Minority of CHD patients do recommended exercise
29 February 2008
Study findings reveal that patients with coronary heart disease often do not comply with physical activity recommendations, and are less likely to do so than individuals without CHD.
Information, reassurance, and support aid post-CABG recovery
29 February 2008
The results of a small, qualitative UK survey show that patients undergoing coronary bypass grafting surgery who may feel anxious or depressed about their recovery can be helped if they remain optimistic and are given information, reassurance, and support from the healthcare team and their social network.
Persistent hyperglycemia in AMI predicts in-hospital mortality
29 February 2008
Persistent hyperglycemia determined by multiple glucose assessments during hospitalization for acute myocardial infarction better predicts mortality than hyperglycemia on admission, research shows.
Showing posts with label Coronary Artery Disease. Show all posts
Showing posts with label Coronary Artery Disease. Show all posts
Saturday, March 1, 2008
Tuesday, February 12, 2008
Recent Trends in the Prevalence of Coronary Disease - A Population-Based Autopsy Study of Nonnatural Deaths
Arch Intern Med. 2008;168(3):264-270.
Peter N. Nemetz, PhD; Véronique L. Roger, MD, MPH; Jeanine E. Ransom, BS; Kent R. Bailey, PhD; William D. Edwards, MD; Cynthia L. Leibson, PhD
Background Despite increases in obesity and diabetes mellitus, mortality caused by coronary disease continues to decline. Recent trends in coronary disease prevalence are unknown.
Methods There were 3237 deaths among Olmsted County, Minnesota, residents aged 16 through 64 years during the 1981-2004 period. Of the 515 due to accident, suicide, homicide, or a manner that could not be determined, 425 individuals (82%) had coronary anatomy graded. Pathology reports were reviewed for the grade of coronary disease (range, 0-5) assigned each of 4 arteries: left anterior descending (LAD), left circumflex (LCx), right coronary artery (RCA), and left main artery (LMA). High-grade disease was defined as more than a 75% reduction in cross-sectional luminal area (grade 4) in any of LAD, LCx, or RCA or more than 50% reduction (grade 3) in LMA. Evidence of any disease was defined as a grade higher than 0 in any artery. Calendar-year trends were analyzed as linear and nonlinear functions.
Results Over the full period (1981-2004), 8.2% of the 425 individuals had high-grade disease, and 83% had evidence of any disease. Age- and sex-adjusted regression analyses revealed temporal declines over the full period (1981-2004) for high-grade disease, any disease, and grade of coronary disease. Declines in the grade of coronary disease ended after 1995 (P .01 for every artery) and possibly reversed after 2000 (P = .06 for LCx).
Conclusions Declines in coronary disease prevalence overall (during 1981-2004) reinforce arguments that any increased prevalence resulting from improved survival among persons with disease was offset by reductions in disease incidence. Study findings suggest that declines in coronary disease prevalence have ended. The question of whether recent trends are attributable to increasing obesity and diabetes mellitus awaits further investigation.
Peter N. Nemetz, PhD; Véronique L. Roger, MD, MPH; Jeanine E. Ransom, BS; Kent R. Bailey, PhD; William D. Edwards, MD; Cynthia L. Leibson, PhD
Background Despite increases in obesity and diabetes mellitus, mortality caused by coronary disease continues to decline. Recent trends in coronary disease prevalence are unknown.
Methods There were 3237 deaths among Olmsted County, Minnesota, residents aged 16 through 64 years during the 1981-2004 period. Of the 515 due to accident, suicide, homicide, or a manner that could not be determined, 425 individuals (82%) had coronary anatomy graded. Pathology reports were reviewed for the grade of coronary disease (range, 0-5) assigned each of 4 arteries: left anterior descending (LAD), left circumflex (LCx), right coronary artery (RCA), and left main artery (LMA). High-grade disease was defined as more than a 75% reduction in cross-sectional luminal area (grade 4) in any of LAD, LCx, or RCA or more than 50% reduction (grade 3) in LMA. Evidence of any disease was defined as a grade higher than 0 in any artery. Calendar-year trends were analyzed as linear and nonlinear functions.
Results Over the full period (1981-2004), 8.2% of the 425 individuals had high-grade disease, and 83% had evidence of any disease. Age- and sex-adjusted regression analyses revealed temporal declines over the full period (1981-2004) for high-grade disease, any disease, and grade of coronary disease. Declines in the grade of coronary disease ended after 1995 (P .01 for every artery) and possibly reversed after 2000 (P = .06 for LCx).
Conclusions Declines in coronary disease prevalence overall (during 1981-2004) reinforce arguments that any increased prevalence resulting from improved survival among persons with disease was offset by reductions in disease incidence. Study findings suggest that declines in coronary disease prevalence have ended. The question of whether recent trends are attributable to increasing obesity and diabetes mellitus awaits further investigation.
Thursday, January 24, 2008
Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease
Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease
New England Journal of Medicine, January 24, 2008.
Edward L. Hannan, Ph.D., Chuntao Wu, M.D., Ph.D., Gary Walford, M.D., Alfred T. Culliford, M.D., Jeffrey P. Gold, M.D., Craig R. Smith, M.D., Robert S.D. Higgins, M.D., Russell E. Carlson, M.D., and Robert H. Jones, M.D.
ABSTRACT
Background Numerous studies have compared the outcomes of two competing interventions for multivessel coronary artery disease: coronary-artery bypass grafting (CABG) and coronary stenting. However, little information has become available since the introduction of drug-eluting stents.
Methods We identified patients with multivessel disease who received drug-eluting stents or underwent CABG in New York State between October 1, 2003, and December 31, 2004, and we compared adverse outcomes (death, death or myocardial infarction, or repeat revascularization) through December 31, 2005, after adjustment for differences in baseline risk factors among the patients.
Results In comparison with treatment with a drug-eluting stent, CABG was associated with lower 18-month rates of death and of death or myocardial infarction both for patients with three-vessel disease and for patients with two-vessel disease. Among patients with three-vessel disease who underwent CABG, as compared with those who received a stent, the adjusted hazard ratio for death was 0.80 (95% confidence interval [CI], 0.65 to 0.97) and the adjusted survival rate was 94.0% versus 92.7% (P=0.03); the adjusted hazard ratio for death or myocardial infarction was 0.75 (95% CI, 0.63 to 0.89) and the adjusted rate of survival free from myocardial infarction was 92.1% versus 89.7% (P<0.001). Among patients with two-vessel disease who underwent CABG, as compared with those who received a stent, the adjusted hazard ratio for death was 0.71 (95% CI, 0.57 to 0.89) and the adjusted survival rate was 96.0% versus 94.6% (P=0.003); the adjusted hazard ratio for death or myocardial infarction was 0.71 (95% CI, 0.59 to 0.87) and the adjusted rate of survival free from myocardial infarction was 94.5% versus 92.5% (P<0.001). Patients undergoing CABG also had lower rates of repeat revascularization.
Conclusions For patients with multivessel disease, CABG continues to be associated with lower mortality rates than does treatment with drug-eluting stents and is also associated with lower rates of death or myocardial infarction and repeat revascularization.
Wednesday, January 23, 2008
Work stress and coronary heart disease: what are the mechanisms?
Work stress and coronary heart disease: what are the mechanisms?
European Heart Journal Advance Access published online on January 23, 2008
Aims: To determine the biological and behavioural factors linking work stress with coronary heart disease (CHD).
Methods and results: A total of 10 308 London-based male and female civil servants aged 35–55 at phase 1 (1985–88) of the Whitehall II study were studied. Exposures included work stress (assessed at phases 1 and 2), and outcomes included behavioural risk factors (phase 3), the metabolic syndrome (phase 3), heart rate variability, morning rise in cortisol (phase 7), and incident CHD (phases 2–7) on the basis of CHD death, non-fatal myocardial infarction, or definite angina. Chronic work stress was associated with CHD and this association was stronger among participants aged under 50 (RR 1.68, 95% CI 1.17–2.42). There were similar associations between work stress and low physical activity, poor diet, the metabolic syndrome, its components, and lower heart rate variability. Cross-sectionally, work stress was associated with a higher morning rise in cortisol. Around 32% of the effect of work stress on CHD was attributable to its effect on health behaviours and the metabolic syndrome.
Conclusion: Work stress may be an important determinant of CHD among working-age populations, which is mediated through indirect effects on health behaviours and direct effects on neuroendocrine stress pathways.
European Heart Journal Advance Access published online on January 23, 2008
Aims: To determine the biological and behavioural factors linking work stress with coronary heart disease (CHD).
Methods and results: A total of 10 308 London-based male and female civil servants aged 35–55 at phase 1 (1985–88) of the Whitehall II study were studied. Exposures included work stress (assessed at phases 1 and 2), and outcomes included behavioural risk factors (phase 3), the metabolic syndrome (phase 3), heart rate variability, morning rise in cortisol (phase 7), and incident CHD (phases 2–7) on the basis of CHD death, non-fatal myocardial infarction, or definite angina. Chronic work stress was associated with CHD and this association was stronger among participants aged under 50 (RR 1.68, 95% CI 1.17–2.42). There were similar associations between work stress and low physical activity, poor diet, the metabolic syndrome, its components, and lower heart rate variability. Cross-sectionally, work stress was associated with a higher morning rise in cortisol. Around 32% of the effect of work stress on CHD was attributable to its effect on health behaviours and the metabolic syndrome.
Conclusion: Work stress may be an important determinant of CHD among working-age populations, which is mediated through indirect effects on health behaviours and direct effects on neuroendocrine stress pathways.
Wednesday, December 12, 2007
Coronary Artery Calcium Scores and Risk for Cardiovascular Events in Women Classified as "Low Risk" Based on Framingham Risk Score
Coronary Artery Calcium Scores and Risk for Cardiovascular Events in Women Classified as "Low Risk" Based on Framingham Risk Score
The Multi-Ethnic Study of Atherosclerosis (MESA)
Susan G. Lakoski, MD, MS; Philip Greenland, MD; Nathan D. Wong, PhD, MPH; Pamela J. Schreiner, PhD; David M. Herrington, MD, MHS; Richard A. Kronmal, PhD; Kiang Liu, PhD; Roger S. Blumenthal, MD
Arch Intern Med. 2007;167(22):2437-2442.
Objective To assess coronary artery calcium (CAC) score and subsequent risk for coronary heart disease (CHD) and cardiovascular (CVD) events among asymptomatic women judged to be at low risk by the Framingham risk score (FRS), a common approach for determining 10-year absolute risk for CHD. Based on population survey data, 95% of American women are considered at low risk based on FRS.
Methods The Multi-Ethnic Study of Atherosclerosis (MESA) included 3601 women aged 45 to 84 years at baseline. The CAC score was measured by coronary computed tomography. Cox proportional hazard models were used to examine the CHD and CVD risk associated with CAC score among women classified as "low risk" based on FRS.
Results Excluding women with diabetes and those older than 79 years, 90% of women in MESA (mean ± SD age, 60 ± 9 years) were classified as "low risk" based on FRS. The prevalence of CAC (CAC score > 0) in this low-risk subset was 32% (n = 870). Compared with women with no detectable CAC, low-risk women with a CAC score greater than 0 were at increased risk for CHD (hazard ratio, 6.5; 95% confidence interval, 2.6-16.4) and CVD events (hazard ratio, 5.2; 95% confidence interval, 2.5-10.8). In addition, advanced CAC (CAC score 300) was highly predictive of future CHD and CVD events compared with women with nondetectable CAC and identified a group of low-risk women with a 6.7% and 8.6% absolute CHD and CVD risk, respectively, over a 3.75-year period.
Conclusions The presence of CAC in women considered to be at low risk based on FRS was predictive of future CHD and CVD events. Advanced CAC identified a subset of low-risk women at higher risk based on current risk stratification strategies.
The Multi-Ethnic Study of Atherosclerosis (MESA)
Susan G. Lakoski, MD, MS; Philip Greenland, MD; Nathan D. Wong, PhD, MPH; Pamela J. Schreiner, PhD; David M. Herrington, MD, MHS; Richard A. Kronmal, PhD; Kiang Liu, PhD; Roger S. Blumenthal, MD
Arch Intern Med. 2007;167(22):2437-2442.
Objective To assess coronary artery calcium (CAC) score and subsequent risk for coronary heart disease (CHD) and cardiovascular (CVD) events among asymptomatic women judged to be at low risk by the Framingham risk score (FRS), a common approach for determining 10-year absolute risk for CHD. Based on population survey data, 95% of American women are considered at low risk based on FRS.
Methods The Multi-Ethnic Study of Atherosclerosis (MESA) included 3601 women aged 45 to 84 years at baseline. The CAC score was measured by coronary computed tomography. Cox proportional hazard models were used to examine the CHD and CVD risk associated with CAC score among women classified as "low risk" based on FRS.
Results Excluding women with diabetes and those older than 79 years, 90% of women in MESA (mean ± SD age, 60 ± 9 years) were classified as "low risk" based on FRS. The prevalence of CAC (CAC score > 0) in this low-risk subset was 32% (n = 870). Compared with women with no detectable CAC, low-risk women with a CAC score greater than 0 were at increased risk for CHD (hazard ratio, 6.5; 95% confidence interval, 2.6-16.4) and CVD events (hazard ratio, 5.2; 95% confidence interval, 2.5-10.8). In addition, advanced CAC (CAC score 300) was highly predictive of future CHD and CVD events compared with women with nondetectable CAC and identified a group of low-risk women with a 6.7% and 8.6% absolute CHD and CVD risk, respectively, over a 3.75-year period.
Conclusions The presence of CAC in women considered to be at low risk based on FRS was predictive of future CHD and CVD events. Advanced CAC identified a subset of low-risk women at higher risk based on current risk stratification strategies.
Tuesday, December 11, 2007
Based Upon the Results of the COURAGE Clinical Trial, What Is the Best Treatment for Stable Angina?
Based Upon the Results of the COURAGE Clinical Trial, What Is the Best Treatment for Stable Angina?
Raymond J. Gibbons, MD; George D. Lundberg, MD
Medscape General Medicine. 2007;9(4):49. ©2007 Medscape
Posted 12/05/2007
Dr. Lundberg: It was a forerunner of a lot of good things. Let's talk about cardiology, and let's talk about angina pectoris: stable, unstable. Stable is more common?
Dr. Gibbons: Stable is much more common, and I think it's of more current interest. Our management of stable angina has obviously consisted of medications. But we knew from randomized trials in bypass surgery conducted 20 years ago that certain patients with very severe problems, particularly left main disease and 3-vessel disease with prior abnormal ventricular function, benefited from surgery from the standpoint of survival. As percutaneous coronary intervention [PCI] came along, we thought that patients who had less severe coronary artery disease probably would benefit, from the standpoint of survival and myocardial infarction, from PCI.
Dr. Lundberg: That's sensible.
Dr. Gibbons: And that was incorporated into national guidelines. This year, however, there have been 2 studies that have been published, OAT and COURAGE, that have both challenged that assumption. I think the study that is most pertinent to chronic stable angina is COURAGE. In a large trial conducted in the VA [Veterans Administration], certain other academic medical centers in the United States, including my own, and Canada, the investigators showed that with optimal medical therapy.
Dr. Lundberg: Okay. What do you call that? What is optimal medical therapy?
Dr. Gibbons: Well, previous trials had focused on just relieving angina. That trial had a different comprehensive approach: risk factor reduction. They just didn't treat angina, they also treated the risk factors very aggressively, and did very well even after 5 years at meeting targets for LDL [low density lipoprotein], for blood pressure, getting patients to stop smoking, getting them to exercise. And compared to optimal therapy, optimal therapy plus PCI did not convey an advantage with respect to heart attack or death. That was news, challenging the assumption that we had all along. It has led to a decrease, already, in the use of stents in the country. And I think it poses a challenge for practicing physicians to do as well with medical therapy in treating risk factors and symptoms, as occurred in the trial.
Dr. Lundberg: And of course, one of the things they have to do is handle patient compliance in terms of long-term use of whatever they're supposed to do.
Dr. Gibbons: I think they need to be very clear on educating the patient about the importance of, not just treatment for their chest pain, but treatment for the plaque and underlying coronary artery disease to prevent events. The patients have to understand the importance of taking aspirin, the importance of lowering their cholesterol to appropriate targets -- ideally an LDL of less than 100 -- and also not to smoke.
Dr. Lundberg: Of course, we live in a society with a medical-industrial complex with huge amounts of money that flow through the system into lots of people's pockets. If you're going to do surgery, or if you're going to do percutaneous stent implants, etc, it probably accrues a lot more money to people who are doing it, and it costs the insurance companies and the government a lot more to do that. So, there must be a tension developing there.
Dr. Gibbons: There's a clear tension, and I think there is an undercurrent of concern raised about the trial. For example, there's a tendency to point out there was a modest difference in pain relief, but it was modest. It was less than 10% of the patients had more complete pain relief by PCI at a year, and that [number] diminished over subsequent management of the patients. And a very comprehensive quality-of-life cost-effectiveness analysis presented here at the American Heart Association meeting this year by Dr. Weintraub, an expert in cost-effectiveness, showed that no matter what assumption you made, the effect on quality of life was minimal and very cost-ineffective.
Dr. Lundberg: So, for a stable angina at this time, optimal medical therapy is the best way to go?
Dr. Gibbons: It's clearly the best way to go. The challenge for all of us in the healthcare system is to do the best job we can of getting patients to comply with guideline-indicated medications.
Dr. Lundberg: There you are. Thank you all for being with us today. We've been talking with Dr. Raymond Gibbons, professor of medicine at the Mayo Clinic College of Medicine and a former president of the American Heart Association. Thank you for being with us. And thank you for being with us.
Reader Comments on: Based Upon the Results of the COURAGE Clinical Trial, What Is the Best Treatment for Stable Angina?See reader comments on this article and provide your own.
Readers are encouraged to respond to the author at gibbons.raymond@mayo.edu or to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication as an actual Letter in MedGenMed via email: pblumen@stanford.edu
Raymond J. Gibbons, MD, Arthur M. and Gladys D. Gray Professor of Medicine, Mayo Clinic, Rochester, MinnesotaGeorge D. Lundberg, MD, Editor-in-Chief, Medscape General Medicine; Adjunct Professor of Health Policy, Harvard School of Public Health, Boston, Massachusetts; Consulting Professor, Stanford University School of Medicine, Stanford, CaliforniaAuthor's email: gibbons.raymond@mayo.edu
Raymond J. Gibbons, MD; George D. Lundberg, MD
Medscape General Medicine. 2007;9(4):49. ©2007 Medscape
Posted 12/05/2007
Dr. Lundberg: It was a forerunner of a lot of good things. Let's talk about cardiology, and let's talk about angina pectoris: stable, unstable. Stable is more common?
Dr. Gibbons: Stable is much more common, and I think it's of more current interest. Our management of stable angina has obviously consisted of medications. But we knew from randomized trials in bypass surgery conducted 20 years ago that certain patients with very severe problems, particularly left main disease and 3-vessel disease with prior abnormal ventricular function, benefited from surgery from the standpoint of survival. As percutaneous coronary intervention [PCI] came along, we thought that patients who had less severe coronary artery disease probably would benefit, from the standpoint of survival and myocardial infarction, from PCI.
Dr. Lundberg: That's sensible.
Dr. Gibbons: And that was incorporated into national guidelines. This year, however, there have been 2 studies that have been published, OAT and COURAGE, that have both challenged that assumption. I think the study that is most pertinent to chronic stable angina is COURAGE. In a large trial conducted in the VA [Veterans Administration], certain other academic medical centers in the United States, including my own, and Canada, the investigators showed that with optimal medical therapy.
Dr. Lundberg: Okay. What do you call that? What is optimal medical therapy?
Dr. Gibbons: Well, previous trials had focused on just relieving angina. That trial had a different comprehensive approach: risk factor reduction. They just didn't treat angina, they also treated the risk factors very aggressively, and did very well even after 5 years at meeting targets for LDL [low density lipoprotein], for blood pressure, getting patients to stop smoking, getting them to exercise. And compared to optimal therapy, optimal therapy plus PCI did not convey an advantage with respect to heart attack or death. That was news, challenging the assumption that we had all along. It has led to a decrease, already, in the use of stents in the country. And I think it poses a challenge for practicing physicians to do as well with medical therapy in treating risk factors and symptoms, as occurred in the trial.
Dr. Lundberg: And of course, one of the things they have to do is handle patient compliance in terms of long-term use of whatever they're supposed to do.
Dr. Gibbons: I think they need to be very clear on educating the patient about the importance of, not just treatment for their chest pain, but treatment for the plaque and underlying coronary artery disease to prevent events. The patients have to understand the importance of taking aspirin, the importance of lowering their cholesterol to appropriate targets -- ideally an LDL of less than 100 -- and also not to smoke.
Dr. Lundberg: Of course, we live in a society with a medical-industrial complex with huge amounts of money that flow through the system into lots of people's pockets. If you're going to do surgery, or if you're going to do percutaneous stent implants, etc, it probably accrues a lot more money to people who are doing it, and it costs the insurance companies and the government a lot more to do that. So, there must be a tension developing there.
Dr. Gibbons: There's a clear tension, and I think there is an undercurrent of concern raised about the trial. For example, there's a tendency to point out there was a modest difference in pain relief, but it was modest. It was less than 10% of the patients had more complete pain relief by PCI at a year, and that [number] diminished over subsequent management of the patients. And a very comprehensive quality-of-life cost-effectiveness analysis presented here at the American Heart Association meeting this year by Dr. Weintraub, an expert in cost-effectiveness, showed that no matter what assumption you made, the effect on quality of life was minimal and very cost-ineffective.
Dr. Lundberg: So, for a stable angina at this time, optimal medical therapy is the best way to go?
Dr. Gibbons: It's clearly the best way to go. The challenge for all of us in the healthcare system is to do the best job we can of getting patients to comply with guideline-indicated medications.
Dr. Lundberg: There you are. Thank you all for being with us today. We've been talking with Dr. Raymond Gibbons, professor of medicine at the Mayo Clinic College of Medicine and a former president of the American Heart Association. Thank you for being with us. And thank you for being with us.
Reader Comments on: Based Upon the Results of the COURAGE Clinical Trial, What Is the Best Treatment for Stable Angina?See reader comments on this article and provide your own.
Readers are encouraged to respond to the author at gibbons.raymond@mayo.edu or to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication as an actual Letter in MedGenMed via email: pblumen@stanford.edu
Raymond J. Gibbons, MD, Arthur M. and Gladys D. Gray Professor of Medicine, Mayo Clinic, Rochester, MinnesotaGeorge D. Lundberg, MD, Editor-in-Chief, Medscape General Medicine; Adjunct Professor of Health Policy, Harvard School of Public Health, Boston, Massachusetts; Consulting Professor, Stanford University School of Medicine, Stanford, CaliforniaAuthor's email: gibbons.raymond@mayo.edu
"Body fat distribution and risk of coronary heart disease in men and women in the European Prospective Investigation into Cancer and Nutrition in Norfolk cohort: a population-based prospective study"
Circulation: Journal of the American Heart AssociationSource reference:
Canoy D, et al Circulation 2007; DOI: 10.1161/CIRCULATIONAHA.106.673756.
Background—Body fat distribution has been cross-sectionally associated with atherosclerotic disease risk factors, but the prospective relation with coronary heart disease remains uncertain.
Methods and Results—We examined the prospective relation between fat distribution indices and coronary heart disease among 24 508 men and women 45 to 79 years of age using proportional hazards regression. During a mean 9.1 years of follow-up, 1708 men and 892 women developed coronary heart disease. The risk for developing subsequent coronary heart disease increased continuously across the range of waist-hip ratio. Hazard ratios (95% CI) of the top versus bottom fifth of waist-hip ratio were 1.55 (1.28 to 1.73) in men and 1.91 (1.44 to 2.54) in women after adjustment for body mass index and other coronary heart disease risk factors. Hazard ratios increased with waist circumference, but risk estimates for waist circumference without hip circumference adjustment were lower by 10% to 18%. After adjustment for waist circumference, body mass index, and coronary heart disease risk factors, hazard ratios for 1-SD increase in hip circumference were 0.80 (95% CI, 0.74 to 0.87) in men and 0.80 (95% CI, 0.69 to 0.93) in women. Hazard ratios for body mass index were greatly attenuated when we adjusted for waist-hip ratio or waist circumference and other covariates.
Conclusions—Indices of abdominal obesity were more consistently and strongly predictive of coronary heart disease than body mass index. These simple and inexpensive measurements could be used to assess obesity-related coronary heart disease risk in relatively healthy men and women.
Circulation: Journal of the American Heart AssociationSource reference:
Canoy D, et al Circulation 2007; DOI: 10.1161/CIRCULATIONAHA.106.673756.
Background—Body fat distribution has been cross-sectionally associated with atherosclerotic disease risk factors, but the prospective relation with coronary heart disease remains uncertain.
Methods and Results—We examined the prospective relation between fat distribution indices and coronary heart disease among 24 508 men and women 45 to 79 years of age using proportional hazards regression. During a mean 9.1 years of follow-up, 1708 men and 892 women developed coronary heart disease. The risk for developing subsequent coronary heart disease increased continuously across the range of waist-hip ratio. Hazard ratios (95% CI) of the top versus bottom fifth of waist-hip ratio were 1.55 (1.28 to 1.73) in men and 1.91 (1.44 to 2.54) in women after adjustment for body mass index and other coronary heart disease risk factors. Hazard ratios increased with waist circumference, but risk estimates for waist circumference without hip circumference adjustment were lower by 10% to 18%. After adjustment for waist circumference, body mass index, and coronary heart disease risk factors, hazard ratios for 1-SD increase in hip circumference were 0.80 (95% CI, 0.74 to 0.87) in men and 0.80 (95% CI, 0.69 to 0.93) in women. Hazard ratios for body mass index were greatly attenuated when we adjusted for waist-hip ratio or waist circumference and other covariates.
Conclusions—Indices of abdominal obesity were more consistently and strongly predictive of coronary heart disease than body mass index. These simple and inexpensive measurements could be used to assess obesity-related coronary heart disease risk in relatively healthy men and women.
Friday, December 7, 2007
Comparison of bypass surgery with drug‐eluting stents for diabetic patients with multivessel disease
Comparison of bypass surgery with drug‐eluting stents for diabetic patients with multivessel disease
International Journal of Cardiology
Volume 123, Issue 1, Pages 34-42 (15 December 2007)
Michael S. Leea, Faizi Jamalb, Gautam Kediab, Gilbert Changb, Nikhil Kapoorb, James Forresterb, Lawrence Czerb, Raymond Zimmera, Michele DeRobertisb, Alfredo Trentob, Raj R. Makkarb
Abstract
Background
This retrospective study of prospectively collected data compared coronary artery bypass graft (CABG) surgery to drug‐eluting stenting (DES) in diabetic patients with multivessel coronary artery disease (CAD). Prior randomized trials and clinical studies have suggested that CABG may be the preferred revascularization strategy in diabetic patients with multivessel CAD. Data are limited regarding the impact of DES vs. CABG on clinical outcomes.
Methods
We included 205 consecutive diabetic patients who underwent either CABG (n=103) or DES (n=102). The primary clinical end points were freedom from major adverse cardiac events (MACE) at 30 days and 1 year.
Results
Baseline characteristics were similar between both groups. At 1 year, the mortality rate was similar in the CABG and DES group (8% vs. 10%, p=0.6) but the MACE rate was lower in the CABG group (12% vs. 27%, p=0.006) due to less repeat revascularization with CABG (3% vs. 20%, p<0.001). Stroke occurred only in the CABG group (4% vs. 0%, p=0.04). Angiographically‐documented stent thrombosis after DES occurred in 3%. Presentation with acute myocardial infarction (hazard ratio [HR], 2.26, 95% CI, 1.13 to 4.55) and DES (HR, 2.4, 95% CI, 1.23 to 4.77) were positive independent predictors, whereas therapy with a statin was a negative independent predictor of MACE (HR, 0.40, 95% CI, 0.21 to 0.76).
Conclusions
Bypass surgery was associated with less MACE primarily due to the higher repeat revascularization rate with DES and is therefore superior to DES despite more extensive CAD in CABG patients.
International Journal of Cardiology
Volume 123, Issue 1, Pages 34-42 (15 December 2007)
Michael S. Leea, Faizi Jamalb, Gautam Kediab, Gilbert Changb, Nikhil Kapoorb, James Forresterb, Lawrence Czerb, Raymond Zimmera, Michele DeRobertisb, Alfredo Trentob, Raj R. Makkarb
Abstract
Background
This retrospective study of prospectively collected data compared coronary artery bypass graft (CABG) surgery to drug‐eluting stenting (DES) in diabetic patients with multivessel coronary artery disease (CAD). Prior randomized trials and clinical studies have suggested that CABG may be the preferred revascularization strategy in diabetic patients with multivessel CAD. Data are limited regarding the impact of DES vs. CABG on clinical outcomes.
Methods
We included 205 consecutive diabetic patients who underwent either CABG (n=103) or DES (n=102). The primary clinical end points were freedom from major adverse cardiac events (MACE) at 30 days and 1 year.
Results
Baseline characteristics were similar between both groups. At 1 year, the mortality rate was similar in the CABG and DES group (8% vs. 10%, p=0.6) but the MACE rate was lower in the CABG group (12% vs. 27%, p=0.006) due to less repeat revascularization with CABG (3% vs. 20%, p<0.001). Stroke occurred only in the CABG group (4% vs. 0%, p=0.04). Angiographically‐documented stent thrombosis after DES occurred in 3%. Presentation with acute myocardial infarction (hazard ratio [HR], 2.26, 95% CI, 1.13 to 4.55) and DES (HR, 2.4, 95% CI, 1.23 to 4.77) were positive independent predictors, whereas therapy with a statin was a negative independent predictor of MACE (HR, 0.40, 95% CI, 0.21 to 0.76).
Conclusions
Bypass surgery was associated with less MACE primarily due to the higher repeat revascularization rate with DES and is therefore superior to DES despite more extensive CAD in CABG patients.
Thursday, December 6, 2007
Childhood Body-Mass Index and the Risk of Coronary Heart Disease in Adulthood
New England Journal of Medicine
December 6, 2007
Jennifer L. Baker, Ph.D., Lina W. Olsen, Ph.D., and Thorkild I.A. Sørensen, M.D., Dr.Med.Sci.
ABSTRACT
Background The worldwide epidemic of childhood obesity is progressing at an alarming rate. Risk factors for coronary heart disease (CHD) are already identifiable in overweight children. The severity of the long-term effects of excess childhood weight on CHD, however, remains unknown.
Methods We investigated the association between body-mass index (BMI) in childhood (7 through 13 years of age) and CHD in adulthood (25 years of age or older), with and without adjustment for birth weight. The subjects were a cohort of 276,835 Danish schoolchildren for whom measurements of height and weight were available. CHD events were ascertained by linkage to national registers. Cox regression analyses were performed.
Results In 5,063,622 person-years of follow-up, 10,235 men and 4318 women for whom childhood BMI data were available received a diagnosis of CHD or died of CHD as adults. The risk of any CHD event, a nonfatal event, and a fatal event among adults was positively associated with BMI at 7 to 13 years of age for boys and 10 to 13 years of age for girls. The associations were linear for each age, and the risk increased across the entire BMI distribution. Furthermore, the risk increased as the age of the child increased. Adjustment for birth weight strengthened the results.
Conclusions Higher BMI during childhood is associated with an increased risk of CHD in adulthood. The associations are stronger in boys than in girls and increase with the age of the child in both sexes. Our findings suggest that as children are becoming heavier worldwide, greater numbers of them are at risk of having CHD in adulthood
New England Journal of Medicine
December 6, 2007
Jennifer L. Baker, Ph.D., Lina W. Olsen, Ph.D., and Thorkild I.A. Sørensen, M.D., Dr.Med.Sci.
ABSTRACT
Background The worldwide epidemic of childhood obesity is progressing at an alarming rate. Risk factors for coronary heart disease (CHD) are already identifiable in overweight children. The severity of the long-term effects of excess childhood weight on CHD, however, remains unknown.
Methods We investigated the association between body-mass index (BMI) in childhood (7 through 13 years of age) and CHD in adulthood (25 years of age or older), with and without adjustment for birth weight. The subjects were a cohort of 276,835 Danish schoolchildren for whom measurements of height and weight were available. CHD events were ascertained by linkage to national registers. Cox regression analyses were performed.
Results In 5,063,622 person-years of follow-up, 10,235 men and 4318 women for whom childhood BMI data were available received a diagnosis of CHD or died of CHD as adults. The risk of any CHD event, a nonfatal event, and a fatal event among adults was positively associated with BMI at 7 to 13 years of age for boys and 10 to 13 years of age for girls. The associations were linear for each age, and the risk increased across the entire BMI distribution. Furthermore, the risk increased as the age of the child increased. Adjustment for birth weight strengthened the results.
Conclusions Higher BMI during childhood is associated with an increased risk of CHD in adulthood. The associations are stronger in boys than in girls and increase with the age of the child in both sexes. Our findings suggest that as children are becoming heavier worldwide, greater numbers of them are at risk of having CHD in adulthood
Friday, November 30, 2007
Cholesterol seen tied to heart disease, not stroke
Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55 000 vascular deaths
The Lancet 2007; 370:1829-1839
Summary
Background
Age, sex, and blood pressure could modify the associations of total cholesterol (and its main two fractions, HDL and LDL cholesterol) with vascular mortality. This meta-analysis combined prospective studies of vascular mortality that recorded both blood pressure and total cholesterol at baseline, to determine the joint relevance of these two risk factors.
Methods
Information was obtained from 61 prospective observational studies, mostly in western Europe or North America, consisting of almost 900 000 adults without previous disease and with baseline measurements of total cholesterol and blood pressure. During nearly 12 million person years at risk between the ages of 40 and 89 years, there were more than 55 000 vascular deaths (34 000 ischaemic heart disease [IHD], 12 000 stroke, 10 000 other). Information about HDL cholesterol was available for 150 000 participants, among whom there were 5000 vascular deaths (3000 IHD, 1000 stroke, 1000 other). Reported associations are with usual cholesterol levels (ie, corrected for the regression dilution bias).
Findings
1 mmol/L lower total cholesterol was associated with about a half (hazard ratio 0·44 [95% CI 0·42–0·48]), a third (0·66 [0·65–0·68]), and a sixth (0·83 [0·81–0·85]) lower IHD mortality in both sexes at ages 40–49, 50–69, and 70–89 years, respectively, throughout the main range of cholesterol in most developed countries, with no apparent threshold. The proportional risk reduction decreased with increasing blood pressure, since the absolute effects of cholesterol and blood pressure were approximately additive. Of various simple indices involving HDL cholesterol, the ratio total/HDL cholesterol was the strongest predictor of IHD mortality (40% more informative than non-HDL cholesterol and more than twice as informative as total cholesterol). Total cholesterol was weakly positively related to ischaemic and total stroke mortality in early middle age (40–59 years), but this finding could be largely or wholly accounted for by the association of cholesterol with blood pressure. Moreover, a positive relation was seen only in middle age and only in those with below-average blood pressure; at older ages (70–89 years) and, particularly, for those with systolic blood pressure over about 145 mm Hg, total cholesterol was negatively related to haemorrhagic and total stroke mortality. The results for other vascular mortality were intermediate between those for IHD and stroke.
Interpretation
Total cholesterol was positively associated with IHD mortality in both middle and old age and at all blood pressure levels. The absence of an independent positive association of cholesterol with stroke mortality, especially at older ages or higher blood pressures, is unexplained, and invites further research. Nevertheless, there is conclusive evidence from randomised trials that statins substantially reduce not only coronary event rates but also total stroke rates in patients with a wide range of ages and blood pressures.
The Lancet 2007; 370:1829-1839
Summary
Background
Age, sex, and blood pressure could modify the associations of total cholesterol (and its main two fractions, HDL and LDL cholesterol) with vascular mortality. This meta-analysis combined prospective studies of vascular mortality that recorded both blood pressure and total cholesterol at baseline, to determine the joint relevance of these two risk factors.
Methods
Information was obtained from 61 prospective observational studies, mostly in western Europe or North America, consisting of almost 900 000 adults without previous disease and with baseline measurements of total cholesterol and blood pressure. During nearly 12 million person years at risk between the ages of 40 and 89 years, there were more than 55 000 vascular deaths (34 000 ischaemic heart disease [IHD], 12 000 stroke, 10 000 other). Information about HDL cholesterol was available for 150 000 participants, among whom there were 5000 vascular deaths (3000 IHD, 1000 stroke, 1000 other). Reported associations are with usual cholesterol levels (ie, corrected for the regression dilution bias).
Findings
1 mmol/L lower total cholesterol was associated with about a half (hazard ratio 0·44 [95% CI 0·42–0·48]), a third (0·66 [0·65–0·68]), and a sixth (0·83 [0·81–0·85]) lower IHD mortality in both sexes at ages 40–49, 50–69, and 70–89 years, respectively, throughout the main range of cholesterol in most developed countries, with no apparent threshold. The proportional risk reduction decreased with increasing blood pressure, since the absolute effects of cholesterol and blood pressure were approximately additive. Of various simple indices involving HDL cholesterol, the ratio total/HDL cholesterol was the strongest predictor of IHD mortality (40% more informative than non-HDL cholesterol and more than twice as informative as total cholesterol). Total cholesterol was weakly positively related to ischaemic and total stroke mortality in early middle age (40–59 years), but this finding could be largely or wholly accounted for by the association of cholesterol with blood pressure. Moreover, a positive relation was seen only in middle age and only in those with below-average blood pressure; at older ages (70–89 years) and, particularly, for those with systolic blood pressure over about 145 mm Hg, total cholesterol was negatively related to haemorrhagic and total stroke mortality. The results for other vascular mortality were intermediate between those for IHD and stroke.
Interpretation
Total cholesterol was positively associated with IHD mortality in both middle and old age and at all blood pressure levels. The absence of an independent positive association of cholesterol with stroke mortality, especially at older ages or higher blood pressures, is unexplained, and invites further research. Nevertheless, there is conclusive evidence from randomised trials that statins substantially reduce not only coronary event rates but also total stroke rates in patients with a wide range of ages and blood pressures.
Wednesday, November 21, 2007
Heart Disease Deaths Among Younger Women Might Be on the Rise
Heart Disease Deaths Among Younger Women Might Be on the Rise
After decades of steady decline, deaths from coronary heart disease in women under 54 may be increasing, according to findings published in the Journal of the American College of Cardiology.
Using CDC and U.S. Census data, researchers found that from 2000 to 2002, the death rate due to CHD in women aged 35 to 54 increased by 1.5% annually. Among the youngest of these women (aged 35-44), the mortality rate had begun to rise in 1997 — averaging a 1.3% increase each year.
In addition, the decline in the CHD death rate among men under 54 appeared to slow — from 2000 to 2002, the rate decreased by only 0.5% annually.
The authors remind physicians to use prevailing guidelines to prevent CHD in patients with one or more risk factors. They conclude, "Complacency runs a high risk: mortality rates among younger adults may represent the leading edge of a brewing storm."
LINK(S):
Journal of the American College of Cardiology article (Free PDF)
Journal of the American College of Cardiology editorial (Subscription required)
Published in Physician's First Watch November 21, 2007
After decades of steady decline, deaths from coronary heart disease in women under 54 may be increasing, according to findings published in the Journal of the American College of Cardiology.
Using CDC and U.S. Census data, researchers found that from 2000 to 2002, the death rate due to CHD in women aged 35 to 54 increased by 1.5% annually. Among the youngest of these women (aged 35-44), the mortality rate had begun to rise in 1997 — averaging a 1.3% increase each year.
In addition, the decline in the CHD death rate among men under 54 appeared to slow — from 2000 to 2002, the rate decreased by only 0.5% annually.
The authors remind physicians to use prevailing guidelines to prevent CHD in patients with one or more risk factors. They conclude, "Complacency runs a high risk: mortality rates among younger adults may represent the leading edge of a brewing storm."
LINK(S):
Journal of the American College of Cardiology article (Free PDF)
Journal of the American College of Cardiology editorial (Subscription required)
Published in Physician's First Watch November 21, 2007
Friday, November 16, 2007
Obesity Paradox in Patients with Hypertension and Coronary Artery Disease
Obesity Paradox in Patients with Hypertension and Coronary Artery Disease
The American Journal of Medicine
Volume 120, Issue 10, October 2007, Pages 863-870
Abstract
Purpose
An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.
Methods
A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66 ± 9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m2 (thin), 20 to 25 kg/m2 (normal weight), 25 to 30 kg/m2 (overweight), 30 to 35 kg/m2 (class I obesity), and 35 kg/m2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.
Results
With patients of normal weight (BMI 20 to <25 kg/m2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P <.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P <.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5 ± 21.9 mm Hg/−9.8 ± 12.4 mm Hg vs −20.7 ± 23.1 mm Hg /−10.6 ± 12.5 mm Hg, P <.001).
Conclusion
In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.
The American Journal of Medicine
Volume 120, Issue 10, October 2007, Pages 863-870
Abstract
Purpose
An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.
Methods
A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66 ± 9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m2 (thin), 20 to 25 kg/m2 (normal weight), 25 to 30 kg/m2 (overweight), 30 to 35 kg/m2 (class I obesity), and 35 kg/m2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.
Results
With patients of normal weight (BMI 20 to <25 kg/m2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P <.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P <.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5 ± 21.9 mm Hg/−9.8 ± 12.4 mm Hg vs −20.7 ± 23.1 mm Hg /−10.6 ± 12.5 mm Hg, P <.001).
Conclusion
In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.
Monday, November 12, 2007
AHA - 2007: Heart Institute of Japan Candesartan Randomized Trial for evaluation of Coronary Artery Disease: HIJ-CREATE
Heart Institute of Japan Candesartan Randomized Trial for evaluation of Coronary Artery Disease: HIJ-CREATE
Vijay Kunadian MBBS MD MRCP
ORLANDO, Nov. 7: The HIJ-CREATE trial was presented by Dr. Hiroshi Kasanuki, M.D. from Tokyo Women’s Medical University at the American Heart Association, Scientific Sessions 2007.
This study demonstrated that the use of candesartan was not associated with a significant difference in major cardiovascular events at a median follow-up of 4.2 years compared to standard medical therapy without the use of candesartan in patients with coronary artery disease and hypertension.
Briefly, this study evaluated the use of candesartan (angiotensin receptor blocker-ARB) compared to standard medical therapy without the use of an ARB in patients with a history of coronary artery disease and hypertension to determine if there was a reduction in cardiovascular events using candesartan.
In this study patients were randomized to treatment with candesartan or standard medical therapy without the use of the ARB in an open-label manner. The target blood pressure was 130/85 mmHg. Patients were followed up at 6, 12, 24, 36, 48 and 60-month intervals. In total 1024 patients were in the candesartan group and 1025 patients were in the standard medical therapy group. Patients were recruited from 14 sites in Japan between June 2001 and April 2004. The primary endpoint of the study was to determine the time to occurrence of first major adverse cardiovascular event. The major secondary endpoints included the incidence of coronary revascularization and new-onset diabetes.
About 35% of the patients had suffered a prior acute coronary syndrome and 38% had suffered a prior myocardial infarction. The ARB-based approach was associated with significantly fewer drug-related adverse events (p=0.027), and fewer patients discontinued the ARB than the ACE inhibitor (p<0.001). Patients in the ARB group had significantly less cough (p<0.001). There were no differences in development of dizziness, hyperkalemia, or liver dysfunction. There were 552 primary events during a mean follow-up of 4.2 years: 264 (25.8%) in the candesartan group and 288 (28.1%) in the non-ARB group (relative risk 0.89 [95% CI 0.76-1.06], p=0.19). There was no difference in the occurrence of revascularization between the candesartan and the standard therapy groups [25% vs. 26.6%, RR 0.92 (0.77-1.12), p=0.41]. There was a difference in the occurrence of new-onset diabetes in the ARB and the standard therapy groups [1.1% vs. 2.9%, RR 0.37 (0.15-0.94), p=0.04]. In patients with creatinine clearance <60ml/min, the HR was 0.79 (0.63-0.99), p=0.039.
Therefore, the HIJ CREATE study demonstrated that candesartan did not significantly improve the occurrence of major adverse cardiac events compared to standard medical therapy at a median follow-up of 4.2 years. However, candesartan was associated with fewer adverse effects. Treatment with candesartan may be beneficial in patients with glucose metabolism abnormalities and those with mild to moderate renal dysfunction. These findings are comparable to the VALIANT study which was conducted in patients with acute myocardial infarction.
References: Originally presented at AHA Scientific Sessions 2007.
Vijay Kunadian MBBS MD MRCP
ORLANDO, Nov. 7: The HIJ-CREATE trial was presented by Dr. Hiroshi Kasanuki, M.D. from Tokyo Women’s Medical University at the American Heart Association, Scientific Sessions 2007.
This study demonstrated that the use of candesartan was not associated with a significant difference in major cardiovascular events at a median follow-up of 4.2 years compared to standard medical therapy without the use of candesartan in patients with coronary artery disease and hypertension.
Briefly, this study evaluated the use of candesartan (angiotensin receptor blocker-ARB) compared to standard medical therapy without the use of an ARB in patients with a history of coronary artery disease and hypertension to determine if there was a reduction in cardiovascular events using candesartan.
In this study patients were randomized to treatment with candesartan or standard medical therapy without the use of the ARB in an open-label manner. The target blood pressure was 130/85 mmHg. Patients were followed up at 6, 12, 24, 36, 48 and 60-month intervals. In total 1024 patients were in the candesartan group and 1025 patients were in the standard medical therapy group. Patients were recruited from 14 sites in Japan between June 2001 and April 2004. The primary endpoint of the study was to determine the time to occurrence of first major adverse cardiovascular event. The major secondary endpoints included the incidence of coronary revascularization and new-onset diabetes.
About 35% of the patients had suffered a prior acute coronary syndrome and 38% had suffered a prior myocardial infarction. The ARB-based approach was associated with significantly fewer drug-related adverse events (p=0.027), and fewer patients discontinued the ARB than the ACE inhibitor (p<0.001). Patients in the ARB group had significantly less cough (p<0.001). There were no differences in development of dizziness, hyperkalemia, or liver dysfunction. There were 552 primary events during a mean follow-up of 4.2 years: 264 (25.8%) in the candesartan group and 288 (28.1%) in the non-ARB group (relative risk 0.89 [95% CI 0.76-1.06], p=0.19). There was no difference in the occurrence of revascularization between the candesartan and the standard therapy groups [25% vs. 26.6%, RR 0.92 (0.77-1.12), p=0.41]. There was a difference in the occurrence of new-onset diabetes in the ARB and the standard therapy groups [1.1% vs. 2.9%, RR 0.37 (0.15-0.94), p=0.04]. In patients with creatinine clearance <60ml/min, the HR was 0.79 (0.63-0.99), p=0.039.
Therefore, the HIJ CREATE study demonstrated that candesartan did not significantly improve the occurrence of major adverse cardiac events compared to standard medical therapy at a median follow-up of 4.2 years. However, candesartan was associated with fewer adverse effects. Treatment with candesartan may be beneficial in patients with glucose metabolism abnormalities and those with mild to moderate renal dysfunction. These findings are comparable to the VALIANT study which was conducted in patients with acute myocardial infarction.
References: Originally presented at AHA Scientific Sessions 2007.
Wednesday, November 7, 2007
Efficacy of CABG vs. Percutaneous Coronary Intervention
Efficacy of CABG vs. Percutaneous Coronary Intervention
CABG increases rates of relief of angina (NNT 12 at 1 year, NNT 20 at 5 years) and decreases rates of repeat revascularization (NNT 5 at 1 year, NNT 3 at 5 years) compared to percutaneous coronary intervention (PCI), but no difference in overall survival (level 1 [likely reliable] evidence), based on a systematic review of 23 randomized trials in 9,963 patients. CABG increased 30-day risk of stroke (NNH 167). PCI included balloon angioplasty or stents in most trials; only 1 small trial used drug-eluting stents
(Ann Intern Med 2007 Nov 20;147(10):early online full-text, AHRQ Comparative Effectiveness Review 2007 Oct:9 PDF).
Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery
Bravata DM, Gienger AL, McDonald KM, Sundaram V, Perez MV, Varghese R, Kapoor JR, Ardehali R, Owens DK, Hlatky MA.
the Center for Primary Care and Outcomes Research and Stanford University School of Medicine, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
20 November 2007 Volume 147 Issue 10
Background: The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood.
Purpose: To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated.
Data Sources: MEDLINE, EMBASE, and Cochrane databases (1966–2006); conference proceedings; and bibliographies of retrieved articles.
Study Selection: Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.
Data Extraction: Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.
Data Synthesis: We identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedural strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG–PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.
Limitations: The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.
Conclusion: Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures.
Editors' Notes
Context
The relative benefits and harms of coronary artery bypass surgery (CABG) versus percutaneous coronary intervention (PCI) are sometimes unclear.
Contribution
This systematic review of 23 randomized trials found that survival at 10 years was similar for CABG and PCI, even among diabetic patients. Procedural strokes and angina relief were more common after CABG (risk difference, 0.6% and about 5% to 8%, respectively), whereas repeated revascularization procedures were more common after PCI (risk difference, 24% at 1 year).
Caution
Only 1 small trial used drug-eluting stents, and Few patients with extensive coronary disease or poor ventricular function were enrolled.
CABG increases rates of relief of angina (NNT 12 at 1 year, NNT 20 at 5 years) and decreases rates of repeat revascularization (NNT 5 at 1 year, NNT 3 at 5 years) compared to percutaneous coronary intervention (PCI), but no difference in overall survival (level 1 [likely reliable] evidence), based on a systematic review of 23 randomized trials in 9,963 patients. CABG increased 30-day risk of stroke (NNH 167). PCI included balloon angioplasty or stents in most trials; only 1 small trial used drug-eluting stents
(Ann Intern Med 2007 Nov 20;147(10):early online full-text, AHRQ Comparative Effectiveness Review 2007 Oct:9 PDF).
Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery
Bravata DM, Gienger AL, McDonald KM, Sundaram V, Perez MV, Varghese R, Kapoor JR, Ardehali R, Owens DK, Hlatky MA.
the Center for Primary Care and Outcomes Research and Stanford University School of Medicine, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
20 November 2007 Volume 147 Issue 10
Background: The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood.
Purpose: To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated.
Data Sources: MEDLINE, EMBASE, and Cochrane databases (1966–2006); conference proceedings; and bibliographies of retrieved articles.
Study Selection: Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.
Data Extraction: Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.
Data Synthesis: We identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedural strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG–PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.
Limitations: The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.
Conclusion: Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures.
Editors' Notes
Context
The relative benefits and harms of coronary artery bypass surgery (CABG) versus percutaneous coronary intervention (PCI) are sometimes unclear.
Contribution
This systematic review of 23 randomized trials found that survival at 10 years was similar for CABG and PCI, even among diabetic patients. Procedural strokes and angina relief were more common after CABG (risk difference, 0.6% and about 5% to 8%, respectively), whereas repeated revascularization procedures were more common after PCI (risk difference, 24% at 1 year).
Caution
Only 1 small trial used drug-eluting stents, and Few patients with extensive coronary disease or poor ventricular function were enrolled.
Monday, November 5, 2007
Supine bicycle exercise echocardiography improves CAD detection
Supine bicycle exercise echocardiography improves CAD detection
5 November 2007
MedWire News: Supine bicycle exercise echocardiography (BEE) improves coronary artery disease (CAD) detection and evaluation of coronary stenosis severity, researchers report in the Journal of the American College of Cardiology.
"The possible assessment of the ischemic threshold in addition to the site, extent, and severity of induced ischemia might be a useful tool for stratifying the need for coronary revascularization in symptomatic patients," Luc Piérard (University Hospital Sart Tilman, Liège, Belgium) writes in an accompanying editorial.
William Zoghbi (The Methodist DeBakey Heart Center, Houston, Texas, USA) and colleagues assessed whether imaging during the intermediate stages of exercise using supine BEE improves the diagnosis of CAD, compared with just rest and peak exercise echocardiography, in 104 patients suspected of CAD.
Echocardiography was performed while the patient pedalled at a constant speed in a BEE bed with a maximum head elevation of 20°, beginning at a workload of 25 W and increasing by 25 W every 3-minute stage. Images were digitized at rest, 25 W, 50 W, and peak exercise.
Overall, 30 patients had one-vessel disease, 24 had two-vessels affected, seven had three-vessel CAD, and 43 had no significant coronary artery lesions.
Imaging during intermediate stages of exercise significantly improved the sensitivity for detection of all individual vessel stenosis (78% vs 58%, p<0.001) and the patient's overall CAD (94% vs 74%, p<0.001) compared with peak exercise imaging.
Intermediate stages and peak exercise imaging had similar specificities for the detection of affected vessels (83% and 81%, respectively) and patients (64% and 60%).
Furthermore, patients with ischemia had a significantly increased ventricular end-systolic volume (LVESV) from the intermediate stage to peak exercise, compared with the change from rest to peak exercise (33.5% vs 17.5%, p<0.001).
A change in LVESV from intermediate stage to peak exercise of more than 10% predicted CAD with a sensitivity of 94% and a specificity of 74%. The researchers therefore suggest that "the change in LVESV during exercise is a useful parameter for the detection of CAD."
Zoghbi et al conclude: "During BEE, the acquisition and interpretation of images during the intermediate stages of exercise, in addition to those at peak exercise, improve the detection of CAD and allow a physiologic assessment of the severity of coronary stenosis."
J Am Coll Cardiol 2007; 50: 1857-1863
5 November 2007
MedWire News: Supine bicycle exercise echocardiography (BEE) improves coronary artery disease (CAD) detection and evaluation of coronary stenosis severity, researchers report in the Journal of the American College of Cardiology.
"The possible assessment of the ischemic threshold in addition to the site, extent, and severity of induced ischemia might be a useful tool for stratifying the need for coronary revascularization in symptomatic patients," Luc Piérard (University Hospital Sart Tilman, Liège, Belgium) writes in an accompanying editorial.
William Zoghbi (The Methodist DeBakey Heart Center, Houston, Texas, USA) and colleagues assessed whether imaging during the intermediate stages of exercise using supine BEE improves the diagnosis of CAD, compared with just rest and peak exercise echocardiography, in 104 patients suspected of CAD.
Echocardiography was performed while the patient pedalled at a constant speed in a BEE bed with a maximum head elevation of 20°, beginning at a workload of 25 W and increasing by 25 W every 3-minute stage. Images were digitized at rest, 25 W, 50 W, and peak exercise.
Overall, 30 patients had one-vessel disease, 24 had two-vessels affected, seven had three-vessel CAD, and 43 had no significant coronary artery lesions.
Imaging during intermediate stages of exercise significantly improved the sensitivity for detection of all individual vessel stenosis (78% vs 58%, p<0.001) and the patient's overall CAD (94% vs 74%, p<0.001) compared with peak exercise imaging.
Intermediate stages and peak exercise imaging had similar specificities for the detection of affected vessels (83% and 81%, respectively) and patients (64% and 60%).
Furthermore, patients with ischemia had a significantly increased ventricular end-systolic volume (LVESV) from the intermediate stage to peak exercise, compared with the change from rest to peak exercise (33.5% vs 17.5%, p<0.001).
A change in LVESV from intermediate stage to peak exercise of more than 10% predicted CAD with a sensitivity of 94% and a specificity of 74%. The researchers therefore suggest that "the change in LVESV during exercise is a useful parameter for the detection of CAD."
Zoghbi et al conclude: "During BEE, the acquisition and interpretation of images during the intermediate stages of exercise, in addition to those at peak exercise, improve the detection of CAD and allow a physiologic assessment of the severity of coronary stenosis."
J Am Coll Cardiol 2007; 50: 1857-1863
AHa - 2007: Drug-eluting stents: Do the outcomes justify their use?
Drug-eluting stents: Do the outcomes justify their use?
MedWire - AHA (Orlando, Florida, USA), November 4, 2007: This session on the second day of the American Heart Association Congress focused on controversies in clinical cardiology, with speakers arguing for and against the motion. The highlight was a debate on the value of drug-eluting stents (DES), which is summarized below.
Yes
Gregg Stone, Columbia University Medical Center, New York, NY, USA
Dr. Stone spoke in favor of DES, which he described as a “transforming technology” in view of their proven ability to reduce restenosis compared with bare-metal stents (BMS). “It is a misconception that restenosis is benign,” he commented. “Restenosis negatively impacts quality of life and leads to symptoms as well as to repeat angioplasty and acute coronary syndromes (ACS) in a substantial number of patients.”
The “flipside” of the benefit of DES on restenosis is the risk of late stent thrombosis, which can be a devastating and even fatal complication in a “really small minority” of patients. However, he stressed that this risk needs to be put into perspective.
Dr. Stone then reviewed the data that triggered concerns about the safety of DES, much of which was presented at the annual European Society of Cardiology (ESC) congress in Barcelona, Spain, in 2006. In an episode dubbed the “ESC firestorm”, Salim Yusuf told ESC delegates that widespread use of DES is “an epidemic of madness”. DES use has since markedly declined in Europe and Canada.
At today’s session, Dr. Stone said that the studies presented at the ESC 2006 were methodologically flawed. Two of the meta-analyses used data from abstracts and the internet rather than primary sources and had never been subjected to peer review. Another study was retracted following publication, while another failed to adjust fully for potential confounders.
In December 2006, the US Food and Drug Administration reviewed the most robust available data, including registry studies and updated meta-analyses. The panel concluded that DES are not associated with an increased risk of death or myocardial infarction (MI) when used according to the labeled indication.
Dr. Stone then showed an assortment of new registry data, much of which was presented at the recent Transcatheter Cardiovascular Therapeutics 2007 meeting in Washington DC. These studies consistently found that DES are associated with a lower risk of mortality/MI when compared with BMS, as well as confirming their marked superiority in preventing restenosis.
“These findings still need to be confirmed in prospective randomized controlled trials,” Dr. Stone admitted. “Three such studies are currently underway.”
No
Salim Yusuf, McMaster University, Hamilton, ON, Canada
Dr. Yusuf was billed as the antagonist in the debate over whether or not outcomes justify the use of DES. However, he said the debate was “irrelevant” as it failed to address a “more important question”, namely, whether routine percutaneous intervention (and all its associated paraphernalia) justifies the widespread use of stents in stable and unstable coronary artery disease (CAD). “The real issue is what is good for patients and society, not what makes doctors feel good,” he said.
Instead of arguing against the use of DES, Dr. Yusuf discussed the broader question of how best to manage CAD. He said there were four main reasons for using any medical therapy: To improve survival; to reduce morbidity; to improve symptoms and quality of life; and/or to reduce costs.
In patients with CAD, angioplasty of the culprit lesion is of proven value in two settings: ST-elevation MI (in place of thrombolytics) to reduce mortality, stroke, and probably reinfarction; and in high-risk non-ST-elevation ACS to reduce new MI and avoid repeated rehospitalization for unstable angina. “In both these acute conditions, timely PCI in selected patients is an important advance,” Dr. Yusuf stated.
The problem, according to Dr. Yusuf, is that PCI is now routinely performed outside these two acute settings. In the United States, the use of PCI increased by 5,946% between 1987 and 2004, compared with a rise of 102% in coronary artery bypass surgery. “In 2005 over one million PCIs were performed,” he said. “Most of these were in patients with stable CAD.”
Dr. Yusuf said that neither epidemiology nor pathophysiology support the use of PCI in stable disease. Post-mortem studies show that most MIs originate from non-critical lesions that would not be considered suitable for stenting. Atherosclerosis is generalized, even when only one lesion is apparent on an angiogram. Furthermore, dilating a lesion - akin to “crushing” it - is not physiologic and can destabilize the lesion. Indeed, he said that stents actually worsen endothelial vascular dysfunction.
Since PCI is associated with both short- and long-term risks, these must be weighed against the small increased risk associated with stable angina. Studies comparing PCI with medical therapy in stable disease have found that the approaches are equivalent for reducing the risk of death and MI, but that PCI has much higher costs. In addition, stents have not been shown to reduce angina, improve quality of life, or prevent CABG. DES definitely reduces the rate of angiographic restenosis but this is merely a surrogate endpoint, and Dr. Yusuf warned against formulating clinical practice around surrogates.
“The overall cost of PCI plus DES plus prolonged dual antiplatelet therapy (possibly plus intravascular ultrasound to enhance stent deployment) is astronomical compared to initial medical therapy - but with little clinical gain,” Dr. Yusuf stated. “Prolonged antiplatelet therapy is also associated with an increased risk of bleeding, of a magnitude associated with warfarin therapy.”
Accordingly, he proposed that patients with stable CAD should be treated with medical therapy in the first instance, and that PCI and stenting should be reserved for those who remain symptomatic on maximal medical therapy. If stents are used, there is no evidence that DES offer clinical benefits over BMS, while they are undoubtedly associated with increased costs.
Dr. Yusuf ended by calling for patients with stable CAD to be managed with evidence-based pharmacologic therapy and lifestyle modification, and for a more selective use of PCI and stenting. “We are being seduced by technology,” he concluded. “We need to close down 50% of cath labs and retrain interventional cardiologists in the use of drugs and lifestyle modification.”
MedWire - AHA (Orlando, Florida, USA), November 4, 2007: This session on the second day of the American Heart Association Congress focused on controversies in clinical cardiology, with speakers arguing for and against the motion. The highlight was a debate on the value of drug-eluting stents (DES), which is summarized below.
Yes
Gregg Stone, Columbia University Medical Center, New York, NY, USA
Dr. Stone spoke in favor of DES, which he described as a “transforming technology” in view of their proven ability to reduce restenosis compared with bare-metal stents (BMS). “It is a misconception that restenosis is benign,” he commented. “Restenosis negatively impacts quality of life and leads to symptoms as well as to repeat angioplasty and acute coronary syndromes (ACS) in a substantial number of patients.”
The “flipside” of the benefit of DES on restenosis is the risk of late stent thrombosis, which can be a devastating and even fatal complication in a “really small minority” of patients. However, he stressed that this risk needs to be put into perspective.
Dr. Stone then reviewed the data that triggered concerns about the safety of DES, much of which was presented at the annual European Society of Cardiology (ESC) congress in Barcelona, Spain, in 2006. In an episode dubbed the “ESC firestorm”, Salim Yusuf told ESC delegates that widespread use of DES is “an epidemic of madness”. DES use has since markedly declined in Europe and Canada.
At today’s session, Dr. Stone said that the studies presented at the ESC 2006 were methodologically flawed. Two of the meta-analyses used data from abstracts and the internet rather than primary sources and had never been subjected to peer review. Another study was retracted following publication, while another failed to adjust fully for potential confounders.
In December 2006, the US Food and Drug Administration reviewed the most robust available data, including registry studies and updated meta-analyses. The panel concluded that DES are not associated with an increased risk of death or myocardial infarction (MI) when used according to the labeled indication.
Dr. Stone then showed an assortment of new registry data, much of which was presented at the recent Transcatheter Cardiovascular Therapeutics 2007 meeting in Washington DC. These studies consistently found that DES are associated with a lower risk of mortality/MI when compared with BMS, as well as confirming their marked superiority in preventing restenosis.
“These findings still need to be confirmed in prospective randomized controlled trials,” Dr. Stone admitted. “Three such studies are currently underway.”
No
Salim Yusuf, McMaster University, Hamilton, ON, Canada
Dr. Yusuf was billed as the antagonist in the debate over whether or not outcomes justify the use of DES. However, he said the debate was “irrelevant” as it failed to address a “more important question”, namely, whether routine percutaneous intervention (and all its associated paraphernalia) justifies the widespread use of stents in stable and unstable coronary artery disease (CAD). “The real issue is what is good for patients and society, not what makes doctors feel good,” he said.
Instead of arguing against the use of DES, Dr. Yusuf discussed the broader question of how best to manage CAD. He said there were four main reasons for using any medical therapy: To improve survival; to reduce morbidity; to improve symptoms and quality of life; and/or to reduce costs.
In patients with CAD, angioplasty of the culprit lesion is of proven value in two settings: ST-elevation MI (in place of thrombolytics) to reduce mortality, stroke, and probably reinfarction; and in high-risk non-ST-elevation ACS to reduce new MI and avoid repeated rehospitalization for unstable angina. “In both these acute conditions, timely PCI in selected patients is an important advance,” Dr. Yusuf stated.
The problem, according to Dr. Yusuf, is that PCI is now routinely performed outside these two acute settings. In the United States, the use of PCI increased by 5,946% between 1987 and 2004, compared with a rise of 102% in coronary artery bypass surgery. “In 2005 over one million PCIs were performed,” he said. “Most of these were in patients with stable CAD.”
Dr. Yusuf said that neither epidemiology nor pathophysiology support the use of PCI in stable disease. Post-mortem studies show that most MIs originate from non-critical lesions that would not be considered suitable for stenting. Atherosclerosis is generalized, even when only one lesion is apparent on an angiogram. Furthermore, dilating a lesion - akin to “crushing” it - is not physiologic and can destabilize the lesion. Indeed, he said that stents actually worsen endothelial vascular dysfunction.
Since PCI is associated with both short- and long-term risks, these must be weighed against the small increased risk associated with stable angina. Studies comparing PCI with medical therapy in stable disease have found that the approaches are equivalent for reducing the risk of death and MI, but that PCI has much higher costs. In addition, stents have not been shown to reduce angina, improve quality of life, or prevent CABG. DES definitely reduces the rate of angiographic restenosis but this is merely a surrogate endpoint, and Dr. Yusuf warned against formulating clinical practice around surrogates.
“The overall cost of PCI plus DES plus prolonged dual antiplatelet therapy (possibly plus intravascular ultrasound to enhance stent deployment) is astronomical compared to initial medical therapy - but with little clinical gain,” Dr. Yusuf stated. “Prolonged antiplatelet therapy is also associated with an increased risk of bleeding, of a magnitude associated with warfarin therapy.”
Accordingly, he proposed that patients with stable CAD should be treated with medical therapy in the first instance, and that PCI and stenting should be reserved for those who remain symptomatic on maximal medical therapy. If stents are used, there is no evidence that DES offer clinical benefits over BMS, while they are undoubtedly associated with increased costs.
Dr. Yusuf ended by calling for patients with stable CAD to be managed with evidence-based pharmacologic therapy and lifestyle modification, and for a more selective use of PCI and stenting. “We are being seduced by technology,” he concluded. “We need to close down 50% of cath labs and retrain interventional cardiologists in the use of drugs and lifestyle modification.”
Tuesday, October 9, 2007
Job Strain and Risk of Acute Recurrent Coronary Heart Disease Events
Job Strain and Risk of Acute Recurrent Coronary Heart Disease Events
Corine Aboa-Éboulé, MD, PhD; Chantal Brisson, PhD; Elizabeth Maunsell, PhD; Benoît Mâsse, PhD; Renée Bourbonnais, PhD; Michel Vézina, MD, MPH; Alain Milot, MD, MSc; Pierre Théroux, MD; Gilles R. Dagenais, MD
JAMA. 2007;298:1652-1660. (October10, 2007)
Context There is evidence that job strain increases the risk of a first coronary heart disease (CHD) event. However, little is known about its association with the risk of recurrent CHD events after a first myocardial infarction (MI).
Objective To determine whether job strain increases the risk of recurrent CHD events.
Design, Setting, and Patients Prospective cohort study of 972 men and women aged 35 to 59 years who returned to work after a first MI and were then followed up between February 10, 1996, and June 22, 2005. Patients were interviewed at baseline (on average, 6 weeks after their return to work), then after 2 and 6 years subsequently. Job strain, a combination of high psychological demands and low decision latitude, was evaluated in 4 quadrants: high strain (high demands and low latitude), active (high demands and high latitude), passive (low demands and low latitude), and low strain. A chronic job strain variable was constructed based on the first 2 interviews, and patients were divided into those exposed to high strain at both interviews and those unexposed to high strain at 1 or both interviews. The survival analyses were presented separately for 2 periods: before 2.2 years and at 2.2 years and beyond.
Main Outcome Measure The outcome was a composite of fatal CHD, nonfatal MI, and unstable angina.
Results The outcome was documented in 206 patients. In the unadjusted analysis, chronic job strain was associated with recurrent CHD in the second period after 2.2 years of follow-up (hazard ratio [HR], 2.20; 95% CI, 1.32-3.66; respective event rates for patients exposed and unexposed to chronic job strain, 6.18 and 2.81 per 100 person-years). Chronic job strain remained an independent predictor of recurrent CHD in a multivariate model adjusted for 26 potentially confounding factors (HR, 2.00; 95% CI, 1.08-3.72).
Conclusion Chronic job strain after a first MI was associated with an increased risk of recurrent CHD.
Corine Aboa-Éboulé, MD, PhD; Chantal Brisson, PhD; Elizabeth Maunsell, PhD; Benoît Mâsse, PhD; Renée Bourbonnais, PhD; Michel Vézina, MD, MPH; Alain Milot, MD, MSc; Pierre Théroux, MD; Gilles R. Dagenais, MD
JAMA. 2007;298:1652-1660. (October10, 2007)
Context There is evidence that job strain increases the risk of a first coronary heart disease (CHD) event. However, little is known about its association with the risk of recurrent CHD events after a first myocardial infarction (MI).
Objective To determine whether job strain increases the risk of recurrent CHD events.
Design, Setting, and Patients Prospective cohort study of 972 men and women aged 35 to 59 years who returned to work after a first MI and were then followed up between February 10, 1996, and June 22, 2005. Patients were interviewed at baseline (on average, 6 weeks after their return to work), then after 2 and 6 years subsequently. Job strain, a combination of high psychological demands and low decision latitude, was evaluated in 4 quadrants: high strain (high demands and low latitude), active (high demands and high latitude), passive (low demands and low latitude), and low strain. A chronic job strain variable was constructed based on the first 2 interviews, and patients were divided into those exposed to high strain at both interviews and those unexposed to high strain at 1 or both interviews. The survival analyses were presented separately for 2 periods: before 2.2 years and at 2.2 years and beyond.
Main Outcome Measure The outcome was a composite of fatal CHD, nonfatal MI, and unstable angina.
Results The outcome was documented in 206 patients. In the unadjusted analysis, chronic job strain was associated with recurrent CHD in the second period after 2.2 years of follow-up (hazard ratio [HR], 2.20; 95% CI, 1.32-3.66; respective event rates for patients exposed and unexposed to chronic job strain, 6.18 and 2.81 per 100 person-years). Chronic job strain remained an independent predictor of recurrent CHD in a multivariate model adjusted for 26 potentially confounding factors (HR, 2.00; 95% CI, 1.08-3.72).
Conclusion Chronic job strain after a first MI was associated with an increased risk of recurrent CHD.
IDSA: No Evidence of Infectious Link to Coronary Disease Revealed
IDSA: No Evidence of Infectious Link to Coronary Disease Revealed
Review
SAN DIEGO, Oct. 8 -- The infectious link to coronary artery disease, if there is one, remained as elusive as ever after scrutiny of peripheral blood mononuclear cells (PMBCs), investigators said here.
The examination of PMBCs from patients with coronary disease failed to turn up any evidence of Chlamydia pneumoniae, Sarah West, M.D., of Oregon Health & Science University in Portland reported at the Infectious Diseases Society of America meeting.
However, Dr. West and colleagues are not ready to close the door on investigation of an infectious etiology for coronary disease.
"All we can say on the basis of this work is that we were unable to detect the pathogen with the methods we used," said Dr. West. "We're confident in our results, but the data on human atheromas and from animal models are just too compelling to say there is nothing to this."
Previous studies of C. pneumoniae and coronary disease have yielded mixed results. Nucleic acid from the pathogen has been reported in 0% to 90% of atherosclerotic plaques. Similar variation has emerged from studies of C. pneumoniae nucleic acid in PBMCs of patients with coronary disease.
"I think our study differs from some of the others in that we used a very sensitive PCR assay, and we performed the assay three times with each specimen to ensure reliability," said Dr. West. "We also sent samples to an outside laboratory for confirmation."
Investigators tested the theory that C. pneumoniae spread to atherosclerotic plaque by PBMCs or vice versa would be detectable and serve as a marker for coronary disease. The study involved 86 patients with angiographically proven coronary disease and 90 age- and sex-matched controls without coronary disease or modifiable risk factors for coronary disease.
PBMCs in blood samples from patients and controls were probed for C. pneumoniae DNA and RNA by means of two different real-time PCR assays. Additionally, microimmunofluorescence assays were used to screen specimens for IgG for C. pneumoniae.
Three fourths of the patients and controls had serologic evidence of prior exposure to C. pneumoniae, as determined by microimmunofluorescence. Even so, none of the patients or controls had evidence of C. pneumoniae nucleic acid in PBMCs.
Samples sent to an outside laboratory yielded the same results.
"Our results were uniformly negative, using highly sensitive PCR techniques," said Dr. West. "The results indicate that PBMCs can't be used as a means of determining whether C. pneumoniae is in atheromatous lesions and that the presence or absence of C. pneumoniae nucleic acid in PBMCs is not a useful risk factor for coronary artery disease."
Primary source: Infectious Diseases Society of America
Source reference:
West SK et al. "No evidence of circulating C. pneumoniae nucleic acid in patients with coronary artery disease (CAD) or healthy controls." Infectious Diseases Society of American 45th Annual Meeting. Oct. 4-7, 2007. San Diego. Final Program and Abstracts. Abstract 464.
Review
SAN DIEGO, Oct. 8 -- The infectious link to coronary artery disease, if there is one, remained as elusive as ever after scrutiny of peripheral blood mononuclear cells (PMBCs), investigators said here.
The examination of PMBCs from patients with coronary disease failed to turn up any evidence of Chlamydia pneumoniae, Sarah West, M.D., of Oregon Health & Science University in Portland reported at the Infectious Diseases Society of America meeting.
However, Dr. West and colleagues are not ready to close the door on investigation of an infectious etiology for coronary disease.
"All we can say on the basis of this work is that we were unable to detect the pathogen with the methods we used," said Dr. West. "We're confident in our results, but the data on human atheromas and from animal models are just too compelling to say there is nothing to this."
Previous studies of C. pneumoniae and coronary disease have yielded mixed results. Nucleic acid from the pathogen has been reported in 0% to 90% of atherosclerotic plaques. Similar variation has emerged from studies of C. pneumoniae nucleic acid in PBMCs of patients with coronary disease.
"I think our study differs from some of the others in that we used a very sensitive PCR assay, and we performed the assay three times with each specimen to ensure reliability," said Dr. West. "We also sent samples to an outside laboratory for confirmation."
Investigators tested the theory that C. pneumoniae spread to atherosclerotic plaque by PBMCs or vice versa would be detectable and serve as a marker for coronary disease. The study involved 86 patients with angiographically proven coronary disease and 90 age- and sex-matched controls without coronary disease or modifiable risk factors for coronary disease.
PBMCs in blood samples from patients and controls were probed for C. pneumoniae DNA and RNA by means of two different real-time PCR assays. Additionally, microimmunofluorescence assays were used to screen specimens for IgG for C. pneumoniae.
Three fourths of the patients and controls had serologic evidence of prior exposure to C. pneumoniae, as determined by microimmunofluorescence. Even so, none of the patients or controls had evidence of C. pneumoniae nucleic acid in PBMCs.
Samples sent to an outside laboratory yielded the same results.
"Our results were uniformly negative, using highly sensitive PCR techniques," said Dr. West. "The results indicate that PBMCs can't be used as a means of determining whether C. pneumoniae is in atheromatous lesions and that the presence or absence of C. pneumoniae nucleic acid in PBMCs is not a useful risk factor for coronary artery disease."
Primary source: Infectious Diseases Society of America
Source reference:
West SK et al. "No evidence of circulating C. pneumoniae nucleic acid in patients with coronary artery disease (CAD) or healthy controls." Infectious Diseases Society of American 45th Annual Meeting. Oct. 4-7, 2007. San Diego. Final Program and Abstracts. Abstract 464.
Monday, October 8, 2007
Obesity Paradox in Patients with Hypertension and Coronary Artery Disease
Obesity Paradox in Patients with Hypertension and Coronary Artery Disease
The American Journal of Medicine
Volume 120, Issue 10, Pages 825-918 (October 2007)
Abstract
Purpose
An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.
Methods
A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66±9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m2 (thin), 20 to 25 kg/m2 (normal weight), 25 to 30 kg/m2 (overweight), 30 to 35 kg/m2 (class I obesity), and 35 kg/m2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.
Results
With patients of normal weight (BMI 20 to<25 kg/m2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P<.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P<.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5±21.9 mm Hg/−9.8±12.4 mm Hg vs −20.7±23.1 mm Hg /−10.6±12.5 mm Hg, P<.001).
Conclusion
In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.
Study Limitations
This was a post hoc analysis and thus suffers from the limitations of such studies. Our conclusions should be considered to be hypothesis generating. The INVEST did not collect the waist-to-hip ratio data; therefore, we could not compare BMI with waist-to-hip ratio. Although we did find differences in the primary and secondary outcomes between BMI groups, the baseline characteristics of the BMI categories were not well matched. Although a stepwise model was used, the impact of these baseline differences cannot be ruled out.
The American Journal of Medicine
Volume 120, Issue 10, Pages 825-918 (October 2007)
Abstract
Purpose
An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.
Methods
A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66±9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m2 (thin), 20 to 25 kg/m2 (normal weight), 25 to 30 kg/m2 (overweight), 30 to 35 kg/m2 (class I obesity), and 35 kg/m2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.
Results
With patients of normal weight (BMI 20 to<25 kg/m2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P<.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P<.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5±21.9 mm Hg/−9.8±12.4 mm Hg vs −20.7±23.1 mm Hg /−10.6±12.5 mm Hg, P<.001).
Conclusion
In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.
Study Limitations
This was a post hoc analysis and thus suffers from the limitations of such studies. Our conclusions should be considered to be hypothesis generating. The INVEST did not collect the waist-to-hip ratio data; therefore, we could not compare BMI with waist-to-hip ratio. Although we did find differences in the primary and secondary outcomes between BMI groups, the baseline characteristics of the BMI categories were not well matched. Although a stepwise model was used, the impact of these baseline differences cannot be ruled out.
Friday, October 5, 2007
Left Main Heart Disease Runs in the Family
Familial aggregation of left main coronary artery disease and future risk of coronary events in asymptomatic siblings of affected patients
Primary source: European Heart Journal Advance Access published online on October 3, 2007
Fischer M, et al "Familial aggregation of left main coronary artery disease and future risk of coronary events in asymptomatic siblings of affected patients"
Aims: Recently, we observed in a hypothesis-generating exploratory search on the heritability of coronary morphology that left main coronary disease (LMD) was frequently shared by siblings with coronary artery disease (CAD). Thus, our aims were, first, to test specifically the familial aggregation of LMD and second, to investigate whether LMD is a stronger predictor for future incident events than other manifestations of CAD in seemingly healthy siblings of CAD patients.
Methods and results: Coronary angiograms of 1801 patients (n = 882 from the initial exploratory study and 919 additional angiograms) were analysed from families with 2 affected CAD siblings. We estimated the heritability using the variance-component methodology and sibling recurrent risks by logistic regression analysis. Moreover, we studied 1369 healthy siblings of CAD patients with known coronary morphology who had a subsequent coronary event by conducting a prospective, nested case–control study. LMD-frequency was comparable in our initial exploratory study (11%) and the new sample (12%). The heritability of LMD was significant in the exploratory 48%, P = 0.010, in the subsequent 45%, P = 0.045, and in the total study sample 49%, P = 0.002. The sibling recurrent risk ratio to present with LMD was 3.6 [CI 1.7–7.1] when another sibling was affected by LMD. In the prospective study on initially healthy family members of CAD patients, 79 siblings experienced an event during follow-up. LMD was more frequently found in families with an event than in families without (13.9 vs. 6.4%, P = 0.036). The relative risk for initially asymptomatic siblings of patients with LMD to suffer from a coronary event was 2.5 [CI 1.1–5.8] compared with siblings of patients with other manifestations of CAD.
Conclusion: These data confirm our initial observation of familial aggregation of LMD. Moreover, in apparently healthy siblings of patients with LMD, this heritable component results in a risk increase for future events that is greater than that of a strong positive family history by itself.
Primary source: European Heart Journal Advance Access published online on October 3, 2007
Fischer M, et al "Familial aggregation of left main coronary artery disease and future risk of coronary events in asymptomatic siblings of affected patients"
Aims: Recently, we observed in a hypothesis-generating exploratory search on the heritability of coronary morphology that left main coronary disease (LMD) was frequently shared by siblings with coronary artery disease (CAD). Thus, our aims were, first, to test specifically the familial aggregation of LMD and second, to investigate whether LMD is a stronger predictor for future incident events than other manifestations of CAD in seemingly healthy siblings of CAD patients.
Methods and results: Coronary angiograms of 1801 patients (n = 882 from the initial exploratory study and 919 additional angiograms) were analysed from families with 2 affected CAD siblings. We estimated the heritability using the variance-component methodology and sibling recurrent risks by logistic regression analysis. Moreover, we studied 1369 healthy siblings of CAD patients with known coronary morphology who had a subsequent coronary event by conducting a prospective, nested case–control study. LMD-frequency was comparable in our initial exploratory study (11%) and the new sample (12%). The heritability of LMD was significant in the exploratory 48%, P = 0.010, in the subsequent 45%, P = 0.045, and in the total study sample 49%, P = 0.002. The sibling recurrent risk ratio to present with LMD was 3.6 [CI 1.7–7.1] when another sibling was affected by LMD. In the prospective study on initially healthy family members of CAD patients, 79 siblings experienced an event during follow-up. LMD was more frequently found in families with an event than in families without (13.9 vs. 6.4%, P = 0.036). The relative risk for initially asymptomatic siblings of patients with LMD to suffer from a coronary event was 2.5 [CI 1.1–5.8] compared with siblings of patients with other manifestations of CAD.
Conclusion: These data confirm our initial observation of familial aggregation of LMD. Moreover, in apparently healthy siblings of patients with LMD, this heritable component results in a risk increase for future events that is greater than that of a strong positive family history by itself.
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