Unrecognised myocardial infarction and long-term risk of heart failure in the elderly: the Rotterdam Study

Interrelationships Between American Heart Association's Life's Simple 7, ECG Silent Myocardial Infarction, and Cardiovascular Mortality

Background We examined the interrelationships among cardiovascular health (CVH), assessed by the American Heart Association's Life's Simple 7 (LS7) health metrics, silent myocardial infarction (SMI), and cardiovascular disease (CVD) mortality. Methods and Results This analysis included 6766 participants without a history of coronary heart disease from the Third Report of the National Health and Nutrition Examination Survey. Poor, intermediate, and ideal CVH were defined as an LS7 score of 0 to 4, 5 to 9, and 10 to 14, respectively. SMI was defined as ECG evidence of myocardial infarction without a clinical diagnosis of myocardial infarction. Cox proportional hazard analysis was used to examine the association of baseline CVH with CVD death stratified by SMI status on follow-up. In multivariable logistic regression models, ideal CVH was associated with 69% lower odds of SMI compared with poor CVH. During a median follow-up of 14 years, 907 CVD deaths occurred. In patients without SMI, intermediate CVH (hazard ratio, 1.41; 95% CI, 1.14-1.74) and poor CVH (hazard ratio, 2.77; 95% CI, 2.10-3.66) were associated with increased risk of CVD mortality, compared with ideal CVH. However, in the presence of SMI, the magnitude of these associations almost doubled (hazard ratio, 2.17 [95% CI, 1.42-3.32] for intermediate CVH and hazard ratio, 6.28 [95% CI, 3.02-13.07] for poor CVH). SMI predicted a significant increased risk of CVD mortality in the intermediate and poor CVH subgroups but a nonsignificant increased risk in the ideal CVH subgroup. Conclusions Ideal CVH is associated with a lower risk of SMI, and concomitant presence of SMI and poor CVH is associated with a worse prognosis. These novel findings underscore the potential role of maintaining ideal CVH in preventing future CVD outcomes.

Prognosis of unrecognised myocardial infarction determined by electrocardiography or cardiac magnetic resonance imaging: systematic review and meta-analysis

OBJECTIVE

To evaluate the prognosis of unrecognised myocardial infarction determined by electrocardiography (UMI-ECG) or cardiac magnetic resonance imaging (UMI-CMR).

DESIGN

Systematic review and meta-analysis of prospective studies.

DATA SOURCES

Electronic databases, including PubMed, Embase, and Google Scholar.

STUDY SELECTION

Prospective cohort studies were included if they reported adjusted relative risks, odds ratios, or hazard ratios and 95% confidence intervals for all cause mortality or cardiovascular outcomes in participants with unrecognised myocardial infarction compared with those without myocardial infarction.

DATA EXTRACTION AND SYNTHESIS

The primary outcomes were composite major adverse cardiac events, all cause mortality, and cardiovascular mortality associated with UMI-ECG and UMI-CMR. The secondary outcomes were the risks of recurrent coronary heart disease or myocardial infarction, stroke, heart failure, and atrial fibrillation. Pooled hazard ratios and 95% confidence intervals were reported. The heterogeneity of outcomes was compared in clinically recognised and unrecognised myocardial infarction.

RESULTS

The meta-analysis included 30 studies with 253 425 participants and 1 621 920 person years of follow-up. UMI-ECG was associated with increased risks of all cause mortality (hazard ratio 1.50, 95% confidence interval 1.30 to 1.73), cardiovascular mortality (2.33, 1.66 to 3.27), and major adverse cardiac events (1.61, 1.38 to 1.89) compared with the absence of myocardial infarction. UMI-CMR was also associated with increased risks of all cause mortality (3.21, 1.43 to 7.23), cardiovascular mortality (10.79, 4.09 to 28.42), and major adverse cardiac events (3.23, 2.10 to 4.95). No major heterogeneity was observed for any primary outcomes between recognised myocardial infarction and UMI-ECG or UMI-CMR. The absolute risk differences were 7.50 (95% confidence interval 4.50 to 10.95) per 1000 person years for all cause mortality, 11.04 (5.48 to 18.84) for cardiovascular mortality, and 27.45 (17.1 to 40.05) for major adverse cardiac events in participants with UMI-ECG compared with those without myocardial infarction. The corresponding data for UMI-CMR were 32.49 (6.32 to 91.58), 37.2 (11.7 to 104.20), and 51.96 (25.63 to 92.04), respectively.

CONCLUSIONS

UMI-ECG or UMI-CMR is associated with an adverse long term prognosis similar to that of recognised myocardial infarction. Screening for unrecognised myocardial infarction could be useful for risk stratification among patients with a high risk of cardiovascular disease.

Reducing avoidable chest pain admissions and implementing high-sensitivity troponin testing

NHS accident and emergency departments see 0.5 million patients presenting with a cardiac condition each year. The accurate assessment of chest pain and subsequent diagnosis or exclusion of myocardial infarction (MI) represent a significant challenge, with important consequences on patient outcome and healthcare resources. We conducted a cross-sectional analysis of patients admitted with cardiac chest pain to a busy district general hospital in London. The criteria used by physicians to admit patients for further cardiac investigations were measured against national guidance on chest pain assessment and diagnosis of MI. We found that poor adherence to guidance, unsuitable patient pathways and inappropriate diagnostic tools at the point of presentation led to unnecessary inpatient admissions to the hospital. Quality improvement methods were used with the aim to reduce avoidable admissions to hospital in patients presenting with chest pain. We describe a system to implement new high-sensitivity troponin testing into legacy chest pain pathways. This was achieved through local education of National Institute for Health and Care Excellence (NICE) guidance, the use of patient pro formas and the creation of two new chest pain pathway arms to enable physicians to streamline patients for appropriate inpatient or outpatient care. As a result of these changes, we reduced non-compliance with NICE guidance by 83% and achieved a 42% reduction in avoidable chest pain admissions. Overall, the improvements made by this project were sustained over 2 years and saved £21 000 per month in avoidable admissions.

Reprint of "Electrocardiographic definition of silent myocardial infarction in population studies: A call to standardize the standards"

According to the American Heart Association, 170,000 new silent myocardial infarctions (SMI) occur annually in the United States. Prior studies from the general population also have shown that SMI is common, but the rates varied widely. Some studies reported SMI rates as low as 4% while others reported rates as high as 57% of the total MIs. Reports on the prognostic significance of SMI compared to clinically recognized MI also have been inconsistent. Although SMI could be detected using cardiac imaging, electrocardiogram (ECG) has been the most common method for detection of SMI in both clinical and research settings due to it is low-cost and wide availability. This report highlights certain ECG methodological aspects that need to be taken into consideration when interpreting findings from population studies addressing SMI. Examples from population studies will be used in this report to show how deviation and differences in applications of the ECG standard definitions of SMI, ECG processing methods, and the frequency of ECG recording in population studies could impact the results, which may explain the wide range of rates and inconsistent conclusions about the prognostic significance of SMI. A summary of the gaps in knowledge of the SMI research is provided. By highlighting the lack of uniform approach in defining SMI despite the availability of standard definitions and pointing out the gaps in knowledge, it is hoped that a call for standardizing the use of the current standards will emerge.

A combined linkage, microarray and exome analysis suggests MAP3K11 as a candidate gene for left ventricular hypertrophy

BACKGROUND

Electrocardiographic measures of left ventricular hypertrophy (LVH) are used as predictors of cardiovascular risk. We combined linkage and association analyses to discover novel rare genetic variants involved in three such measures and two principal components derived from them.

METHODS

The study was conducted among participants from the Erasmus Rucphen Family Study (ERF), a Dutch family-based sample from the southwestern Netherlands. Variance components linkage analyses were performed using Merlin. Regions of interest (LOD > 1.9) were fine-mapped using microarray and exome sequence data.

RESULTS

We observed one significant LOD score for the second principal component on chromosome 15 (LOD score = 3.01) and 12 suggestive LOD scores. Several loci contained variants identified in GWAS for these traits; however, these did not explain the linkage peaks, nor did other common variants. Exome sequence data identified two associated variants after multiple testing corrections were applied.

CONCLUSIONS

We did not find common SNPs explaining these linkage signals. Exome sequencing uncovered a relatively rare variant in MAPK3K11 on chromosome 11 (MAF = 0.01) that helped account for the suggestive linkage peak observed for the first principal component. Conditional analysis revealed a drop in LOD from 2.01 to 0.88 for MAP3K11, suggesting that this variant may partially explain the linkage signal at this chromosomal location. MAP3K11 is related to the JNK pathway and is a pro-apoptotic kinase that plays an important role in the induction of cardiomyocyte apoptosis in various pathologies, including LVH.

Heart-type fatty acid binding protein levels in elderly diabetics without known cardiovascular disease

Background

Cardiovascular disease (CVD) is reported to be higher in elderly diabetics. Serum heart-type fatty acid binding protein (H-FABP) is a serum marker of myocardial ischemia. We aimed to investigate the association between serum H-FABP level and conventional cardiovascular risk factors, inflammatory markers and subclinical atherosclerosis in elderly diabetics without overt CVD.

Patients and methods

A total of 50 elderly diabetic patients without overt CVD and 30 age-, sex- and body mass index (BMI)-matched healthy controls were enrolled. Anthropometric and biochemical parameters, serum H-FABP, high-sensitivity C-reactive protein (hs-CRP), fibrinogen and carotid intima-media thickness (CIMT) were measured. Logistic regression analyses (adjustments for age, sex, hypertension, smoking, diabetes, BMI, blood pressure, lipid, blood glucose, hemoglobin A1c, hs-CRP and fibrinogen) were performed to evaluate the association between H-FABP and cardiovascular risk factors and atherosclerosis indices.

Results

Serum fibrinogen (421.50±85.52 mg/dL vs 319.17±30.77 mg/dL, p=0.023), CIMT (0.70±0.12 mm vs 0.59±0.06 mm, p<0.001) and hs-CRP (5.72±4.50 mg/dL vs 1.60±0.72 mg/dL, p<0.001) were significantly higher in diabetic patients than controls. The mean serum H-FABP level did not differ between groups (1571.79±604.60 ng/mL vs 1500.25±463.35 ng/mL, p=0.905). H-FABP was positively correlated with fibrinogen (r²=0.473, p<0.001), hs-CRP (r²=0.323, p=0.003) and CIMT (r²=0.467, p<0.001). After full adjustments, the serum H-FABP level was independently associated with an increase in the fibrinogen level (odds ratio [OR] =4.21, 95% confidence level [CI] =1.49–11.90).

Conclusion

Serum H-FABP was similar in the elderly diabetic patients without known CVD when compared with the nondiabetic control group. H-FABP does not possess a high diagnostic value as a cardiovascular marker when used alone; however, it may add supplementary information in patients with a high fibrinogen level.

Women's Heart Health: Knowledge, Beliefs, and Practices of Canadian Physicians

BACKGROUND

Heart disease is a leading cause of morbidity and mortality in women. To date, the majority of knowledge regarding heart disease is based on research conducted in men. As a result, a male-oriented model of heart disease constitutes the basis for diagnostic and therapeutic strategies for both sexes. This article reports findings from the first survey of Canadian physicians to examine their knowledge, beliefs, and practices regarding heart disease in women.

MATERIALS AND METHODS

This cross-sectional survey, adapted from an instrument used in the United States, was undertaken in the spring of 2015. A sample of 504 physicians from a randomly selected sample of online responses was produced.

RESULTS

Overall, physician responses demonstrate a general lack of awareness regarding the prevalence and approaches to the identification of, and treatments for, heart disease in women. In addition, physicians did not provide high ratings of their own effectiveness in supporting female patients to prevent or manage heart disease. The barriers that physicians face and the strategies to support them in improving women's heart health were explored.

CONCLUSIONS

There is a clear need to educate physicians about heart disease in women and its prevention and management. More female-specific research, prevention, and clinical programs will enhance our ability to significantly improve cardiovascular health in Canadian women.

Serial heart rhythm complexity changes in patients with anterior wall ST segment elevation myocardial infarction

Heart rhythm complexity analysis has been shown to have good prognostic power in patients with cardiovascular disease. The aim of this study was to analyze serial changes in heart rhythm complexity from the acute to chronic phase of acute myocardial infarction (MI). We prospectively enrolled 27 patients with anterior wall ST segment elevation myocardial infarction (STEMI) and 42 control subjects. In detrended fluctuation analysis (DFA), the patients had significantly lower DFAα2 in the acute stage (within 72 hours) and lower DFAα1 at 3 months and 12 months after MI. In multiscale entropy (MSE) analysis, the patients had a lower slope 5 in the acute stage, which then gradually increased during the follow-up period. The areas under the MSE curves for scale 1 to 5 (area 1–5) and 6 to 20 (area 6–20) were lower throughout the chronic stage. Area 6–20 had the greatest discriminatory power to differentiate the post-MI patients (at 1 year) from the controls. In both the net reclassification improvement and integrated discrimination improvement models, MSE parameters significantly improved the discriminatory power of the linear parameters to differentiate the post-MI patients from the controls. In conclusion, the patients with STEMI had serial changes in cardiac complexity.

Anti-Müllerian Hormone Trajectories Are Associated With Cardiovascular Disease in Women: Results From the Doetinchem Cohort Study

BACKGROUND

Earlier age at menopause is widely considered to be associated with an increased risk of cardiovascular disease. However, the underlying mechanisms of this relationship remain undetermined. Indications suggest that anti-Müllerian hormone (AMH), an ovarian reserve marker, plays a physiological role outside of the reproductive system. Therefore, we investigated whether longitudinal AMH decline trajectories are associated with an increased risk of cardiovascular disease (CVD) occurrence.

METHODS

This study included 3108 female participants between 20 and 60 years of age at baseline of the population-based Doetinchem Cohort. Participants completed ≥1 of 5 consecutive quinquennial visits between 1987 and 2010, resulting in a total follow-up time of 20 years. AMH was measured in 8507 stored plasma samples. Information on total CVD, stroke, and coronary heart disease was obtained through a hospital discharge registry linkage. The association of AMH trajectories with CVD was quantified with joint modeling, with adjustment for age, smoking, oral contraceptive use, body mass index, menopausal status, postmenopausal hormone therapy use, diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, and glucose levels.

RESULTS

By the end of follow-up, 8.2% of the women had suffered from CVD, 4.9% had suffered from coronary heart disease, and 2.6% had experienced a stroke. After adjustment, each ng/mL lower _logAMH level was associated with a 21% higher risk of CVD (hazard ratio, 1.21; 95% confidence interval, 1.07-1.36) and a 26% higher risk of coronary heart disease (hazard ratio, 1.25; 95% confidence interval, 1.08-1.46). Each additional ng/mL/year decrease of _logAMH was associated with a significantly higher risk of CVD (hazard ratio, 1.46; 95% confidence interval, 1.14-1.87) and coronary heart disease (hazard ratio, 1.56; 95% confidence interval, 1.15-2.12). No association between AMH and stroke was found.

CONCLUSIONS

These results indicate that AMH trajectories in women are independently associated with CVD risk. Therefore, we postulate that the decline of circulating AMH levels may be part of the pathophysiology of the increased cardiovascular risk of earlier menopause. Confirmation of this association and elucidation of its underlying mechanisms are needed to place these results in a clinical perspective.

A Combined Linkage and Exome Sequencing Analysis for Electrocardiogram Parameters in the Erasmus Rucphen Family Study

Electrocardiogram (ECG) measurements play a key role in the diagnosis and prediction of cardiac arrhythmias and sudden cardiac death. ECG parameters, such as the PR, QRS, and QT intervals, are known to be heritable and genome-wide association studies of these phenotypes have been successful in identifying common variants; however, a large proportion of the genetic variability of these traits remains to be elucidated. The aim of this study was to discover loci potentially harboring rare variants utilizing variance component linkage analysis in 1547 individuals from a large family-based study, the Erasmus Rucphen Family Study (ERF). Linked regions were further explored using exome sequencing. Five suggestive linkage peaks were identified: two for QT interval (1q24, LOD = 2.63; 2q34, LOD = 2.05), one for QRS interval (1p35, LOD = 2.52) and two for PR interval (9p22, LOD = 2.20; 14q11, LOD = 2.29). Fine-mapping using exome sequence data identified a C > G missense variant (c.713C > G, p.Ser238Cys) in the FCRL2 gene associated with QT (rs74608430; P = 2.8 × 10^-4, minor allele frequency = 0.019). Heritability analysis demonstrated that the SNP explained 2.42% of the trait’s genetic variability in ERF (P = 0.02). Pathway analysis suggested that the gene is involved in cytosolic Ca²⁺ levels (P = 3.3 × 10^-3) and AMPK stimulated fatty acid oxidation in muscle (P = 4.1 × 10^-3). Look-ups in bioinformatics resources showed that expression of FCRL2 is associated with ARHGAP24 and SETBP1 expression. This finding was not replicated in the Rotterdam study. Combining the bioinformatics information with the association and linkage analyses, FCRL2 emerges as a strong candidate gene for QT interval.

Prevalence and incidence of Q-wave unrecognized myocardial infarction in general population: Diagnostic value of the electrocardiogram. The REGICOR study

BACKGROUND

Diagnosis of unrecognized myocardial infarction (UMI) remains an open question in epidemiological and clinical studies, inhibiting effective secondary prevention of myocardial infarction. We aimed to determine the prevalence and incidence of Q-wave UMI in asymptomatic individuals aged 35 to 74years, and to ascertain the positive predictive value (PPV) of asymptomatic Q-wave to diagnose UMI.

METHODS

Two population-based cross-sectional studies were conducted, in 2000 (with 10-year follow-up) and in 2005. A baseline electrocardiogram was obtained for each participant. Imaging techniques (echocardiography, cardiac magnetic resonance imaging, and myocardial perfusion single-photon emission computerized tomography) were used to confirm UMI in patients with asymptomatic Q-wave.

RESULTS

The prevalence of confirmed Q-wave UMI in the 5580 participants was 0.18% (95% confidence interval [CI]: 0.10-0.33) and the incidence rate was 27.1 Q-wave UMI per 100,000person-years. The proportion of confirmed Q-wave UMI with respect to all prevalent MI was 8.1% (95% CI: 4.4-14.2). The PPV of asymptomatic Q-wave to diagnose Q-wave UMI was 29.2% (95% CI: 18.2-43.2%) overall, but much higher (75%, 95% CI: 40.9-92.9%) in participants with 10-year CHD risk ≥10%, compared to lower-risk participants.

CONCLUSION

Opportunistic identification of asymptomatic Q-waves by routine electrocardiogram overestimates actual Q-wave UMI, which represents 8% to 13% of all myocardial infarction in the population aged 35 to 74years. This overestimation is particularly high in the population at low cardiovascular risk. In epidemiological studies and in clinical practice, diagnosis of a pathologic Q-wave in asymptomatic patients requires detailed analysis of imaging tests to confirm or rule out myocardial necrosis.

Three-dimensional maximum principal strain using cardiac computed tomography for identification of myocardial infarction

OBJECTIVES

To evaluate the feasibility of three-dimensional (3D) maximum principal strain (MP-strain) derived from cardiac computed tomography (CT) for detecting myocardial infarction (MI).

METHODS

Forty-three patients who underwent cardiac CT and magnetic resonance imaging (MRI) were retrospectively selected. Using the voxel tracking of motion coherence algorithm, the peak CT MP-strain was measured using the 16-segment model. With the trans-mural extent of late gadolinium enhancement (LGE) and the distance from MI, all segments were classified into four groups (infarcted, border, adjacent, and remote segments); infarcted and border segments were defined as MI with LGE positive. Diagnostic performance of MP-strain for detecting MI was compared with per cent systolic wall thickening (%SWT) assessed by MRI using receiver-operating characteristic curve analysis at a segment level.

RESULTS

Of 672 segments excluding16 segments influenced by artefacts, 193 were diagnosed as MI. Sensitivity and specificity of peak MP-strain to identify MI were 81 % [95 % confidence interval (95 % CI): 74-88 %] and 86 % (81-92 %) compared with %SWT: 76 % (60-95 %) and 68 % (48-84 %), respectively. The area under the curve of peak MP-strain was superior to %SWT [0.90 (0.87-0.93) vs. 0.80 (0.76-0.83), p < 0.05].

CONCLUSIONS

CT MP-strain has a potential to provide incremental value to coronary CT angiography for detecting MI.

KEY POINTS

• CT MP-strain allows for three-dimensional assessment of regional cardiac function. • CT-MP strain has high diagnostic accuracy for detecting myocardial infarction. • CT-MP strain may assist in tissue characterisation of myocardium assessed by LGE-MRI. • CT-MP strain provides incremental values to coronary CTA for detecting myocardial infarction.

The long-term risk of recognized and unrecognized myocardial infarction for depression in older men

BACKGROUND

The association between myocardial infarction (MI) and depression is well described. Yet, the underlying mechanisms are unclear and the contribution of psychological factors is uncertain. We aimed to determine the risk of recognized (RMI) and unrecognized (UMI) myocardial infections on depression, as both have a similar impact on cardiovascular health but differ in psychological epiphenomena.

METHOD

Participants of the Rotterdam Study, 1823 men aged ⩾55 years, were followed for the occurrence of depression. RMI and UMI were ascertained using electrocardiography and medical history at baseline. We determined the strength of the association of RMI and UMI with mortality, and we studied the relationship of RMI and UMI with depressive symptoms and the occurrence of major depression.

RESULTS

The risk of mortality was similar in men with RMI [adjusted hazard ratio (aHR) 1.71, 95% confidence interval (CI) 1.45-2.03] and UMI (aHR 1.58, 95% CI 1.27-1.97). Men with RMI had on average [unstandardized regression coefficient (B) 1.14, 95% CI 0.07-2.21] higher scores for depressive symptoms. By contrast, we found no clear association between UMI and depressive symptoms (B 0.55, 95% CI -0.51 to 1.62) in men. Analysis including occurrence of major depression as the outcome were consistent with the pattern of association.

CONCLUSION

The discrepant association of RMI and UMI with mortality compared to depression suggests that the psychological burden of having experienced an MI contributes to the long-term risk of depression.

Cardiac cephalalgia: First case from India

A 67-year-old male smoker had exertional headaches for 2 years. The headaches were holocephalic, very severe, excruciating, and occasionally accompanied by nausea. Physical examinations and neuroimaging were normal. Electrocardiogram (ECG) showed old infarct in inferior leads. Sublingual nitrate provided relief in headaches. Stress test was positive with recurrence of similar headaches with ECG changes suggestive of myocardial ischemia. Coronary angiogram revealed three-vessel disease. Coronary artery bypass surgery provided complete resolution of headaches.

Comparison of prognosis in unrecognized versus recognized myocardial infarction in men versus women >55 years of age (from the Rotterdam Study)

Unrecognized myocardial infarction (MI) is frequent in the general population. Its prognosis is reported to be at least as unpropitious as that of recognized MI, particularly in men. However, contemporary data with long follow-up are lacking. The aims of this study were to investigate the long-term prognosis of unrecognized MI with respect to all-cause and cause-specific mortality and to investigate possible differences in prognosis by gender. In the population-based Rotterdam Study (2,672 men and 3,862 women), the presence of unrecognized MI and recognized MI was determined at baseline (1990 to 1993). The cohort was followed for nearly 2 decades for all-cause and cause-specific mortality. During 82,268 patient-years of follow-up (median 15.6 years) 3,412 patients died (1,300 from cardiovascular causes). Men and women with recognized and unrecognized MIs had increased total mortality rates compared with those without MIs. Hazard ratios (HRs) for men and women were 1.57 (95% confidence interval [CI] 1.36 to 1.81) and 1.89 (95% CI 1.56 to 2.30) for recognized MI and 1.72 (95% CI 1.43 to 2.07) and 1.36 (95% CI 1.14 to 1.61) for unrecognized MI. Unrecognized MI was associated with increased risks for cardiovascular mortality (men: HR 2.19, 95% CI 1.66 to 2.91; women: HR 1.36, 95% CI 1.03 to 1.81) and noncardiovascular mortality (men: HR 1.47, 95% CI 1.14 to 1.89; women: HR 1.39, 95% CI 1.10 to 1.75). In conclusion, the long-term prognosis of patients with unrecognized MIs is worse compared with those without MIs and applies not only to cardiovascular mortality but also to noncardiovascular mortality. In men, the prognosis is as unfavorable as that of patients with recognized MIs.

Investigation on cardiovascular risk prediction using physiological parameters

Cardiovascular disease (CVD) is the leading cause of death worldwide. Early prediction of CVD is urgently important for timely prevention and treatment. Incorporation or modification of new risk factors that have an additional independent prognostic value of existing prediction models is widely used for improving the performance of the prediction models. This paper is to investigate the physiological parameters that are used as risk factors for the prediction of cardiovascular events, as well as summarizing the current status on the medical devices for physiological tests and discuss the potential implications for promoting CVD prevention and treatment in the future. The results show that measures extracted from blood pressure, electrocardiogram, arterial stiffness, ankle-brachial blood pressure index (ABI), and blood glucose carry valuable information for the prediction of both long-term and near-term cardiovascular risk. However, the predictive values should be further validated by more comprehensive measures. Meanwhile, advancing unobtrusive technologies and wireless communication technologies allow on-site detection of the physiological information remotely in an out-of-hospital setting in real-time. In addition with computer modeling technologies and information fusion. It may allow for personalized, quantitative, and real-time assessment of sudden CVD events.

The Rotterdam Study: 2014 objectives and design update

The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, oncological, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. The findings of the Rotterdam Study have been presented in over a 1,000 research articles and reports (see www.erasmus-epidemiology.nl/rotterdamstudy ). This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.

Prevalence, consequences, and implications for clinical trials of unrecognized myocardial infarction

Patients with myocardial infarction (MI) generally present with chest pain or pressure at rest or minimal exertion and have associated electrocardiographic changes and/or elevation of the biomarkers of myocardial necrosis. A subset of patients, however, experience little chest discomfort or do not present to medical attention despite experiencing symptoms. Unrecognized MI might be detected using electrocardiographic or imaging techniques, such as echocardiography, nuclear imaging, or cardiovascular magnetic resonance imaging. Unrecognized MI is a common clinical entity, with an incidence as great as 35% in high-risk populations. Moreover, the risk of a subsequent major adverse cardiovascular event might be similar to the risk after a clinically apparent MI. In the present review, we examined the incidence of unrecognized MI across broad groups of subjects and the subsequent risk of adverse cardiovascular events. Finally, we explored the potential role of including unrecognized MI as a major adverse outcome in randomized clinical trials of agents aimed at reducing cardiovascular morbidity.

Cardioprotective medication use and risk factor control among US adults with unrecognized myocardial infarction: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study

BACKGROUND

Individuals with unrecognized myocardial infarction (UMI) have similar risks for cardiovascular events and mortality as those with recognized myocardial infarction (RMI). The prevalence of cardioprotective medication use and blood pressure and low-density lipoprotein cholesterol control among individuals with UMI is unknown.

METHODS

Participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who were recruited between May 2004 and October 2007 received baseline twelve-lead electrocardiograms (n = 21,036). Myocardial infarction (MI) status was characterized as no MI, UMI (electrocardiogram abnormalities consistent with MI without self-reported history; n = 949; 4.5%), and RMI (self-reported history of MI; n = 1574; 7.5%).

RESULTS

For participants with no MI, UMI, and RMI, prevalence of use was 38.4%, 44.4%, and 75.7% for aspirin; 18.0%, 25.8%, and 57.2% for beta blockers; 31.7%, 38.7%, and 55.0% for angiotensin converting enzyme inhibitors or angiotensin receptor blockers; and 28.1%, 33.9%, and 64.1% for statins, respectively. Participants with RMI were 35% more likely to have low-density lipoprotein cholesterol < 100 mg/dL than participants with UMI (prevalence ratio = 1.35, 95% confidence interval 1.19-1.52). Blood pressure control (,140/90 mmHg) was similar between RMI and UMI groups (prevalence ratio = 1.03, 95% confidence interval 0.93-1.13).

CONCLUSION

Although participants with UMI were somewhat more likely to use cardioprotective medications than those with no MI, they were less likely to use cardioprotective medications and to have controlled low-density lipoprotein cholesterol than participants with RMI. Increasing appropriate treatment and risk factor control among individuals with UMI may reduce risk of mortality and future cardiovascular events.

Prevalence of left ventricular dysfunction in a UK community sample of very old people: the Newcastle 85+ study

Objective

Heart failure (HF) prevalence rises sharply among those aged 85 years and over. Previous population based echocardiographic studies of left ventricular (LV) dysfunction, the substrate for HF, have included only small numbers in this age group. We used domiciliary echocardiography to estimate the prevalence of LV systolic and diastolic dysfunction in 87–89 year olds and the proportion remaining undiagnosed.

Design

Cross sectional analysis of data from Newcastle 85+ Study.

Setting

Primary care, North-East England.

Participants

376 men and women aged 87–89 years.

Measures

Domiciliary echocardiography was performed and LV systolic and diastolic function was graded. The presence of limiting dyspnoea was assessed by questionnaire. Previous diagnoses of HF were abstracted from general practice (GP) records.

Results

32% of participants (119/376) had LV systolic dysfunction (ejection fraction (EF) ≤50%) and a further 20% (75/376) had moderate or severe LV diastolic dysfunction with preserved EF. Both echocardiographic assessment of LV function and dyspnoea status were available in 74% (278/376) of participants. Among these participants, limiting dyspnoea was present in approximately two thirds of those with significant (systolic or isolated moderate/severe diastolic) LV dysfunction. 84% (73/87) of participants with significant LV dysfunction and limiting dyspnoea did not have a pre-existing HF diagnosis in their GP records. Overall, 26% (73/278) of participants with both echocardiographic and dyspnoea data had undiagnosed, symptomatic, significant LV dysfunction.

Conclusion

Significant systolic and diastolic LV dysfunction is much commoner in community dwelling 87–89 year olds than previous studies have suggested. The majority are both symptomatic and undiagnosed.

Methods of data collection and definitions of cardiac outcomes in the Rotterdam Study

The prevalence of cardiovascular diseases is rising. Therefore, adequate risk prediction and identification of its determinants is increasingly important. The Rotterdam Study is a prospective population-based cohort study ongoing since 1990 in the city of Rotterdam, The Netherlands. One of the main targets of the Rotterdam Study is to identify the determinants and prognosis of cardiovascular diseases. Case finding in epidemiological studies is strongly depending on various sources of follow-up and clear outcome definitions. The sources used for collection of data in the Rotterdam Study are diverse and the definitions of outcomes in the Rotterdam Study have changed due to the introduction of novel diagnostics and therapeutic interventions. This article gives the methods for data collection and the up-to-date definitions of the cardiac outcomes based on international guidelines, including the recently adopted cardiovascular disease mortality definitions. In all, detailed description of cardiac outcome definitions enhances the possibility to make comparisons with other studies in the field of cardiovascular research and may increase the strength of collaborations.

[Update on geriatric cardiology]

This article contains a review of the main developments in the field of geriatric cardiology reported during 2011. The principle focus is on research into the characteristics of elderly patients with heart failure, arrhythmias (e.g. into atrial fibrillation and implantable cardioverter-defibrillators), ischemic heart disease and percutaneous interventions.

Women & heart disease: symptoms and treatment guidelines

Coronary heart disease is the leading cause of death for women. Many women and some NPs are not aware of women's risk of myocardial infarction (MI) or that women's MI symptoms often differ from men's. NPs need to educate women about their risk and follow practice guidelines.