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BACKGROUND: There is conflicting evidence about whether mortality after myocardial infarction (MI) is higher among women than among men. This study aimed to compare sex differences in post myocardial infarction mortality in the Veterans Affairs system, a setting where the predominant subjects are men. METHODS: The Veterans Affairs Corporate Data Warehouse inpatient and laboratory chemistry databases were used to identify patients diagnosed with acute myocardial infarction from inpatient records from January 1(st), 2005 to April 25(th), 2015. Mortality data was obtained through the VA’s death registry. RESULTS: A total of 130,241 patients were identified; 127,711 men (98%) and 2,530 women (2%). Men typically had more comorbidities including congestive heart failure (54% vs 46%, p value

Aims Implantable cardioverter-defibrillator (ICD) therapy reduces mortality in patients with heart failure and current guidelines advise implantation of ICDs in patients with a life expectancy of >1 year. We examined trends in all-cause mortality in patients who underwent primary or secondary prevention ICD placement in the Veterans Affairs (VA) Health System. Methods and results US veterans receiving a new ICD placement for primary or secondary prevention of sudden cardiac death between January 2007 and January 2015, who had heart failure with reduced ejection fraction (HFrEF) were included in the analysis. We assessed all-cause mortality 1 year post-ICD implantation. ICD implantation and HFrEF diagnosis were established with associated ICD-9 codes. The VA death registry was utilized to identify mortality rates following ICD placement. Results were subsequently age-stratified. There were 17 901 veterans with HFrEF with ICD placement nationwide. There was no statistically significant difference in 1-year mortality from 2007 (13.1%) to 2014 (13.4%, P > 0.05). There was a significant increase in 1-year mortality in patients in the oldest age quartile (81.6 years, 32.3% mortality) compared to the youngest quartile (55.5 years, 7% mortality). The finding of diverging clinical outcomes extended to the 30-day but also 8-year mark. Conclusions Our data suggest there is a high 1-year mortality in aging HFrEF patients undergoing primary and secondary prevention ICD placement. This highlights the importance of developing better predictive models for mortality in our ICD eligible patient population.

Patients with post-traumatic stress disorder (PTSD) are at risk of multiple co-morbidities and are more likely to develop incident heart failure with reduced ejection fraction (HFrEF). The relation of PTSD with clinical outcomes in HFrEF is not established. US veterans diagnosed with HFrEF from January 2007 to January 2015 and treated nationwide in the Veterans Affairs (VA) Health System were included in the study. Patients with HFrEF were identified through International Classification of Diseases, Ninth Revision (ICD-9) codes. Mortality data were obtained from the VA's death registry. We compared characteristics of patients with HFrEF with and without PTSD. We identified 111,970 VA patients with HFrEF and 11,039 patients with concomitant PTSD (9.9%). Patients with PTSD and HFrEF tended to be younger (64 vs 69 years) and have a higher rate of coronary artery disease (73% vs 64%), chronic obstructive pulmonary disease (42% vs 31%), and hypertension (80% vs 64%, p 0.01 for all variables). Patients with PTSD and HFrEF were more commonly on a high-dose β blocker (70% vs 68%, p 0.01) and angiotensin-converting enzyme inhibitors (96% vs 93%, p 0.01). PTSD was associated with significantly increased mortality at 7 years compared with patients with heart failure without PTSD (adjusted 1.54, 95% confidence interval 1.30 to 1.82, p 0.01). In conclusion, nearly 10% of veterans with HFrEF have PTSD. Patients with HFrEF with PTSD have a higher burden of co-morbidities, and PTSD is associated with a higher rate of all-cause death. Our findings support greater attention to the treatment of patients with PTSD and the causes associated with the poor outcomes.

BACKGROUND: Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with large numbers of patients are required to detect differences in stroke rates between CABG and PCI.OBJECTIVES: This study sought to compare rates of stroke after CABG and PCI and the impact of procedural stroke on long-term mortality.METHODS: We performed a collaborative individual patient-data pooled analysis of 11 randomized clinical trials comparing CABG with PCI using stents; ERACI II (Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease) (n = 450), ARTS (Arterial Revascularization Therapy Study) (n = 1,205), MASS II (Medicine, Angioplasty, or Surgery Study) (n = 408), SoS (Stent or Surgery) trial (n = 988), SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial (n = 1,800), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) trial (n = 600), FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900), VA CARDS (Coronary Artery Revascularization in Diabetes) (n = 198), BEST (Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease) (n = 880), NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trial (n = 1,184), and EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial (n = 1,905). The 30-day and 5-year stroke rates were compared between CABG and PCI using a random effects Cox proportional hazards model, stratified by trial. The impact of stroke on 5-year mortality was explored.RESULTS: The analysis included 11,518 patients randomly assigned to PCI (n = 5,753) or CABG (n = 5,765) with a mean follow-up of 3.8 ± 1.4 years during which a total of 293 strokes occurred. At 30 days, the rate of stroke was 0.4% after PCI and 1.1% after CABG (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.20 to 0.53; p < 0.001). At 5-year follow-up, stroke remained significantly lower after PCI than after CABG (2.6% vs. 3.2%; HR: 0.77; 95% CI: 0.61 to 0.97; p = 0.027). Rates of stroke between 31 days and 5 years were comparable: 2.2% after PCI versus 2.1% after CABG (HR: 1.05; 95% CI: 0.80 to 1.38; p = 0.72). No significant interactions between treatment and baseline clinical or angiographic variables for the 5-year rate of stroke were present, except for diabetic patients (PCI: 2.6% vs. CABG: 4.9%) and nondiabetic patients (PCI: 2.6% vs. CABG: 2.4%) (p for interaction = 0.004). Patients who experienced a stroke within 30 days of the procedure had significantly higher 5-year mortality versus those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and CABG (41.5% vs. 8.9%, p < 0.001).CONCLUSIONS: This individual patient-data pooled analysis demonstrates that 5-year stroke rates are significantly lower after PCI compared with CABG, driven by a reduced risk of stroke in the 30-day post-procedural period but a similar risk of stroke between 31 days and 5 years. The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes. Five-year mortality was markedly higher for patients experiencing a stroke within 30 days after revascularization.

BACKGROUND: Numerous randomised trials have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for patients with coronary artery disease. However, no studies have been powered to detect a difference in mortality between the revascularisation strategies.METHODS: We did a systematic review up to July 19, 2017, to identify randomised clinical trials comparing CABG with PCI using stents. Eligible studies included patients with multivessel or left main coronary artery disease who did not present with acute myocardial infarction, did PCI with stents (bare-metal or drug-eluting), and had more than 1 year of follow-up for all-cause mortality. In a collaborative, pooled analysis of individual patient data from the identified trials, we estimated all-cause mortality up to 5 years using Kaplan-Meier analyses and compared PCI with CABG using a random-effects Cox proportional-hazards model stratified by trial. Consistency of treatment effect was explored in subgroup analyses, with subgroups defined according to baseline clinical and anatomical characteristics.FINDINGS: We included 11 randomised trials involving 11 518 patients selected by heart teams who were assigned to PCI (n=5753) or to CABG (n=5765). 976 patients died over a mean follow-up of 3·8 years (SD 1·4). Mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score was 26·0 (SD 9·5), with 1798 (22·1%) of 8138 patients having a SYNTAX score of 33 or higher. 5 year all-cause mortality was 11·2% after PCI and 9·2% after CABG (hazard ratio [HR] 1·20, 95% CI 1·06-1·37; p=0·0038). 5 year all-cause mortality was significantly different between the interventions in patients with multivessel disease (11·5% after PCI vs 8·9% after CABG; HR 1·28, 95% CI 1·09-1·49; p=0·0019), including in those with diabetes (15·5% vs 10·0%; 1·48, 1·19-1·84; p=0·0004), but not in those without diabetes (8·7% vs 8·0%; 1·08, 0·86-1·36; p=0·49). SYNTAX score had a significant effect on the difference between the interventions in multivessel disease. 5 year all-cause mortality was similar between the interventions in patients with left main disease (10·7% after PCI vs 10·5% after CABG; 1·07, 0·87-1·33; p=0·52), regardless of diabetes status and SYNTAX score.INTERPRETATION: CABG had a mortality benefit over PCI in patients with multivessel disease, particularly those with diabetes and higher coronary complexity. No benefit for CABG over PCI was seen in patients with left main disease. Longer follow-up is needed to better define mortality differences between the revascularisation strategies.FUNDING: None.

This study aimed to compare the effect of β-blocker dose and heart rate (HR) on mortality in patients with heart failure with reduced ejection fraction (HFrEF). The Veteran Affairs databases were queried to identify all patients diagnosed with HFrEF based on International Classification of Diseases Ninth Revision codes from 2007 to 2015 and β-blocker (carvedilol or metoprolol succinate) use. 36,168 patients on low dose β blocker were then matched with 36,168 patients on high dose β-blocker using propensity score matching. The impact of β-blocker dose and HR was assessed on overall mortality using Cox proportional hazard model. After dividing average HR into separate quartiles and adjusting for patient characteristics, high β-blocker dose was associated with lower overall mortality as compared with a low dose of β blocker (hazard ratio 0.75, 95% confidence interval 0.73 to 0.77, p

Background: With the advancement in diabetic management throughout the years, this study aimed to compare the effect of diabetes mellitus on mortality in patients with heart failure with reduced ejection fraction (HFrEF). Methods: The VA’s databases were queried to identify all patients diagnosed with HFrEF from 2007 to 2015. A total of 61,400 diabetic patients were matched to as many non-diabetic patients using propensity score matching with replacement. To estimate the impact of diabetic patients on overall mortality of HFrEF patients, the Cox proportional hazard model was used on the matched sample and adjusted for patient characteristics. Results: From the overall sample of 114,010 patients with HFrEF, 61,400 (54%) had diabetes mellitus. On the matched sample, after adjusting for patient characteristics such as age, sex, high beta blocker dose, heart rate quartile, carvedilol, metoprolol, comorbidities, and medications, we found that the diabetic patients were associated with a higher overall mortality compared to non-diabetic patients (HR: 1.50, 95% CI: 1.48-1.53, p Conclusions: Diabetic HFrEF patients have a higher risk of mortality than non-diabetic HFrEF patients despite controlling for beta blocker dose, medications and comorbidities.

Many ischemic stroke patients do not achieve goal blood pressure (BP

Beta blocker therapy is indicated in all patients with heart failure with reduced ejection fraction (HFrEF) as per current guidelines. The relative benefit of carvedilol to metoprolol succinate remains unknown. This study aimed to compare survival benefit of carvedilol to metoprolol succinate.The VA's databases were queried to identify 114,745 patients diagnosed with HFrEF from 2007 to 2015 who were prescribed carvedilol and metoprolol succinate. The study estimated the survival probability and hazard ratio by comparing the carvedilol and metoprolol patients using propensity score matching with replacement techniques on observed covariates. Sub-group analyses were performed separately for men, women, elderly, duration of therapy of more than 3 months, and diabetic patients.A total of 43,941 metoprolol patients were matched with as many carvedilol patients. The adjusted hazard ratio of mortality for metoprolol succinate compared to carvedilol was 1.069 (95% CI: 1.046-1.092, P value:.001). At six years, the survival probability was higher in the carvedilol group compared to the metoprolol succinate group (55.6% vs 49.2%, P value.001). The sub-group analyses show that the results hold true separately for male, over or under 65 years old, therapy duration more than three months and non-diabetic patients.Patients with HFrEF taking carvedilol had improved survival as compared to metoprolol succinate. The data supports the need for furthering testing to determine optimal choice of beta blockers in patients with heart failure with reduced ejection fraction.

Objectives This study sought to determine the optimal coronary revascularization strategy in patients with diabetes with severe coronary disease. Background Although subgroup analyses from large trials, databases, and meta-analyses have found better survival for patients with diabetes with complex coronary artery disease when treated with surgery, a randomized trial comparing interventions exclusively with drug-eluting stents and surgery in patients with diabetes with high-risk coronary artery disease has not yet been reported. Methods In a prospective, multicenter study, 198 eligible patients with diabetes with severe coronary artery disease were randomly assigned to either coronary artery bypass grafting (CABG) (n = 97) or percutaneous coronary intervention (PCI) with drug-eluting stents (n = 101) and followed for at least 2 years. The primary outcome measure was a composite of nonfatal myocardial infarction or death. Secondary outcome measures included all-cause mortality, cardiac mortality, nonfatal myocardial infarction, and stroke. Results The study was stopped because of slow recruitment after enrolling only 25% of the intended sample size, leaving it severely underpowered for the primary composite endpoint of death plus nonfatal myocardial infarction (hazard ratio: 0.89; 95% confidence interval: 0.47 to 1.71). However, after a mean follow-up period of 2 years, all-cause mortality was 5.0% for CABG and 21% for PCI (hazard ratio: 0.30; 95% confidence interval: 0.11 to 0.80), while the risk for nonfatal myocardial infarction was 15% for CABG and 6.2% for PCI (hazard ratio: 3.32; 95% confidence interval: 1.07 to 10.30). Conclusions This study was severely underpowered for its primary endpoint, and therefore no firm conclusions about the comparative effectiveness of CABG and PCI are possible. There were interesting differences in the components of the primary endpoint. However, the confidence intervals are very large, and the findings must be viewed as hypothesis generating only. (Coronary Artery Revascularization in Diabetes; NCT00326196)

Table A3. Results from linear or Logistic regression of residential distance to A1 or A2 road on markers of cardiac structure among participants in the Jackson Heart Study, excluding those with CVD (Nâ =â 2976).a. aModels adjusted for age, sex, body mass index, alcohol consumption, education level, occupation, neighborhood socioeconomic status z-score, type of medical insurance, and smoking status. (DOCX 13 kb)

Table A1. Results from linear or logistic regression of distance to A1 or A2 roads, in categories of

Table A2. Results from linear regression of distance to A1 or A2 roads, categorized as continuous (untransformed), inverse, and log-transformed distance truncated at 400Â m, on markers of cardiac structure in JHS (Nâ =â 4826)a. aModels adjusted for age, sex, body mass index, alcohol consumption, education level, occupation, neighborhood socioeconomic status z-score, type of medical insurance, and smoking status. (DOCX 12 kb)

Cardiovascular disease (CVD), including heart failure, is a major cause of morbidity and mortality, particularly among African Americans. Exposure to ambient air pollution, such as that produced by vehicular traffic, is believed to be associated with heart failure, possibly by impairing cardiac function. We evaluated the cross-sectional association between residential proximity to major roads, a marker of long-term exposure to traffic-related pollution, and echocardiographic indicators of left and pulmonary vascular function in African Americans enrolled in the Jackson Heart Study (JHS): left ventricular ejection fraction, E-wave velocity, isovolumic relaxation time, left atrial diameter index, and pulmonary artery systolic pressure. We examined these associations using multivariable linear or logistic regression, adjusting for potential confounders. Of 4866 participants at study enrollment, 106 lived

Cardiovascular disease (CVD), including heart failure, is a major cause of morbidity and mortality, particularly among African Americans. Exposure to ambient air pollution, such as that produced by vehicular traffic, is believed to be associated with heart failure, possibly by impairing cardiac function. We evaluated the cross-sectional association between residential proximity to major roads, a marker of long-term exposure to traffic-related pollution, and echocardiographic indicators of left and pulmonary vascular function in African Americans enrolled in the Jackson Heart Study (JHS): left ventricular ejection fraction, E-wave velocity, isovolumic relaxation time, left atrial diameter index, and pulmonary artery systolic pressure. We examined these associations using multivariable linear or logistic regression, adjusting for potential confounders. Of 4866 participants at study enrollment, 106 lived

Waist circumference (WC) is a component used to define metabolic syndrome. However, its role as an independent predictor of silent coronary artery disease (CAD), above its contribution to metabolic syndrome, remains unknown.Male veterans without known CAD, undergoing cardiac stress testing for indications other than typical angina or its equivalent, were evaluated for the presence of silent CAD. High WC and metabolic syndrome were defined per the revised National Cholesterol Education Program (NCEP-R) and the International Diabetes Federation (IDF) criteria.Data on 1,071 patients (age 61±11 years) were analyzed retrospectively. On multivariable logistic regression analysis [odds ratio (OR), 95% confidence interval (CI), P value), a WC ≥94 cm (1.42, 1.04-1.93; P=0.026), metabolic syndrome by NCEP-R (1.73, 1.29-2.33; P0.0001), and metabolic syndrome by IDF (1.57, 1.17-2.11; P=0.003) were independent predictors of silent CAD. When comparing patients meeting criteria for metabolic syndrome defined by either NCEP-R or IDF, the prevalence of silent CAD was not statistically different (P=0.86). The prevalence of silent CAD associated with a high WC was not inferior to that seen between silent CAD and metabolic syndrome as defined by either criterion. Last, among patients with metabolic syndrome defined by NCEP-R, those with a high WC as a defining component of metabolic syndrome had a higher prevalence of silent CAD (30% vs. 20%; P=0.026).A WC ≥94 cm in males is independently associated with an increased prevalence of silent CAD. In patients with metabolic syndrome, this prevalence is increased by the presence of high WC.

The importance of improvement in the ejection fraction to the prognosis of revascularized patients with ischaemic left ventricular (LV) dysfunction is uncertain.Eighty-seven patients with ischaemic LV dysfunction (mean ejection fraction 29 ± 8% by biplane Simpson's) had dobutamine echocardiography before revascularization (coronary bypass graft surgery-81, percutaneous intervention-6). Follow-up echocardiograms were performed a mean of 4.8 ± 6.2 months after revascularization. An 8% increase in the ejection fraction was considered significant (two times the inter-observer difference of 3.7%). Patients were followed for cardiac death. During a mean follow-up of 5.2 ± 3.9 years, there were 20 (23%) cardiac deaths. Class 3/4 heart failure, increasing low-dose wall motion score, increasing % non-viable myocardium, and digoxin use in follow-up were univariate predictors of death. Beta-blocker use, ejection fraction improvement, angina, aspirin use, and increasing fractional shortening were univariate predictors of survival. Ejection fraction improvement [P= 0.02, hazard ratio (HR) = 0.26], digoxin use in follow-up (P= 0.006, HR = 5.85), and low-dose wall motion score (P= 0.017, HR = 4.78) were independent predictors of outcome. In step-wise analysis, low-dose wall motion score added incremental prognostic value to ejection fraction improvement (P= 0.003), and digoxin use in follow-up (P= 0.003) added incremental value to a low-dose score and ejection fraction improvement.Ejection fraction improvement is an independent predictor of long-term outcome in revascularized patients but viability (low-dose wall motion score) and digoxin use in follow-up are also independent predictors and add incremental prognostic value to ejection fraction improvement.

Background Implantable cardioverter-defibrillator (ICD) therapy improves outcomes in patients with heart failure (HF) but current guidelines advise against placement of ICDs in patients with a life expectancy of less than 1 year. We examined the association between age and early mortality rate in patients who underwent primary or secondary prevention ICD in the Veterans Affairs (VA) Health System. Methods The analysis included US veterans with a diagnosis of heart failure and reduced ejection fraction (HFrEF) and a new implantation of primary or secondary prevention ICD. Patients treated nationwide in the VA-Health System from January 2007 to January 2015 were included. Diagnosis of HFrEF and ICD implantation was established through ICD9-codes. Mortality data were obtained fromthe VA's death registry. The patient cohort was divided in age quartiles and the 1-year and 8-year all-cause mortality were examined. Results A total of 17,901 patients with HFrEF and new ICD placement were identified. Distribution of age across quartiles (Q) was as following: Q1 23-61 years, mean 56; Q2 61-67 years, mean 64; Q3 67-76 years, mean 71; Q4 76-99 years, mean 82. The comorbidity burden (i.e. coronary artery disease, atrial fibrillation, chronic kidney disease and diabetes mellitus) was higher in Q3 and Q4 compared to Q1 and Q2. One-year and 8-year mortality are presented in the Figure . In the Q4 group, 32% of patients died within 1 year. Higher age quartiles were associated with significantly worse 1 and 8-year mortality when compared to Q1 (p Conclusion Elderly veterans with HFrEF and a new ICD implantation experience a high early mortality. Knowledge of clinical features associated with early mortality in the elderly population could help in the selection of appropriate ICD candidates in the VA population.

Background Implantable cardioverter-defibrillator (ICD) therapy improves mortality in patients with heart failure (HF) but current guidelines advise against implantation of ICDs in patients with a life expectancy of less than 1 year. We examined the 1-year mortality rate and burden of comorbid diseases in patients who underwent primary or secondary prevention ICD in the Veterans Affairs (VA) Health System. Methods The analysis included US veterans with a diagnosis of heart failure and reduced ejection fraction (HFrEF) and a new implantation of primary or secondary prevention ICD. Patients treated nationwide in the VA-Health System from January 2007 to January 2015 were included. Diagnosis of HFrEF and ICD implantation was established through ICD9-codes. Mortality data were obtained fromthe VA's death registry. We described the Charlson Comorbidity Index (high value = high comorbid index) and all-cause mortality rates within 1 year of device implantation. Results We identified 17,901 VA patients with HFrEF and new ICD implantation. Patients were on average 66 ± 10 years old, predominantly male (99%), and had a history of coronary artery disease (81%), chronic kidney disease (42%) and diabetes mellitus (56%). Average Charlson Comorbidity Index was 3.0 (SD ±1.5). The Comorbidity Index gradually decreased from 2007 to 2014 from 3.1 to 2.8 which represented a statistically significant decrease after the year 2011 (p 0.05) (Figure). Discussion Amongst patients with HFrEF and a new ICD implantation, we found a high 1-year mortality rate. The 1-year mortality rate remained unchanged over an 8-year period even despite a slowly decreasing burden of comorbid disease among ICD patients over the same time period. Future work needs to identify patients with a reduced chance of survival and apply specific risk prediction scores for the selection of appropriate ICD candidates in the VA population.

Background Recent data on trends in diabetes mellitus (DM) prevalence and long-term effect on mortality in peripheral arterial disease (PAD) subjects is lacking. Methods All subjects discharged from any VA medical center between October 1990 to September 1997 with an International Classification of Diseases (ICD)-9 code for PAD and DM in the discharge summary were retrospectively identified. Demographic data were extracted from the database. Mortality data were obtained from the Beneficiary Information and Resource Locator. Outcome measures were age specific DM prevalence over time, and short-term and long-term mortality. Results Of 33, 629 patients with PAD, 9474 (29%) had DM. Diabetes mellitus subjects were less likely to be white and had more comorbidities. Mean length of hospital stay was greater for DM (22.3 d vs 18.7 days, P < 0.001). Mortality was higher for DM at 180 days (9.8% vs 8.4%, P < 0.001), 1 year (16.4% vs 13.7%, P < 0.001), and continues to increase at 8 years of follow-up. Logistic regression analysis showed no interaction between DM and coronary artery disease (CAD). Conclusions Diabetes mellitus increases all-cause mortality in subjects with PAD starting at 6 months post-discharge and continues to be higher even at 8 years of follow-up. There was a lack of interaction of DM and CAD on mortality in this cohort of subjects with PAD. Copyright © 2009 Wiley Periodicals, Inc.

Background and Purpose— Recent data on stroke mortality in diabetics in the United States is lacking. We investigated trends in diabetes prevalence and stroke morality among diabetics in a large veteran cohort. Methods— The Patient Treatment File was used to identify all patients discharged from any Veterans hospital between October 1990 and September 1997 with a diagnosis of ischemic stroke (ICD-9-CM codes 434, 436) listed as primary diagnosis. Demographic, morbidity, and mortality data were recorded. Chi-square tests were used to examine differences between diabetics and nondiabetics, and t tests were used for continuous variables. Cox proportional hazards regression was used to examine the effects of diabetes (DM) on the survival times controlling for multiple covariates. Results— Of 48 733 ischemic stroke patients identified, 98% were male and 13 925 (25%) had DM. Mean age was similar between DM and non-DM (67.2 versus 67.5, P =NS). Prevalence of DM among stroke subjects increased from 25% to 31%. Charlson index >2 was much higher in DM (68.2% versus 47.9%, P P =NS; 12.6 versus 13.1, P =NS). Kaplan-Meier survival plot showed that DM had shorter long term survival time (log-rank, P P Conclusion— Despite greater comorbidity, postacute ischemic stroke mortality at 60 days and 1 year is not different between subjects with and without DM. Long term mortality after stroke is much lower among DM than that reported in older studies.

Impaired relaxation of the left ventricle (LV) (diastolic dysfunction) invariably is associated with LV systolic dysfunction.1 Atrial contribution to ventricular filling (second filling phase of diastole) is pivotal in the presence of impaired relaxation where early filling is reduced. Cardiac Resynchronization Therapy (CRT) has been shown to improve diastolic function in patients with heart failure.2,3 Optimization of atrioventricular (AV) synchrony in sinus rhythm for patients with biventricular ICD (BiV ICD) for CRT is crucial in maximizing hemodynamic improvements.4,5

Background Despite advances in therapy for congestive heart failure (CHF), mortality remains 40% to 80% higher for diabetics with CHF than nondiabetics. Diabetes prevalence is increasing worldwide with prevalence of diabetes among patients with CHF increasing at an even faster pace. Methods and Results Although multiple mechanisms are responsible for development of CHF in diabetes, ischemic heart disease plays a major role. In the foreseeable future, physicians will have to deal with increasing numbers of subjects with diabetes, coronary disease, and heart failure. Several recent developments in the field of heart failure have revolutionized the way patients are treated for CHF with improvements in quality of life and mortality. Although long-term prospective studies specifically addressing heart failure in diabetes are lacking, extrapolation of data from recent large trials has shed light on management of CHF in diabetes. Conclusions This review summarizes new developments in the field of CHF among subjects with diabetes, metabolic syndrome, and obesity.

Background Stroke is the third leading cause of death in the United States. We investigated racial differences in death after hospital discharge for ischemic stroke in a large cohort of Veterans Health Affairs (VHA) stroke patients. We hypothesized that having access to VA care would ameliorate the excess stroke mortality rates in African-Americans (AA) reported in non-VA studies. Methods Hospital administrative data were used to identify all patients discharged from any VA hospital between October 1990 and September 1997 with a primary discharge diagnosis of ischemic stroke (ICD-9-CM codes 434 and 436). We obtained demographic data and clinical data recorded during the index hospitalization and after discharge, including deaths, from VA clinical and administrative databases. The Charlson comorbidity index was constructed for each patient from the index admission's discharge diagnoses. Patients were followed through 1998. Results Of 55,094 VHA stroke patients discharged after ischemic strokes, 34,579 (63%) were white and 11,530 (21%) were AA. Charlson index was similar between the groups. One-year mortality rate was significantly higher for whites: Adjusting for demographic and clinical differences, being white remained predictive of higher mortality rates (multivariable hazard ratio, 1.06; 95% CI, 1.02 to 1.10). From Kaplan-Meier estimates, the probability that whites would survive for 1 year was 0.86 compared with 0.87 for AA. Conclusions Despite having similar severity of illness and adjusting for other clinical differences, mortality rate was marginally lower in AA after being discharged from VA hospitals after ischemic strokes. This is contrary to prior reports from non-VA hospitals and suggests the possibility of access to care playing a role in stroke deaths.

Background: Prognosis of patients with heart failure (HF) has improved in recent years due to advances in therapy. Whether this is also true for diabetic subjects with HF in clinical practice has not been studied in a prospective manner. Methods: All patients with HF and left ventricular systolic dysfunction attending the outpatient clinic at our Veteran's Hospital between October 1999 and November 2000 were enrolled in our study and followed prospectively. Electronic medical records were accessed for data on comorbid conditions, medications, echocardiogram results and mortality information. Mean follow-up was 2.7 years. Results: Of 495 patients with HF due to systolic dysfunction enrolled in the study, 293 (59%) had diabetes. Prevalence of hypertension, diuretic use and angiotensin converting enzyme inhibitor use was higher among diabetics. Beta-blocker usage was equal and high in both groups (60%). On follow-up, 109/273 (37%) patients in the diabetic group died, compared with 49/202 (24%) in the non-diabetic group. Independent predictors of death were diabetes (p

Diabetes prevalence is increasing in the population, both in the young and the elderly. We assessed the impact of increasing prevalence of diabetes on admissions for acute myocardial infarctions (MI) from 1990 through 1997.We retrospectively identified all patients discharged with the primary diagnosis of MI from any Veteran's Affairs Medical Center (VAMC) in the country between October 1990 and September 1997. Patients were classified as having diabetes from the ICD-9-CM codes and stratified by age. Demographic data were extracted from the patient treatment files. Prevalence of diabetes among MI patients for the years 1990 through 1997 was compared to that in the general population obtained from the Center for Disease Control. We identified 67,889 patients with MI of whom 17,756 (26%) had diabetes. In the age groupor =44 years, the prevalence of diabetes remained at approximately 11.5% from 1991 to 1998. In the age group 45-64 years, the increase was from 23% to 28%--a 23% increase (p0.001), while in the older age group over 65 years, it increased from 25% to 33.5%--a 34% increase (p0.001). In the general population, prevalence of diabetes increased by 50%, 63% and 44% in the three age groups.Despite substantial increase in prevalence of diabetes among the younger population, it does not appear to be predisposing them to increased risk for MI. The prevalence of diabetes among older patients with MI paralleled the increase seen in the general population with the steepest increase seen in the groupor =65 years. These data are important in focusing our resources for preventive measures.

Background Data from the 1970s and 1980s suggest that the rate of mortality from coronary disease for patients with diabetes has changed less than that for patients without diabetes. We evaluated trends in post-myocardial infarction mortality and morbidity in patients with and without diabetes over a 7-year period from 1990 through 1997, when substantial changes occurred in the management of coronary disease. Methods All patients discharged with the primary diagnosis of acute myocardial infarction (MI) from any Veterans Affairs Medical Center in the country between October 1990 and September 1997 were identified. Demographic, comorbid conditions, inpatient, outpatient, mortality, and readmission data were extracted. Mortality, trends in mortality overtime, revascularization, readmissions, and length of hospital stay for MI were compared for the group with diabetes and the group without diabetes. Independent predictors of survival using a Cox regression model were examined. Results We identified 67,889 patients with MI, of whom 17,756 (26%) had diabetes. At 60 days post-MI, there was a 29% higher mortality rate in the group with diabetes (5.2% versus 4.0%, P 0.001), which increased to 35% at 1 year (16.1% versus 11.9%, P 0.001). Diabetes was independently associated with increased overall mortality. Age-adjusted 1-year post-MI mortality from 1991 to 1998 had a significant downward trend (4.9% decrease in odds of mortality per year, P 0.001) regardless of diabetes status. Conclusions Patients with diabetes showed a trend toward declining 1-year post-MI mortality rate that was not significantly different from that seen in patients without diabetes. Further work needs to be done to narrow the gap between the two groups.

Background: Subjects with erectile dysfunction share common risk factors as those for coronary artery disease. However, there are no data on the role of stress echocardiography in assessing the prognosis of patients with erectile dysfunction. Hypothesis: We sought to determine the prognostic utility of negative stress echocardiography study in subjects with erectile dysfunction and compare it to similar subjects without erectile dysfunction. Methods: Between October 1996 and December 1997, 236 patients had negative stress echocardiograms. There were 28 patients with erectile dysfunction. There was a higher prevalence of diabetes in the erectile dysfunction group (64% vs. 35%, P=0.005). The prevalence of other risk factors was similar in the two groups. Follow-up was obtained for 233 patients for a mean duration of 25 months. Results: At the end of follow-up, there was no significant difference in the annualized occurrence of cardiac events between the two groups (4.6% vs. 4.3%, P=NS). Of note, none of the patients were prescribed sildenafil and none of the cardiac events were related to sexual activity. Conclusions: Our study shows that subjects with erectile dysfunction who have a negative stress echocardiographic study have a comparable event rate to similar subjects at high risk for cardiac events on long-term follow-up.

Patients with a negative transthoracic stress echocardiographic study (TTE-SE) are at low risk for adverse cardiac events. Because of a higher sensitivity for detection of coronary artery disease, transesophageal dobutamine stress echocardiography (TEE-DSE) might permit identification of an even lower risk population. We compared the relative prognostic values of TTE-SE and TEE-DSE in 236 patients with negative stress echocardiograms. Baseline and follow-up information on 236 consecutive subjects who had a negative stress echocardiographic study during the period of October 1996 to December 1997 was obtained. Baseline cardiac risk factors and major cardiac events (nonfatal myocardial infarct or cardiac death) were identified. Follow-up was obtained in 233 subjects for a mean duration of 25 months. At baseline, the TEE-DSE group had more hypertensives (85% vs 67%, P = 0.02) and more baseline wall-motion abnormalities (41% vs 26%, P = 0.03). At 34 months of follow-up, there was no significant difference in the occurrence of major cardiac events between the two groups (8% vs 8.6%, P = NS). In the TEE-DSE group, there were more than twice as many events in the second year of follow-up as compared with the first year, indicating that a negative TEE-DSE has lessened prognostic value 1 year after the test. Standard TTE-SE provides prognostic data in patients at high risk for major cardiac ischemic events that is equivalent to that obtained by TEE-DSE. While advances in ultrasound techniques may improve our ability to detect coronary artery disease, it remains to be seen whether this will have an impact on prognostication.

Background: The relative importance of dose of beta blocker used versus decrease in average heart rate achieved on survival remains unclear. We aimed to compare the effect of beta blocker dose and heart rate on mortality in patients with heart failure due to systolic dysfunction. Methods: We

Background: Prior studies have shown short term (up to 1 year) increased adverse outcomes in heart failure with reduced ejection fraction (HFrEF) patients with higher heart rates (HR). We investigated long term effect of ambulatory HR on mortality in patients with HFrEF. Methods: We queried the

Background: Mir-486 and mir-146a are cardiomyocyte-enriched microRNAs that target proteins in cell signaling, survival, and self-regulation of inflammation. These microRNAs are released into circulation and can be detected in plasma or in circulating exosomes. Studies show that plasma miR-486 and

Atrial fibrillation (AF) leads to remodeling of the left atrium (LA) and left atrial appendage (LAA), resulting in atrial myopathy. Reduced LA and LAA function in chronic AF leads to thrombus formation and spontaneous echo contrast (SEC). The effect of inotropic stimulation on LAA function in patients with chronic AF is unknown. LAA emptying velocity (LAAEV) and maximal LAA area at baseline and after dobutamine were measured by transesophageal echocardiography in 14 subjects in normal sinus rhythm (NSR) and 6 subjects in AF. SEC in the LA was assessed before and after dobutamine. LAAEV increased significantly in both groups. However, the LAAEV at peak dobutamine in patients with AF remained significantly lower than the baseline LAAEV in patients who were in NSR (P = 0.009). Maximal LAA area decreased significantly with dobutamine in both groups, but LAA area at peak dose of dobutamine in patients with AF remained greater than baseline area in those in NSR (P = 0.01). Despite the increase in LAAEV, SEC improved in only two of five patients. We conclude that during AF, the LAA responds to inotropic stimulation with only a modest improvement in function.

Recently published reviews have called into question the sensitvity of transthoracic stress echocardiography to predict cardiac events, especially when the test is negative, compared with myocardial perfusion imaging studies. To our knowledge there are a lack of data assessing the prognostic value of transesophageal echocardiography–dobutamine stress echocardiography (TEE-DSE) in predicting cardiac events. Because TEE-DSE has been reported to be highly accurate for detecting ischemia in patients with suspected coronary artery disease, we tested the hypothesis that a negative TEE-DSE can identify a low-risk group in a population with a high likelihood of coronary artery disease. Between October 1996 and December 1997, 46 high-risk patients with negative TEE-DSE were identified. Annualized pretest risk for all cardiac events using the Framingham model was 4% based on risk factors. Mean age was 64 years. Mean follow-up time was 16.2 months. There were no cardiac deaths. There were 6 soft and 1 hard cardiac event. The annualized combined ischemic cardiac event rate was 3.8%, and for hard cardiac events it was 1.1%. By Kaplan-Meier analysis, 97% of the population remained free of any ischemic event at the end of 1 year and 93% were free at 22 months. We conclude that optimal image quality and enhanced endocardial definition for assessing wall motion changes with TEE translates into better prognostication and approaches that of myocardial perfusion imaging for negative studies. Advances in ultrasound medicine such as contrast enhancement of myocardial definition, which improve diagnostic accuracy of DSE, should translate into better prognostication.

Background RETRACTION: Publication of the following article is being retracted by the publisher due to erroneous publication. The authors were unable to obtain internal review board permission to publish the work and requested withdrawal after acceptance of: "Relation of Atherosclerotic Cardiovascular Events to Progression of Aortic Stenosis in Older Men" by Masoor Kamalesh, Charlotte Ng, and George Eckert. This article published on EarlyView on December 14, 2009 (DOI: 10.1002/clc.20541. Aortic stenosis (AS) is now considered to be an active disease like atherosclerosis. However, therapies such as statins have not shown benefit in AS patients when studied prospectively. Hypothesis We tested the hypothesis that if AS was indeed similar to atherosclerosis, then subjects with progressive AS should have a higher atherosclerosis related event rate than those without progression of AS. Methods Two readers independently measured the aortic valve area using a continuity equation in 164 consecutive subjects with AS between January 1997 through March 2005, referred to our laboratory for serial echocardiograms for AS. Subjects with no progression of AS were compared to subjects with progression of reduction in valve area with regards to baseline demographics, occurrence of all myocardial infarctions, stroke, unstable angina requiring hospitalization, and coronary revascularization. A χ2 test were use to compare the groups for differences in endpoints. Results The study cohort included 164 males age 70 ± 9 years. Age, low-density lipoprotein level, hypertension, or diabetes status were similar among the 2 groups, while the no progression group had more smokers and fewer patients on statins (P

Aims Calcific aortic valve stenosis (CAS) is an active disease like atherosclerosis. Effect of diabetes (D) on severity of CAS is not well documented. Methods and results We retrospectively analysed 166 consecutive patients with CAS and multiple echocardiograms from January 1997 to March 2005. Aortic valve area (AVA) was measured using the continuity equation. CAS severity was categorized using AVA. D and non-D patients were compared for differences in sex, hypertension, smoking, statin use using χ2 tests. Comparisons between D and non-D for changes in AVA per year were performed using ANOVA. Study cohort included 166 males with age 70 ± 9 years, of which 72 (43%) had D. Baseline CAS was mild in 66 subjects, moderate in 75, and severe in 25. D subjects smoked less ( P = 0.02), but all other variables were similar ( P > 0.05). The interaction between D and baseline CAS severity was significant ( P = 0.0191), indicating comparisons should be viewed by baseline CAS severity. D had significantly larger change in AVA than non-D ( P = 0.0016) for those with moderate CAS at baseline only. Adjusting for statin use did not alter the results. Conclusion CAS severity progresses faster in D than in non-D in subjects with moderate CAS at baseline. Statins do not affect progression of CAS.

Progress in biomedical engineering technology has resulted in major advances in noninvasive cardiac imaging, with noninvasive techniques becoming a real alternative to invasive modalities for diagn...

It is not known whether high-dose statins can reduce the excess burden (and consequent adverse cardiovascular outcomes) of coronary artery disease in patients with metabolic syndrome compared with those without metabolic syndrome. The results of our study suggest that high-dose simvastatin may be required to reduce excess events in very high-risk cohorts with metabolic syndrome.

Despite new therapies, the prevalence of heart failure continues to escalate. The prevalence of diabetes, a risk factor for heart failure, also continues to rise. To further understand the increasing prevalence of heart failure, we compared trends in the prevalence of diabetes among individuals with diagnosed heart failure versus those in the general population.Fourteen randomized trials between 1989 and 1999 including subjects with heart failure (n = 34,633) were reviewed. For each trial, the enrollment date was used to estimate the yearly prevalence of diabetes among study participants with heart failure. The prevalence of diabetes in the general population was estimated based on United State's Center for Disease Control statistics from 1989 to 1999. The prevalence of diabetes between heart failure subjects and the general population was compared using a two-sample t-test for independent samples with unequal variances.The prevalence of diabetes increased from 2.6% to 4.0% from 1989 to 1999 in the general U.S. population. Among patients with heart failure, the prevalence of diabetes increased from 13% to 47%. Diabetes prevalence estimates varied significantly (p0.001) between the general population and individuals with heart failure during the study period.The rising prevalence of diabetes may partially explain the growing epidemic of heart failure. Increased efforts targeting diabetes and other cardiovascular risk factors are warranted in attenuating the rising prevalence of heart failure.

Decreased heart rate variability, which may be due to increased sympathetic and decreased parasympathetic activity, has been shown to be a predictor of cardiac events after acute myocardial infarction. The present study was undertaken to analyze the effect of beta adrenergic blockade on cardiac autonomic system in patients with chronic stable angina. Nineteen patients (15 males and 4 females, age range 44–74 years) with chronic stable angina were enrolled. After stopping all cardiac medications, patients had two baseline treadmill tests with both reproducible angina and ST depression and a baseline 48-hour ambulatory ECG recording. A long-acting beta-blocker (atenolol or betaxolol) was started and titrated to the maximal tolerated dose. After 1–2 months, a repeat 48-hour ambulatory ECG recording on beta-blocker therapy was obtained. Heart rate variability analysis was performed on the baseline and drug therapy ECG recordings. The average heart rate significantly decreased (P < 0.008), and the mean RR interval significantly increased (P < 0.0001). In the time-domain analysis, the standard deviation, variance, ASDNN5, and SDANN5 were not significantly affected, although the PNN50 increased. In the frequency domain, the total power (P < 0.0001) and the low frequency (P < 0.001) components decreased, while the high frequency spectrum was unchanged. Thus, sympathetic activity significantly declined in patients with chronic stable angina on beta-blocker therapy, while parasympathetic tone demonstrated a heterogenous response.

Before heart rate variability (HRV) can be used to investigate the effects of drugs or other clinical interventions in chronic stable angina, it is important to establish the stability and reproducibility of HRV indices over time. HRV analysis was performed on two consecutive 24-hour ambulatory ECG recordings in 19 patients with chronic stable angina. Time-domain analysis included average heart rate, variance, SDNN, SDANN5, ASDNN5, and PNN50. The power spectral analysis was computed using fast Fourier transformation for the total power (0.003 and 0.40 Hz), low frequency (0.04–0.15 Hz), and high frequency (0.15–0.40 Hz) bands. No statistically significant differences in the time or frequency domains were found between the two ambulatory ECG recordings. HRV indices in the time and frequency domains are consistent and reproducible in patients with chronic stable angina. Thus, cardiac autonomic tone can be evaluated using HRV analyses, and any significant changes that occur after medical therapy or other clinical interventions can be ascribed to the intervention rather than the lability of cardiac autonomic tone.