [ABSTRACT FROM AUTHOR]

Background: In the ISCHEMIA-CKD trial, the primary analysis showed no significant difference in the risk of death or myocardial infarction with initial angiography and revascularization plus guideline-based medical therapy (invasive strategy) as compared with guideline-based medical therapy alone (conservative strategy) in participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease (an estimated glomerular filtration rate of <30 ml per minute per 1.73 m2 or receipt of dialysis). A secondary objective of the trial was to assess angina-related health status.Methods: We assessed health status with the Seattle Angina Questionnaire (SAQ) before randomization and at 1.5, 3, and 6 months and every 6 months thereafter. The primary outcome of this analysis was the SAQ Summary score (ranging from 0 to 100, with higher scores indicating less frequent angina and better function and quality of life). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate the treatment effect with the invasive strategy.Results: Health status was assessed in 705 of 777 participants. Nearly half the participants (49%) had had no angina during the month before randomization. At 3 months, the estimated mean difference between the invasive-strategy group and the conservative-strategy group in the SAQ Summary score was 2.1 points (95% credible interval, -0.4 to 4.6), a result that favored the invasive strategy. The mean difference in score at 3 months was largest among participants with daily or weekly angina at baseline (10.1 points; 95% credible interval, 0.0 to 19.9), smaller among those with monthly angina at baseline (2.2 points; 95% credible interval, -2.0 to 6.2), and nearly absent among those without angina at baseline (0.6 points; 95% credible interval, -1.9 to 3.3). By 6 months, the between-group difference in the overall trial population was attenuated (0.5 points; 95% credible interval, -2.2 to 3.4).Conclusions: Participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease did not have substantial or sustained benefits with regard to angina-related health status with an initially invasive strategy as compared with a conservative strategy. (Funded by the National Heart, Lung, and Blood Institute; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.). [ABSTRACT FROM AUTHOR]

The syndrome of heart failure (HF) with preserved ejection fraction (HFpEF) is now recognized to account for up to half of HF cases and is the dominant form of HF in older adults, especially women. Multiple factors conspire in this predilection of HFpEF for older women. This review will discuss the epidemiology, pathophysiology, prognosis, and treatment of HFpEF with emphasis on the similarities and differences in cardiovascular aging changes, and the differential impact of comorbidities in women versus men. Responses to pharmacologic and lifestyle interventions are also reviewed. We conclude by suggesting future directions for both prevention and treatment of this common and highly morbid cardiovascular disorder. [ABSTRACT FROM AUTHOR]

Examines the effects of strength training on glucose homeostasis in older individuals. Comparison on the response of older men with older women; Development of insulin resistance syndrome and other disease related to the deterioration in glucose metabolism; Measurement of plasma concentrations of glucose and insulin after training.

Objectives: To determine the efficacy and safety of statins for primary prevention of atherosclerotic cardiovascular disease (ASCVD) events in older adults, especially those aged 80 and older and with multimorbidity. Methods: The National Institute on Aging and the National Heart, Lung and Blood Institute convened A multidisciplinary expert panel from July 31 to August 1, 2017, to review existing evidence, identify knowledge gaps, and consider whether statin safety and efficacy data in persons aged 75 and older without ASCVD are sufficient; whether existing data can inform the feasibility, design, and implementation of future statin trials in older adults; and clinical trial options and designs to address knowledge gaps. This article summarizes the presentations and discussions at that workshop. Results: There is insufficient evidence regarding the benefits and harms of statins in older adults, especially those with concomitant frailty, polypharmacy, comorbidities, and cognitive impairment; a lack of tools to assess ASCVD risk in those aged 80 and older; and a paucity of evidence of the effect of statins on outcomes of importance to older adults, such as statin‐associated muscle symptoms, cognitive function, and incident diabetes mellitus. Prospective, traditional, placebo‐controlled, randomized clinical trials (RCTs) and pragmatic RCTs seem to be suitable options to address these critical knowledge gaps. Future trials have to consider greater representation of very old adults, women, underrepresented minorities, and individuals of differing health, cognitive, socioeconomic, and educational backgrounds. Feasibility analyses from existing large healthcare networks confirm appropriate power for death and cardiovascular outcomes for future RCTs in this area. Conclusion: Existing data cannot address uncertainties about the benefits and harms of statins for primary ASCVD prevention in adults aged 75 and older, especially those with comorbidities, frailty, and cognitive impairment. Evidence from 1 or more RCTs could address these important knowledge gaps to inform person‐centered decision‐making. J Am Geriatr Soc 66:2188–2196, 2018. [ABSTRACT FROM AUTHOR]