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AimWe investigated temporal trends in major cardiovascular events following first-time myocardial infarction (MI) and trends in revascularization and pharmacotherapy from 2000 to 2017.Methods and resultsUsing nationwide registries, we identified 120 833 Danish patients with a first-time MI between 2000 and 2017. We investigated 30-day and 1-year mortality and the 1-year risk of first-time admission for heart failure (HF) and recurrent MI. Patients were younger with a higher prevalence of hypertension and diabetes in 2015–2017 compared with 2000–2002. The patients were predominantly male (65.6%), and the median age declined by 3 years through the periods. Percutaneous coronary interventions within 7 days after first-time MI increased significantly (2000: 11.4% vs. 2017: 68.6%; Ptrend < 0.001). Cardiovascular medication after first-time MI changed significantly in the same period. Absolute risks and adjusted rates of outcomes were significantly lower in 2015–2017 compared with 2000–2002: 30-day mortality: 6.5% vs. 14.1% [hazard ratio (HR) 0.52, 95% confidence interval (CI): 0.48–0.55); 1-year mortality 10.7% vs. 21.8% (HR 0.52, 95% CI: 0.50–0.55); recurrent MI: 4.0% vs. 7.8% (HR 0.56, 95% CI: 0.51–0.62); and first-time admission for HF: 2.9% vs. 3.7% (HR 0.82, 95% CI: 0.73–0.92). The rates of 30-day/1-year mortality and recurrent MI showed significantly decreasing trends (Ptrend < 0.001). The rates of first-time admission for HF were borderline significant (Ptrend = 0.045).ConclusionFrom 2000 to 2017, we observed a decreasing risk of recurrent MI, first-time admission for HF, and all-cause mortality in patients with a first-time MI. In the same period, we observed a high rate of guideline-recommended pharmacological treatment after first-time MI as well as increasing rate of early revascularization in Denmark.Translational perspectivesThe results from the current study portrait the risk of all-cause mortality, recurrent MI, and first-time admission for HF in a real-life setting with a very high utilization of early revascularization and guideline-recommended pharmacological therapy. We observed a temporal trend of improved survival, reduced risk of recurrent MI, as well as reduced risk of first-time admission for HF after first-time MI from 2000 through 2017. We observed an increase in the overall use of revascularization, as well as early revascularization and use of guideline-recommended pharmacotherapy. Our study reveals important results from real-life, nationwide data, showing a reduced risk of cardiovascular outcomes after first-time MI during the past 20 years. Current guidelines are based on results from clinical trials. Our real-life results add additionally important knowledge on patients’ prognosis after first-time MI and underline the importance of treating MI according to guideline recommendations. AimWe investigated temporal trends in major cardiovascular events following first-time myocardial infarction (MI) and trends in revascularization and pharmacotherapy from 2000 to 2017.Methods and resultsUsing nationwide registries, we identified 120 833 Danish patients with a first-time MI between 2000 and 2017. We investigated 30-day and 1-year mortality and the 1-year risk of first-time admission for heart failure (HF) and recurrent MI. Patients were younger with a higher prevalence of hypertension and diabetes in 2015–2017 compared with 2000–2002. The patients were predominantly male (65.6%), and the median age declined by 3 years through the periods. Percutaneous coronary interventions within 7 days after first-time MI increased significantly (2000: 11.4% vs. 2017: 68.6%; Ptrend < 0.001). Cardiovascular medication after first-time MI changed significantly in the same period. Absolute risks and adjusted rates of outcomes were significantly lower in 2015–2017 compared with 2000–2002: 30-day mortality: 6.5% vs. 14.1% [hazard ratio (HR) 0.52, 95% confidence interval (CI): 0.48–0.55); 1-year mortality 10.7% vs. 21.8% (HR 0.52, 95% CI: 0.50–0.55); recurrent MI: 4.0% vs. 7.8% (HR 0.56, 95% CI: 0.51–0.62); and first-time admission for HF: 2.9% vs. 3.7% (HR 0.82, 95% CI: 0.73–0.92). The rates of 30-day/1-year mortality and recurrent MI showed significantly decreasing trends (Ptrend < 0.001). The rates of first-time admission for HF were borderline significant (Ptrend = 0.045).ConclusionFrom 2000 to 2017, we observed a decreasing risk of recurrent MI, first-time admission for HF, and all-cause mortality in patients with a first-time MI. In the same period, we observed a high rate of guideline-recommended pharmacological treatment after first-time MI as well as increasing rate of early revascularization in Denmark.Translational perspectivesThe results from the current study portrait the risk of all-cause mortality, recurrent MI, and first-time admission for HF in a real-life setting with a very high utilization of early revascularization and guideline-recommended pharmacological therapy. We observed a temporal trend of improved survival, reduced risk of recurrent MI, as well as reduced risk of first-time admission for HF after first-time MI from 2000 through 2017. We observed an increase in the overall use of revascularization, as well as early revascularization and use of guideline-recommended pharmacotherapy. Our study reveals important results from real-life, nationwide data, showing a reduced risk of cardiovascular outcomes after first-time MI during the past 20 years. Current guidelines are based on results from clinical trials. Our real-life results add additionally important knowledge on patients’ prognosis after first-time MI and underline the importance of treating MI according to guideline recommendations.

BackgroundDespite improvements in the management of atrial fibrillation, patients with this condition remain at increased risk for cardiovascular complications. It is unclear whether early rhythm-control therapy can reduce this risk. MethodsIn this international, investigator-initiated, parallel-group, open, blinded-outcome-assessment trial, we randomly assigned patients who had early atrial fibrillation (diagnosed

Childhood hypertrophic cardiomyopathy; Outcomes; Phenotype Miocardiopatía hipertrófica infantil; Resultados; Fenotipo Miocardiopatia hipertròfica infantil; Resultats; Fenotip Background Up to one-half of childhood sarcomeric hypertrophic cardiomyopathy (HCM) presents before the age of 12 years, but this patient group has not been systematically characterized. Objectives The aim of this study was to describe the clinical presentation and natural history of patients presenting with nonsyndromic HCM before the age of 12 years. Methods Data from the International Paediatric Hypertrophic Cardiomyopathy Consortium on 639 children diagnosed with HCM younger than 12 years were collected and compared with those from 568 children diagnosed between 12 and 16 years. Results At baseline, 339 patients (53.6%) had family histories of HCM, 132 (20.9%) had heart failure symptoms, and 250 (39.2%) were prescribed cardiac medications. The median maximal left ventricular wall thickness z-score was 8.7 (IQR: 5.3-14.4), and 145 patients (27.2%) had left ventricular outflow tract obstruction. Over a median follow-up period of 5.6 years (IQR: 2.3-10.0 years), 42 patients (6.6%) died, 21 (3.3%) underwent cardiac transplantation, and 69 (10.8%) had life-threatening arrhythmic events. Compared with those presenting after 12 years, a higher proportion of younger patients underwent myectomy (10.5% vs 7.2%; P = 0.045), but fewer received primary prevention implantable cardioverter-defibrillators (18.9% vs 30.1%; P = 0.041). The incidence of mortality or life-threatening arrhythmic events did not differ, but events occurred at a younger age. Conclusions Early-onset childhood HCM is associated with a comparable symptom burden and cardiac phenotype as in patients presenting later in childhood. Long-term outcomes including mortality did not differ by age of presentation, but patients presenting at younger than 12 years experienced adverse events at younger ages. This work was supported by the British Heart Foundation (grant FS/16/72/32270) to Drs Norrish and Kaski. This work is (partly) funded by the National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre. Dr Norrish is supported by Great Ormond Street Hospital Children’s Charity. Drs Field and Kaski are supported by Max’s Foundation and Great Ormond Street Hospital Children’s Charity. Dr Kaski is supported by a Medical Research Council–National Institute for Health Research Clinical Academic Research Partnership award. This work was financially supported by the Foundation for Paediatric Research of Finland (Dr Ojala). Dr Fernandez has received speaker fees from Sanofi-Genzyme. Dr Kubus is supported by MH CZ – DRO, Motol University Hospital (00064203). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

BACKGROUND: Epidemiologic studies suggest cadmium exposure is associated with cardiovascular disease risk, including heart failure. However, prior findings may be influenced by tobacco smoking, a dominant source of cadmium exposure and risk factor for heart failure. The present study leverages up to 20 years of follow-up in the Danish Diet, Cancer and Health cohort to examine the relationship between urinary cadmium and incident heart failure among people who never smoked.METHODS: Between 1993 and 1997, 19,394 never-smoking participants (ages 50-64 years) enrolled and provided a urine sample. From this sample, we randomly selected a subcohort of 600 men and 600 women and identified 958 incident heart failure cases occurring between baseline and 2015. Using a case-cohort approach, we estimated adjusted hazard ratios (aHR) for heart failure in Cox proportional hazards models with age as the time scale.RESULTS: Participants had relatively low concentrations of urinary cadmium, as expected for never smokers (median= 0.20; 25th, 75th= 0.13, 0.32 µg cadmium/g creatinine). In adjusted models, we found that higher urinary cadmium was associated with a higher rate of incident heart failure overall (aHR=1.1 per interquartile range difference; 95% CI= 1.0 - 1.2). In sex-stratified analyses the association seemed restricted to men (aHR= 1.5; 95% CI= 1.2 - 1.9).CONCLUSION: In this cohort of people who never smoked tobacco, environmental cadmium was positively associated with incident heart failure, especially among men.

Background Cardiovascular disease is a leading cause of death in general population and the second leading cause of mortality and morbidity in cancer survivors after recurrent malignancy in the United States. The growing awareness of cancer therapy–related cardiac dysfunction (CTRCD) has led to an emerging field of cardio-oncology; yet, there is limited knowledge on how to predict which patients will experience adverse cardiac outcomes. We aimed to perform unbiased cardiac risk stratification for cancer patients using our large-scale, institutional electronic medical records. Methods and findings We built a large longitudinal (up to 22 years’ follow-up from March 1997 to January 2019) cardio-oncology cohort having 4,632 cancer patients in Cleveland Clinic with 5 diagnosed cardiac outcomes: atrial fibrillation, coronary artery disease, heart failure, myocardial infarction, and stroke. The entire population includes 84% white Americans and 11% black Americans, and 59% females versus 41% males, with median age of 63 (interquartile range [IQR]: 54 to 71) years old. We utilized a topology-based K-means clustering approach for unbiased patient–patient network analyses of data from general demographics, echocardiogram (over 25,000), lab testing, and cardiac factors (cardiac). We performed hazard ratio (HR) and Kaplan–Meier analyses to identify clinically actionable variables. All confounding factors were adjusted by Cox regression models. We performed random-split and time-split training-test validation for our model. We identified 4 clinically relevant subgroups that are significantly correlated with incidence of cardiac outcomes and mortality. Among the 4 subgroups, subgroup I (n = 625) has the highest risk of de novo CTRCD (28%) with an HR of 3.05 (95% confidence interval (CI) 2.51 to 3.72). Patients in subgroup IV (n = 1,250) had the worst survival probability (HR 4.32, 95% CI 3.82 to 4.88). From longitudinal patient–patient network analyses, the patients in subgroup I had a higher percentage of de novo CTRCD and a worse mortality within 5 years after the initiation of cancer therapies compared to long-time exposure (6 to 20 years). Using clinical variable network analyses, we identified that serum levels of NT-proB-type Natriuretic Peptide (NT-proBNP) and Troponin T are significantly correlated with patient’s mortality (NT-proBNP > 900 pg/mL versus NT-proBNP = 0 to 125 pg/mL, HR = 2.95, 95% CI 2.28 to 3.82, p < 0.001; Troponin T > 0.05 μg/L versus Troponin T ≤ 0.01 μg/L, HR = 2.08, 95% CI 1.83 to 2.34, p < 0.001). Study limitations include lack of independent cardio-oncology cohorts from different healthcare systems to evaluate the generalizability of the models. Meanwhile, the confounding factors, such as multiple medication usages, may influence the findings. Conclusions In this study, we demonstrated that the patient–patient network clustering methodology is clinically intuitive, and it allows more rapid identification of cancer survivors that are at greater risk of cardiac dysfunction. We believed that this study holds great promise for identifying novel cardiac risk subgroups and clinically actionable variables for the development of precision cardio-oncology., Yuan Hou and co-workers investigate risk of cardiac dysfunction in cancer patients., Author summary Why was this study done? An increasing number of oncology patients are facing cancer therapy–related cardiac dysfunction (CTRCD) risk, leading to the emerging field of cardio-oncology (also known as onco-cardiology); however, there are limited clinical guidelines in terms of how to prevent and treat for the new cardiotoxicity among cancer survivors. Development of novel clinical tools would offer unique opportunities for precision cardio-oncology by utilizing the large-scale, longitudinal patient data from healthcare systems. What did the researchers do and find? We developed a longitudinal patient–patient network clustering methodology for cardiac risk stratification in cancer patients during anticancer therapies. We identified 4 clinically relevant subgroups that are statistically significantly correlated with incidence of cardiac outcomes and all-cause mortality. Using longitudinal patient–patient network analyses (over 20 years’ follow-up), we showed crucial roles of early cardiovascular care in improving quality of life of cancer survivors and reducing incidence of CTRCD. We identified multiple clinically relevant predictors (including Troponin T and NT-proB-type Natriuretic Peptide (NT-proBNP)) that are significantly correlated with incidence of cardiac outcomes and patients’ mortality, which offers actionable biomarkers for rapid risk assessment of cardiac dysfunction during cardio-oncology clinical practices. What do these findings mean? Our findings suggest that an unbiased, systems-based network analysis of large-scale, longitudinal patient data is more interpretable, visualizing the decision boundary to cardiac risk stratification for patients before, during, and after cancer treatment. Troponin T and NT-proBNP offer clinically actionable biomarkers for cardiac risk stratification in cardio-oncology clinical practices. Extended independent cohort validations are needed before the predictors are introduced to clinical implementation.

OBJECTIVE: The optimal target heart rate in patients with prevalent atrial fibrillation (AF) is not well defined. The aim of this study was to analyse the associations between heart rate and adverse outcomes in a large contemporary cohort of patients with prevalent AF. METHODS: From two prospective cohort studies, we included stable AF outpatients who were in AF on the baseline ECG. The main outcome events assessed during prospective follow-up were heart failure hospitalisation, stroke or systemic embolism and death. The associations between heart rate and adverse outcomes were evaluated using multivariable Cox regression models. RESULTS: The study population consisted of 1679 patients who had prevalent AF at baseline. Mean age was 74 years, and 24.6% were women. The mean heart rate on the baseline ECG was 78 (±19) beats per minute (bpm). The median follow-up was 3.9 years (IQR 2.2-5.0). Heart rate was not significantly associated with heart failure hospitalisation (adjusted HR (aHR) per 10 bpm increase, 1.00, 95% CI 0.94 to 1.07, p=0.95), stroke or systemic embolism (aHR 0.95, 95% CI 0.84 to 1.07, p=0.38) or death (aHR 1.02, 95% CI 0.95 to 1.09, p=0.66). There was no evidence of a threshold effect for heart rates 100 bpm. CONCLUSIONS: In this large contemporary cohort of outpatients with prevalent AF, we found no association between heart rate and adverse outcome events. These data are in line with recommendations that strict heart rate control is not needed in otherwise stable outpatients with AF.

Background: Transparent and robust real-world evidence sources are increasingly important for global health, including cardiovascular (CV) diseases. We aimed to identify global real-world data (RWD) sources for heart failure (HF), acute coronary syndrome (ACS), and atrial fibrillation (AF). Methods: We conducted a systematic review of publications with RWD pertaining to HF, ACS, and AF (2010–2018), generating a list of unique data sources. Metadata were extracted based on the source type (e.g., electronic health records, genomics, and clinical data), study design, population size, clinical characteristics, follow-up duration, outcomes, and assessment of data availability for future studies and linkage. Results: Overall, 11,889 publications were retrieved for HF, 10,729 for ACS, and 6,262 for AF. From these, 322 (HF), 287 (ACS), and 220 (AF) data sources were selected for detailed review. The majority of data sources had near complete data on demographic variables (HF: 94%, ACS: 99%, and AF: 100%) and considerable data on comorbidities (HF: 77%, ACS: 93%, and AF: 97%). The least reported data categories were drug codes (HF, ACS, and AF: 10%) and caregiver involvement (HF: 6%, ACS: 1%, and AF: 1%). Only a minority of data sources provided information on access to data for other researchers (11%) or whether data could be linked to other data sources to maximize clinical impact (20%). The list and metadata for the RWD sources are publicly available at www.escardio.org/bigdata. Conclusions: This review has created a comprehensive resource of CV data sources, providing new avenues to improve future real-world research and to achieve better patient outcomes.

Aims We aimed to derive and validate clinically useful clusters of patients with heart failure with preserved ejection fraction (HFpEF; left ventricular ejection fraction ≥50%). Methods and results We derived a cluster model from 6909 HFpEF patients from the Swedish Heart Failure Registry (SwedeHF) and externally validated this in 2153 patients from the Chronic Heart Failure ESC‐guideline based Cardiology practice Quality project (CHECK‐HF) registry. In SwedeHF, the median age was 80 [interquartile range 72–86] years, 52% of patients were female and most frequent comorbidities were hypertension (82%), atrial fibrillation (68%), and ischaemic heart disease (48%). Latent class analysis identified five distinct clusters: cluster 1 (10% of patients) were young patients with a low comorbidity burden and the highest proportion of implantable devices; cluster 2 (30%) patients had atrial fibrillation, hypertension without diabetes; cluster 3 (25%) patients were the oldest with many cardiovascular comorbidities and hypertension; cluster 4 (15%) patients had obesity, diabetes and hypertension; and cluster 5 (20%) patients were older with ischaemic heart disease, hypertension and renal failure and were most frequently prescribed diuretics. The clusters were reproduced in the CHECK‐HF cohort. Patients in cluster 1 had the best prognosis, while patients in clusters 3 and 5 had the worst age‐ and sex‐adjusted prognosis. Conclusions Five distinct clusters of HFpEF patients were identified that differed in clinical characteristics, heart failure drug therapy and prognosis. These results confirm the heterogeneity of HFpEF and form a basis for tailoring trial design to individualized drug therapy in HFpEF patients., Latent class analysis identified 5 patient clusters with differences in clinical characteristics in 6909 patients from the Swedish Heart Failure Registry. BMI, body mass index; COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerular filtration rate; HFpEF, heart failure with preserved ejection fraction; IHD, ischaemic heart disease; NYHA, New York Heart Association.

International audience; Background: According to guidelines, implantable cardioverter defibrillator (ICD) candidates must have a "reasonable expectation of survival with a good functional status >1 year". Identifying risk for early mortality in ICD candidates could be challenging. We aimed to identify factors associated with a =1-year survival among patients implanted with ICDs.Methods: The DAI-PP program was a multicenter, observational French study that included all patients who received a primary prevention ICD in the 2002-2012 period. Characteristics of patients who survived = III), and atrial fibrillation were significantly associatedwith

A Sociedade Brasileira de Cardiologia (SBC) tem como missao ampliar e difundir o conhecimento em Ciencia Cardiovascular e sensibilizar cada cardiologista para a realizacao de acoes em prol da saude cardiovascular da sociedade brasileira. Desde sua fundacao, a SBC vem estimulando a pesquisa e divulgacao, junto a sociedade civil, de aspectos epidemiologicos, preventivos e ligados ao tratamento das enfermidades cardiovasculares, dentre elas a insuficiencia cardiaca (IC). A IC tem sido identificada como uma epidemia cardiovascular em todo o mundo e [...]

Background The effect of implantable cardioverter-defibrillator (ICD) therapy in patients with heart failure with reduced ejection fraction (HFrEF) and diabetes is not fully elucidated. Methods We examined the effect of ICD therapy on sudden cardiac death, cardiovascular death and all-cause mortality, according to diabetes status at baseline in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). The outcomes were analyzed by use of cumulative incidence curves and Cox regressions models. Results Of the 1676 patients randomized to an ICD or placebo, 540 (32%) had diabetes at baseline. Patients with diabetes were slightly older (61 vs 58 years) and were more often in NYHA class III (37% vs 28%). ICD therapy did not reduce the risk of sudden cardiac death in HFrEF patients with diabetes (HR = 0.85; 95% CI 0.52–1.40); even though these patients had a higher risk of sudden cardiac death compared to patients without diabetes (HR = 1.73 95% CI 1.22–2.47). By contrast, ICD therapy did reduce sudden cardiac death in HFrEF patients without diabetes (HR = 0.26; 95% CI 0.15–0.46); Pinteraction=0.002. The findings for cardiovascular and all-cause death were similar. Conclusion ICD therapy did not reduce the risk of sudden cardiac death (or, as a consequence, all-cause death) in HFrEF patients with diabetes. Conversely, an ICD reduced the risk of sudden death in patients without diabetes, irrespective of etiology. Electronic supplementary material The online version of this article (10.1007/s00392-019-01415-z) contains supplementary material, which is available to authorized users.

Objective To assess age differences in risk factors for incident heart failure in the general population. Design Pooled population based cohort study. Setting Framingham Heart Study, Prevention of Renal and Vascular End-stage Disease Study, and Multi-Ethnic Study of Atherosclerosis. Participants 24 675 participants without a history of heart failure stratified by age into young ( Main outcome measure Incident heart failure. Results Over a median follow-up of 12.7 years, 138/11 599 (1%), 293/5587 (5%), 538/5190 (10%), and 412/2299 (18%) of young, middle aged, old, and elderly participants, respectively, developed heart failure. In young participants, 32% (n=44) of heart failure cases were classified as heart failure with preserved ejection fraction compared with 43% (n=179) in elderly participants. Risk factors including hypertension, diabetes, current smoking history, and previous myocardial infarction conferred greater relative risk in younger compared with older participants (P for interaction v 53% in elderly participants), with better model performance (C index 0.79 v 0.64). Similarly, the population attributable risks of obesity (21% v 13%), hypertension (35% v 23%), diabetes (14% v 7%), and current smoking (32% v 1%) were higher in young compared with elderly participants. Conclusions Despite a lower incidence and absolute risk of heart failure among younger compared with older people, the stronger association and greater attributable risk of modifiable risk factors among young participants highlight the importance of preventive efforts across the adult life course.

Background: To investigate the incidence of heart failure (HF) and ischaemic heart disease (IHD) in different time spans following incident rheumatoid arthritis (RA) and, furthermore, to investigate the impact of IHD on the development of HF and the impact of different treatment era of RA. Materials and methods: This matched cohort study used nationwide, prospectively collected data. From the total Danish population of approximately 5.7 million inhabitants, we identified 51 859 patients (between 1995 and July 2016) with incident RA and a sex- and age-matched cohort from the general population (256 653 persons). Results: The hazard ratio (HR) for HF among RA patients compared with persons from comparison cohort was 2.28 within the first year of index date, 1.39 within the 1-5 years of index date and 1.38 within the 5-10 years of index date. No difference was identified regarding different treatment era of RA. For IHD, the subdistribution hazard ratio (sHR) was 1.93 within the first year of index date, 1.26 within the 1-5 years of index date and 1.31 within the 5-10 years of index date. Coronary revascularization was also more common within the first year after diagnosis of RA. An increased risk of percutaneous coronary intervention and coronary artery bypass grafting within 10 years following the RA diagnosis was observed. HR for new onset of HF in RA without IHD was 1.23, while the HR for new onset of HF in patients with RA and IHD was 2.06. Conclusions: Rheumatoid arthritis patients had higher rates of HF and IHD throughout the entire observation period compared to the comparison cohort. RA was associated with a larger risk of developing HF.

Heart failure is a complex clinical syndrome and one of the leading causes of morbidity and mortality with a prevalence of 1%-2% of the adult population. The prognosis is poor with a 5-year mortality rate of 50%, which partly can be attributed to the presence of concomitant comorbidity, including neurological and psychiatric comorbidities. However, the prognostic impact of depression and the role of heart failure as a risk factor for dementia and stroke are not fully understood. Denmark is well-known for its unique health registries. The DNPR has been widely used in cardiovascular research in the past decades, although the accuracy of several diseases and interventions is largely unknown. This thesis explored the PPV of a range of cardiovascular diagnoses including heart failure (study I) and cardiac interventions (study II) recorded in the DNPR. In addition, we aimed to provide new insights into the impact of depression on mortality in heart failure patients with reduced and preserved left ventricular ejection fraction (study III). Finally, we studied the association between heart failure and subsequent short-term and long-term risks of dementia (study IV) and ischemic and hemorrhagic stroke (study V). In studies I-II, we identified 3386 patients with various cardiovascular diagnoses or cardiac interventions during 2010-2012 using the DNPR. Patient medical charts served as the gold standard for diagnosis confirmation and were adjudicated by physicians. We found a high PPV (≥90%) for the majority of the patients while the PPV was somewhat lower for myocarditis, heart failure, and recurrent events. In study III, we analyzed 205,719 patients with incident heart failure during 1995-2014. A history of depression was associated with 15%-20% increased mortality rate in patients with LVEF ≤35% and when defining depression based on a combination of redeemed antidepressant prescription and hospital-based diagnoses, but not when depression was ascertained based solely on diagnoses. In study IV, we included 324,418 heart failure patients and a general population comparison cohort comprising 1,622,079 individuals matched for age and sex during 1980-2012. The heart failure cohort had a 21% increased rate of all-cause dementia, mainly driven by increased hazards of vascular dementia and other dementia, whereas heart failure was not associated with Alzheimer's disease. In study V, we identified and followed 289,353 patients with heart failure and 1,446,765 individuals from the general population matched for age, sex, and calendar year. Heart failure patients had a five-fold elevated rate of ischemic stroke, two-fold increased rate of ICH, and a four-fold increased rate of SAH within 30 days. These associations receded towards the null but persisted over 30 years. In conclusion, the DNPR contains data on several cardiovascular diagnoses and cardiac interventions recorded with high PPVs. Our data also suggest that a history of depression is an adverse prognostic factor for death in patients with heart failure and low LVEF. Finally, heart failure emerged as a risk factor for all-cause dementia as well as for both ischemic and hemorrhagic stroke.

BACKGROUND: The management of patients with non-valvular atrial fibrillation (NVAF) with rate-lowering or anti-arrhythmic drugs has markedly changed over the last decade, but it is unknown how these changes have affected patients with NVAF with a permanent pacemaker (PPM).METHODS: Through Danish nationwide registries, patients with NVAF and a PPM were identified from 2001 to 2012. Changes in concomitant pharmacotherapy and comorbidities were tested using the Cochran-Armitage trend test and linear regression. Patients with NVAF were identified to calculate the proportional amount of PPM implants.RESULTS: A total of 12,231 NVAF patients with a PPM were included in the study, 55.6% of which were men. Median age was 78 years (interquartile range 70-84). From 2001 to 2012, the number of NVAF patients with a PPM increased from 850 to 1344, while the number of NVAF patients increased from 67,478 to 127,261. Thus, the proportional amount of NVAF patients with a PPM decreased from 1.3% to 1.1% (p = 0.015). Overall 45.9% had atrial fibrillation (AF) duration less than one year and the proportion declined from 55.5% to 42.4% (p CONCLUSION: From 2001 to 2012, the absolute number of NVAF patients with a PPM increased while the proportional amount decreased. The number of NVAF patients receiving a PPM within one year of AF diagnosis decreased. The prevalence of DM increased, while the prevalence of HF and IHD was high but decreasing. The use of beta-blockers increased markedly, while use of digoxin and anti-arrhythmic drugs decreased over time.

OBJECTIVE: To examine the risks of myocardial infarction, stroke (ischaemic and haemorrhagic), peripheral artery disease, venous thromboembolism, atrial fibrillation or atrial flutter, and heart failure in patients with migraine and in a general population comparison cohort.DESIGN: Nationwide, population based cohort study.SETTING: All Danish hospitals and hospital outpatient clinics from 1995 to 2013.PARTICIPANTS: 51 032 patients with migraine and 510 320 people from the general population matched on age, sex, and calendar year.MAIN OUTCOME MEASURES: Comorbidity adjusted hazard ratios of cardiovascular outcomes based on Cox regression analysis.RESULTS: Higher absolute risks were observed among patients with incident migraine than in the general population across most outcomes and follow-up periods. After 19 years of follow-up, the cumulative incidences per 1000 people for the migraine cohort compared with the general population were 25v17 for myocardial infarction, 45v25 for ischaemic stroke, 11v6 for haemorrhagic stroke, 13v11 for peripheral artery disease, 27v18 for venous thromboembolism, 47v34 for atrial fibrillation or atrial flutter, and 19v18 for heart failure. Correspondingly, migraine was positively associated with myocardial infarction (adjusted hazard ratio 1.49, 95% confidence interval 1.36 to 1.64), ischaemic stroke (2.26, 2.11 to 2.41), and haemorrhagic stroke (1.94, 1.68 to 2.23), as well as venous thromboembolism (1.59, 1.45 to 1.74) and atrial fibrillation or atrial flutter (1.25, 1.16 to 1.36). No meaningful association was found with peripheral artery disease (adjusted hazard ratio 1.12, 0.96 to 1.30) or heart failure (1.04, 0.93 to 1.16). The associations, particularly for stroke outcomes, were stronger during the short term (0-1 years) after diagnosis than the long term (up to 19 years), in patients with aura than in those without aura, and in women than in men. In a subcohort of patients, the associations persisted after additional multivariable adjustment for body mass index and smoking.CONCLUSIONS: Migraine was associated with increased risks of myocardial infarction, ischaemic stroke, haemorrhagic stroke, venous thromboembolism, and atrial fibrillation or atrial flutter. Migraine may be an important risk factor for most cardiovascular diseases.

International audience; BACKGROUND: Very little is known about the costs of mitral regurgitation (MR) in Europe. AIM: To evaluate the cost of MR from a French National Payer perspective, based on annual costs of surgical and non-surgical patients. METHODS: A 12-month retrospective population-based analysis of patient demographics, outcomes and acute hospital and post-discharge resource utilizations, extracted from the 2009 French Medical Information System. RESULTS: A total of 19,868 patients with MR were identified. Surgical group (n=4099): index hospitalization length of stay (LOS), 17+/-14.7 days; patients discharged to rehabilitation, 72% (LOS 23+/-16 days); 12-month rehospitalization rate, 25%; total cost per surgical patient, euro24,871+/-13,940 (ranging from euro21,970+/-11,787 for mitral valve repair [n=2567, 62.6%] to euro29,732+/-15,796 for mitral valve replacement). Non-surgical group (n=15,769): number of hospitalizations over 12 months, 3.1+/-1.5 (LOS 23.5+/-20.4 days); admitted to rehabilitation, 24% (LOS 38.8+/-37.6 days); total cost per patient, euro12,177+/-10,913 (varying between euro9957+/-9080 and euro13,538+/-11,692 for those without and with heart failure [HF], respectively). The total observed cost for 19,868 MR patients over 12 months was euro292.8 million: surgical group, euro100.8 million; medical group euro192.0 million. Patients with MR and HF who were managed medically consumed 45% (euro132.3 million) of the overall annual cost of MR. CONCLUSION: The costs of care associated with MR are highly heterogeneous. There are significant differences in costs and resources used between the surgical and medical MR subgroups, with further differences depending on type of surgery and presence of HF.

PURPOSE: Renal dysfunction is often associated with chronic heart failure, leading to increased morbi-mortality. However, data regarding these patients after cardiac resynchronization therapy (CRT) is sparse. We sought to evaluate response and long-term mortality in patients with heart failure and renal dysfunction and assess renal improvement after CRT. METHODS: We analyzed 178 consecutive patients who underwent successful CRT device implantation (age 64 ± 11 years; 69% male; 92% in New York Heart Association (NYHA) functional class ≥ III; 34% with ischemic cardiomyopathy). Echocardiographic response was defined as ≥ 15% reduction in left ventricular end-systolic diameter and clinical response as a sustained improvement of at least one NYHA functional class. Renal dysfunction was defined as an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m2. RESULTS: Renal dysfunction was present in 34.7%. Renal dysfunction was not an independent predictor of echocardiographic response (OR 1.109, 95% CI 0.713-1.725, p 0.646) nor clinical response (OR 1.003; 95% CI 0.997-1.010; p 0.324). During follow-up (mean 55.2 ± 32 months), patients with eGFR < 60mL/min/1.73 m2 had higher overall mortality (HR 4.902, 95% CI 1.118-21.482, p 0.035). However, clinical response in patients with renal dysfunction was independently associated with better long-term survival (HR 0.236, 95% CI 0.073-0.767, p 0.016). Renal function was significantly improved in patients who respond to CRT (ΔeGFR + 5.5 mL/min/1.73 m2 at baseline vs. follow-up, p 0.049), while this was not evident in nonresponders. Improvements in eGFR of at least 10 mL/min/1.73 m2 were associated with improved survival in renal dysfunction patients (log-rank p 0.036). CONCLUSION: Renal dysfunction was associated with higher long-term mortality in CRT patients, though, it did not influence echocardiographic nor functional response. Despite worse overall prognosis, renal dysfunction patients who are responders showed long-term survival benefit and improvement in renal function following CRT. info:eu-repo/semantics/publishedVersion

Patients in the latest stages of heart failure are severely compromised, with poor quality of life and frequent hospitalizations. Heart transplantation and left ventricular assist device implantation are viable options only for a minority, and intermittent or continuous infusions of positive inotropes may be needed as a bridge therapy or as a symptomatic approach. In these settings, levosimendan has potential advantages over conventional inotropes (catecholamines and phosphodiesterase inhibitors), such as sustained effects after initial infusion, synergy with beta-blockers, and no increase in oxygen consumption. Levosimendan has been suggested as a treatment that reduces re-hospitalization and improves quality of life. However, previous clinical studies of intermittent infusions of levosimendan were not powered to show statistical significance on key outcome parameters. A panel of 45 expert clinicians from 12 European countries met in Rome on November 24-25, 2016 to review the literature and envision an appropriately designed clinical trial addressing these needs. In the earlier FIGHT trial (daily subcutaneous injection of liraglutide in heart failure patients with reduced ejection fraction) a composite Global Rank Score was used as primary end-point where death, re-hospitalization, and change in N-terminal-prohormone-brain natriuretic peptide level were considered in a hierarchical order. In the present study, we tested the same end-point post hoc in the PERSIST and LEVOREP trials on oral and repeated i.v. levosimendan, respectively, and demonstrated superiority of levosimendan treatment vs placebo. The use of the same composite end-point in a properly powered study on repetitive levosimendan in advanced heart failure is strongly advocated.

PURPOSE: The efficacy and tolerability of vitamin K antagonists (VKAs) depends on the quality of anticoagulant control, reflected by the mean time in therapeutic range (TTR) of international normalized ratio 2.0 to 3.0. In the present study, we aimed to investigate the association between TTR and change in TTR (ΔTTR) with the risk of mortality and clinically significant events in a consecutive cohort of atrial fibrillation (AF) patients.METHODS: We included 1361 AF patients stable on VKAs (international normalized ratio 2.0-3.0) during at least the previous 6 months. After 6 months of follow-up we recalculated TTR, calculated ΔTTR (ie, the difference between baseline and 6-month TTRs) and investigated the association of both with the risk of mortality and "clinically significant events" (defined as the composite of stroke or systemic embolism, major bleeding, acute coronary syndrome, acute heart failure, and all-cause deaths).FINDINGS: The median ΔTTR at 6 months of entry was 20% (interquartile range 0-34%), 796 (58.5%) patients had a TTR reduction of at least 20%, while 330 (24.2%) had a TTR IMPLICATIONS: Our findings suggest that in AF patients anticoagulated with VKAs, a change in TTR over 6 months (ie, ΔTTR) is an independent risk factor for mortality and clinically significant events. Even in a cohort with good anticoagulation control, the risk for mortality and clinically significant events increases with every point deterioration of TTR.

Background Fragments of insulin‐like growth factor binding protein 4 ( IGFBP ‐4) are potential new biomarkers for cardiac risk assessment. The fragments are generated on specific cleavage by pregnancy‐associated plasma protein‐A, which exerts proatherogenic activity. This study investigated the prognostic value of IGFBP ‐4 fragments in patients with ST ‐segment elevation myocardial infarction. Methods and Results We prospectively included 656 patients with ST ‐segment elevation myocardial infarction treated with percutaneous coronary intervention from September 2006 to December 2008. Blood samples were drawn before percutaneous coronary intervention, and levels of intact IGFBP ‐4 and N‐terminal and C‐terminal IGFBP ‐4 fragments were measured by specific assays. End points were 5‐year all‐cause and cardiovascular mortality and the combined end point of major adverse cardiac events. Prognostic potential was evaluated on top of a clinical model in terms of discrimination, calibration, and reclassification analysis. During follow‐up, 166 patients experienced a major adverse cardiac event and 136 patients died, of whom 69 died from cardiovascular causes. Both IGFBP ‐4 fragments were associated with all end points ( P IGFBP ‐4 fragment levels remained associated with all end points, including cardiovascular mortality with hazard ratios per doubling in protein concentration of 2.54 (95% CI 1.59–4.07; P P IGFBP ‐4 fragments into a clinical model with 15 risk factors improved C‐statistics and model calibration and provided incremental prognostic contribution, as assessed by net reclassification improvement and integrated discrimination improvement. Conclusions IGFBP ‐4 fragments are associated with increased risk of all‐cause mortality, cardiovascular mortality, and major adverse cardiac events in patients with ST ‐segment elevation myocardial infarction.

Importance: Ischemic postconditioning of the heart during primary percutaneous coronary intervention (PCI) induced by repetitive interruptions of blood flow to the ischemic myocardial region immediately after reopening of the infarct-related artery may limit myocardial damage.Objective: To determine whether ischemic postconditioning can improve the clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI).Design, Setting, And Participants: In this multicenter, randomized clinical trial, patients with onset of symptoms within 12 hours, STEMI, and thrombolysis in myocardial infarction (TIMI) grade 0-1 flow in the infarct-related artery at arrival were randomized to conventional PCI or postconditioning. Inclusion began on March 21, 2011, through February 2, 2014, and follow-up was completed on February 2, 2016. Analysis was based on intention to treat.Interventions: Patients were randomly allocated 1:1 to conventional primary PCI, including stent implantation, or postconditioning performed as 4 repeated 30-second balloon occlusions followed by 30 seconds of reperfusion immediately after opening of the infarct-related artery and before stent implantation.Main Outcome and Measures: A combination of all-cause death and hospitalization for heart failure.Results: During the inclusion period, 1234 patients (975 men [79.0%] and 259 women [21.0%]; mean [SD] age, 62 [11] years) underwent randomization in the trial. Median follow-up was 38 months (interquartile range, 24-58 months). The primary outcome occurred in 69 patients (11.2%) who underwent conventional primary PCI and in 65 (10.5%) who underwent postconditioning (hazard ratio, 0.93; 95% CI, 0.66-1.30; P = .66). The hazard ratios were 0.75 (95% CI, 0.49-1.14; P = .18) for all-cause death and 0.99 (95% CI, 0.60-1.64; P = .96) for heart failure.Conclusions and Relevance: Routine ischemic postconditioning during primary PCI failed to reduce the composite outcome of death from any cause and hospitalization for heart failure in patients with STEMI and TIMI grade 0-1 flow at arrival.Trial Registration: clinicaltrials.gov Identifier: NCT01435408.

Background The influence of comorbid conditions on ventricular remodeling, functional status, and clinical outcome after cardiac resynchronization therapy (CRT) is insufficiently elucidated. Methods and Results The influence of different comorbid conditions on left ventricular remodeling, improvement in New York Heart Association (NYHA) functional class, hospitalizations for heart failure, and all-cause mortality after CRT implantation was analyzed in 172 consecutive patients (mean age 71 ± 9 y), implanted from October 2008 to April 2011 in a single tertiary care hospital. During mean follow-up of 18 ± 9 months, 21 patients died and 57 were admitted for heart failure. Left ventricular remodeling and improvement in NYHA functional class were independent from comorbidity burden. However, diabetes mellitus (hazard ratio [HR] 3.45, 95% confidence interval [CI] 1.24–9.65) and chronic kidney disease (HR 3.11, 95% CI 1.10–8.81) were predictors of all-cause mortality, and the presence of chronic obstructive pulmonary disease (HR 1.89, 95% CI 1.02–3.53) was independently associated with heart failure admissions. Importantly, those 3 comorbid conditions had an additive negative impact on survival and heart failure admissions, even in patients with reverse left ventricular remodeling. Conclusions Reverse ventricular remodeling and improvement in functional status after CRT implantation are independent from comorbidity burden. However, comorbid conditions remain important predictors of all-cause mortality and heart failure admissions.

Background: Though the incidence of new Trypanosoma cruzi infections has decreased significantly in endemic regions in the Americas, medical professionals continue to encounter a high burden of resulting Chagas disease among infected adults. The current prevalence of Chagas heart disease in a community setting is not known; nor is it known how recent insecticide vector control measures may have impacted the progression of cardiac disease in an infected population.Objectives: We sought to determine the current prevalence of T. cruzi infection and associated Chagas heart disease in a Bolivian community endemic for T. cruzi.Methods: Nested within a community serosurvey in rural and periurban communities in central Bolivia, we performed a cross-sectional cardiac substudy to evaluate adults for historical, clinical, and electrocardiographic evidence of cardiac disease. All adults between the ages of 20 and 60 years old with T. cruzi infection and those with a clinical history, physical exam, or electrocardiogram consistent with cardiac abnormalities were also scheduled for echocardiography.Results: Of the 604 cardiac substudy participants with definitive serology results, 183 were seropositive for infection with T. cruzi (30.3%). Participants who were seropositive for T. cruzi infection were more likely to have conduction system defects (1.6% vs. 0% for complete right bundle branch block and 10.4% vs. 1.9% for any bundle branch block; p = 0.008 and p < 0.001, respectively). However, there was no statistically significant difference in the prevalence of bradycardia among seropositive versus seronegative participants. Echocardiogram findings were not consistent with a high burden of Chagas cardiomyopathy: valvulopathies were the most common abnormality, and few participants were found to have low ejection fraction or left ventricular dilatation. No participants had significant heart failure.Conclusions: Though almost one-third of adults in the community were seropositive for T. cruzi infection, few had evidence of Chagas heart disease.HighlightsWe conducted a community survey of Trypanosoma cruzi infection in central Bolivia.We evaluated adults ages 20 to 60 years old for evidence of Chagas heart disease.We found 30.3% of adults were seropositive for T. cruzi infection.Bundle branch blocks were more common among participants with T. cruzi infection.Overall rates of Chagas cardiomyopathy were lower than in previous community studies.

Background Unless effective preventive strategies are implemented, aging of the population will result in a significant worsening of the heart failure (HF) epidemic. Few data exist on whether baseline electrocardiographic (ECG) abnormalities can refine risk prediction for HF. Methods We examined a prospective cohort of 2,915 participants aged 70 to 79 years without preexisting HF, enrolled between April 1997 and June 1998 in the Health, Aging, and Body Composition (Health ABC) study. Minnesota Code was used to define major and minor ECG abnormalities at baseline and at year 4 follow-up. Using Cox models, we assessed (1) the association between ECG abnormalities and incident HF and (2) the incremental value of adding ECG to the Health ABC HF Risk Score using the net reclassification index. Results At baseline, 380 participants (13.0%) had minor, and 620 (21.3%) had major ECG abnormalities. During a median follow-up of 11.4 years, 485 participants (16.6%) developed incident HF. After adjusting for the Health ABC HF Risk Score variables, the hazard ratio (HR) was 1.27 (95% CI 0.96-1.68) for minor and 1.99 (95% CI 1.61-2.44) for major ECG abnormalities. At year 4, 263 participants developed new and 549 had persistent abnormalities; both were associated with increased subsequent HF risk (HR 1.94, 95% CI 1.38-2.72 for new and HR 2.35, 95% CI 1.82-3.02 for persistent ECG abnormalities). Baseline ECG correctly reclassified 10.5% of patients with HF events, 0.8% of those without HF events, and 1.4% of the overall population. The net reclassification index across the Health ABC HF risk categories was 0.11 (95% CI 0.03-0.19). Conclusions Among older adults, baseline and new ECG abnormalities are independently associated with increased risk of HF. The contribution of ECG screening for targeted prevention of HF should be evaluated in clinical trials.

Objective This study aimed to assess the impact of individual comorbid conditions as well as the weight assignment, predictive properties and discriminating power of the Charlson Comorbidity Index (CCI) on outcome in patients with acute coronary syndrome (ACS). Methods A prospective multicentre observational study (AMIS Plus Registry) from 69 Swiss hospitals with 29 620 ACS patients enrolled from 2002 to 2012. The main outcome measures were in-hospital and 1-year follow-up mortality. Results Of the patients, 27% were female (age 72.1±12.6 years) and 73% were male (64.2±12.9 years). 46.8% had comorbidities and they were less likely to receive guideline-recommended drug therapy and reperfusion. Heart failure (adjusted OR 1.88; 95% CI 1.57 to 2.25), metastatic tumours (OR 2.25; 95% CI 1.60 to 3.19), renal diseases (OR 1.84; 95% CI 1.60 to 2.11) and diabetes (OR 1.35; 95% CI 1.19 to 1.54) were strong predictors of in-hospital mortality. In this population, CCI weighted the history of prior myocardial infarction higher (1 instead of −0.4, 95% CI −1.2 to 0.3 points) but heart failure (1 instead of 3.7, 95% CI 2.6 to 4.7) and renal disease (2 instead of 3.5, 95% CI 2.7 to 4.4) lower than the benchmark, where all comorbidities, age and gender were used as predictors. However, the model with CCI and age has an identical discrimination to this benchmark (areas under the receiver operating characteristic curves were both 0.76). Conclusions Comorbidities greatly influenced clinical presentation, therapies received and the outcome of patients admitted with ACS. Heart failure, diabetes, renal disease or metastatic tumours had a major impact on mortality. CCI seems to be an appropriate prognostic indicator for in-hospital and 1-year outcomes in ACS patients. ClinicalTrials.gov Identifier NCT01305785

Background— American College of Cardiology/American Heart Association guidelines for the diagnosis and management of heart failure recommend investigating exacerbating conditions such as thyroid dysfunction, but without specifying the impact of different thyroid-stimulation hormone (TSH) levels. Limited prospective data exist on the association between subclinical thyroid dysfunction and heart failure events. Methods and Results— We performed a pooled analysis of individual participant data using all available prospective cohorts with thyroid function tests and subsequent follow-up of heart failure events. Individual data on 25 390 participants with 216 248 person-years of follow-up were supplied from 6 prospective cohorts in the United States and Europe. Euthyroidism was defined as TSH of 0.45 to 4.49 mIU/L, subclinical hypothyroidism as TSH of 4.5 to 19.9 mIU/L, and subclinical hyperthyroidism as TSH P for quadratic pattern P for trend P for trend=0.047). Risks remained similar after adjustment for cardiovascular risk factors. Conclusion— Risks of heart failure events were increased with both higher and lower TSH levels, particularly for TSH ≥10 and

AIMS: The purpose of the present study was to determine the prognostic importance for all-cause mortality of lung function variables obtained by spirometry in an unselected group of patients admitted with heart failure (HF).METHODS AND RESULTS: This was a prospective prognostic study performed as part of the EchoCardiography and Heart Outcome Study (ECHOS). This analysis included 532 patients admitted with a clinical diagnosis of HF. All patients underwent spirometry and echocardiography and the diagnosis of HF was made according to established criteria. Mean forced expiratory volume in 1 s (FEV(1)) was 65% of the predicted value [95% confidence interval (CI) 63-67%], mean forced vital capacity (FVC) was 71% of predicted (95% CI 69-72%), and FEV(1)/FVC was 0.72 (95% CI 0.71-0.73). FEV(1), FVC, and FEV(1)/FVC were all significant prognostic factors for all-cause mortality in univariate analyses. In a multivariate analysis, FEV(1) had independent prognostic value (hazard ratio 0.86 per 10% change, P < 0.001) after adjusting for demographic variables, known risk factors, ejection fraction, and self-reported chronic obstructive pulmonary disease.CONCLUSION: Pulmonary function provides significant prognostic information for all-cause mortality in patients admitted with HF. Spirometry therefore seems to be worth considering for all patients admitted with HF in order to identify patients at high risk.

AIMS: To compare the treatment and outcomes of myocardial infarction patients in hospitals with and without catheterization laboratory. METHODS AND RESULTS: The Hellenic Infarction Observation Study was a countrywide registry of acute myocardial infarction, conducted during 2005-2006. The registry enrolled 1840 patients with myocardial infarction from 31 hospitals with a proportional representation of all types of hospitals and of all geographical areas. Out of these patients, 645 (35%) were admitted in 11 hospitals with and 1195 (65%) in 20 hospitals without catheterization laboratory. Patients admitted in hospitals with catheterization laboratory in comparison with patients admitted in hospitals without were younger (66+/-14 vs. 68+/-13, P1 22 vs. 23%). Reperfusion rates for ST-segment elevation myocardial infarction were 67% (43% lytic, 24% primary percutaneous coronary interventions) versus 56% (55% lytic, 1% percutaneous coronary interventions; P

Background: With regard to patients' self-reported somatic diseases some researchers transformed "don't know (DK)" responses into "no" responses. The present study examines the appropriateness of this procedure. Methods: Analyses were based on the nationally representative German National Health Interview and Examination Survey (GHS), which assessed both self-reported diseases and physician-diagnosed diseases (N = 7124). Prevalence rates of persons' DK responses and the corresponding prevalences of physicians' diagnoses were calculated for persons with hypertension, coronary heart disease (CHD), heart failure, asthma, chronic bronchitis, thyroid disease, diabetes, cancer, gout, arthrosis, arthritis and osteoporosis. Correlates of physicians' diagnosed diseases of DK cases are reported. Results: Between 1.6% and 9.8% of the participants responded with DK to the question of whether they have the disease. In 3.7% to 29.5% of DK cases, the physicians did regard the respective disease as being present. With regard to persons who responded with DK, the probability of a physicians' diagnosis was increased in the case of increased age and a higher number of somatic comorbidities. Conclusion: The procedure of transforming DK responses into "no" answers does not appear to be recommendable. Hintergrund: "Weiß nicht"-Antworten von Patienten auf die Frage nach dem Vorliegen einer körperlichen Erkrankung werden in verschiedenen Studien zu "Nein"-Antworten umkodiert. Die vorliegende Studie untersucht die Validität dieses Vorgehens. Methodik: Die Studie basiert auf Daten des Bundesgesundheitssurveys 1998 (BGS98), in dessen Rahmen sowohl seitens der Probanden berichtete als auch ärztlich diagnostizierte Erkrankungsangaben vorliegen (N=7124). Untersucht wurden probandenseitig berichtete "weiß nicht"-Antworten im Vergleich zu den Arztdiagnosen (liegt vor: ja/nein) in Bezug auf Hypertension, koronare Herzkrankheit (KHK), Herzinsuffizienz, Asthma, chronisch Bronchitis, Schilddrüsenerkrankung, Diabetes, Tumor, Gicht, Arthrose, Arthritis und Osteoporose. Ergebnisse: Zwischen 1,6% und 9,8% der Probanden antworteten mit "weiß nicht" auf die Frage, ob die entsprechende Erkrankung jemals vorlag. In 3,7% bis 29,5% dieser Fälle diagnostizierte der Arzt die Erkrankung als gegeben. Bei Personen mit DK-Antworten, war die Wahrscheinlichkeit, dass ärztlicherseits eine Erkrankung diagnostiziert wurde, bei älteren Patienten und Patienten mit einer höheren Anzahl somatischer Erkrankungen erhöht. Schlussfolgerung: Die Umkodierung von "weiß nicht"-Antworten zu "nein"-Antworten erscheint nicht empfehlenswert.

The objective of the study was to describe seasonality of hospitalizations for heart failure in tropical climate as it has been described in cold climates. Seasonal Auto-regressive Integrated Moving-Average model was applied to time-series data of heart failure hospitalizations between 1996 and 2004 in Niteroi (Southeastern Brazil), collected from the Brazilian National Health Service Database. The standard seasonal variation was obtained by means of moving-average filtering and averaging data. The lowest and the highest annual hospital admissions were 507 (1997) and 849 (2002), respectively; the lowest and the highest monthly rates were 419 (December) and 681 (October), respectively. Peak admission rates were seen during the fall and winter. Although weak, the seasonality observed indicates that slight variations result in increased hospitalizations for heart failure. O objetivo do estudo foi descrever a sazonalidade das hospitalizações por insuficiência cardíaca em climas tropicais, aspecto já conhecido em climas frios. Aplicou-se o Modelo Sazonal Auto-Regressivo Integrado de Médias Móveis a uma série histórica de 6.596 hospitalizações por insuficiência cardíaca no município de Niterói, RJ, de 1996 a 2004, obtida do Banco de Dados do Sistema Único de Saúde. A variação sazonal padrão foi obtida por meio da filtragem e cálculo da média-móvel dos dados. O menor número de hospitalizações por ano foi 507 (1997) e o maior 849 (2002); e por mês 419 (dezembro) e 681 (outrubro), respectivamente. Foram observados picos de internação no outono e inverno. Ainda que fraca, a sazonalidade observada mostra que uma pequena variação pode levar ao aumento de hospitalizações. El objetivo del estudio fue describir la estacionalidad de las hospitalizaciones por insuficiencia cardiaca en climas tropicales, aspecto ya conocido en climas fríos. Se aplicó el Modelo Estacional Auto-Regresivo Integrado de Promedios Móviles a una serie histórica de 6.596 hospitalizaciones por insuficiencia cardiaca en el municipio de Niteroi, Sureste de Brasil, de 1996 a 2004, obtenida del Banco de Datos del Sistema Único de Salud. La variación estacional estándar fue obtenida por medio de la filtración y cálculo del promedio-móvil de los datos. El menor número de hospitalizaciones por año fue 507 (1997) y el mayor 849 (2002); e por mes 419 (diciembre) y 681 (octubre), respectivamente. Se observaron picos de internación en otoño e invierno. A pesar de que fue débil, la estacionalidad observada muestra que una pequeña variación puede llevar al aumento de hospitalizaciones.