Retrospective validation of acute heart failure risk stratification in the emergency department

BACKGROUND

Heart Failure (HF) is a primary diagnosis for hospital admission from the Emergency Department (ED), although not all patients require hospitalization. The Emergency Heart Failure Mortality Risk Grade (EHMRG) estimates 7-day mortality in patients with acute HF in ED settings, but further validation is needed in the United States (US).

OBJECTIVES

To validate EHMRG scores by risk-stratifying patients with acute HF in a large tertiary healthcare center in the US and analyze outcome measures to determine if EHMRG risk scores safely identify low-risk groups that may be discharged or managed in ED observation units (EDOUs).

METHODS

A retrospective cohort analysis of 304 patients with acute HF presenting to an ED at a large, tertiary healthcare center was completed. EHMRG scores were calculated to stratify patients according to published thresholds. Mortality and major adverse cardiac event (MACE) rates were analyzed.

RESULTS

No deaths occurred in very low and low-risk EHMRG groups at 7 days post discharge. 30-day mortality was significantly less in the lower risk groups (3.1%) when compared to all other patients (11.1%). MACE rates at 30 days in the very low risk group (15%) were significantly less when compared to all other patients (31.3%). Hospitalizations occurred in 23.4% of patients in lower risk groups.

CONCLUSIONS

ED risk stratification with EHMRG differentiates high-risk patients requiring hospitalization from lower risk patients who can be safely managed in alternative settings with good outcomes. Data supports improved pathways for patients with acute HF during a time of high hospital volumes.

Validation of a Brief Dietary Questionnaire for Use in Clinical Practice: Mini-EAT (Eating Assessment Tool)

Background There is a scarcity of validated rapid dietary screening tools for patient use in the clinical setting to improve health and reduce cardiovascular risk. The Healthy Eating Index (HEI) 2015 measures compliance with the 2015 to 2020 Dietary Guidelines for Americans but requires completion of an extensive diet assessment to compute, which is time consuming and impractical. The authors hypothesize that a 19-item dietary survey assessing consumption of common food groups known to affect health will be correlated with the HEI-2015 assessed by a validated food frequency questionnaire and can be further reduced without affecting validity. Methods and Results A 19-item Eating Assessment Tool (EAT) of common food groups was created through literature review and expert consensus. A cross-sectional survey was then conducted in adult participants from a preventive cardiology clinic or cardiac rehabilitation and in healthy volunteers (n=661, mean age, 36 years; 76% women). Participants completed an online 156-item food frequency questionnaire, which was used to calculate the HEI score using standard methods. The association between each EAT question and HEI group was analyzed by Kruskal-Wallis test. Linear regression models were subsequently used to identify univariable and multivariable predictors for HEI score for further reduction in the number of items. The final 9-item model of Mini-EAT was validated by 5-fold cross validation. The 19-item EAT had a strong correlation with the HEI score (r=0.73) and was subsequently reduced to the 9 items independently predictive of the HEI score: fruits, vegetables, whole grains, refined grains, fish or seafood, legumes/nuts/seeds, low-fat dairy, high-fat dairy, and sweets consumption, without affecting the predictive ability of the tool (r=0.71). Conclusions Mini-EAT is a 9-item validated brief dietary screener that correlates well with a comprehensive food frequency questionnaire. Future studies to test the Mini-EAT's validity in diverse populations and for development of clinical decision support systems to capture changes over time are needed.

Reduction in Serum LDL Cholesterol Using a Nutrient Compendium in Hyperlipidemic Adults Unable or Unwilling to Use Statin Therapy: A Double-Blind Randomized Crossover Clinical Trial

BACKGROUND

Many hyperlipidemic patients prescribed β-hydroxy-β-methylglutaryl coenzyme A reductase inhibitors (statins) are unable or unwilling to take them. A hedonically acceptable snack-based solution formulated from cholesterol-lowering food ingredients could represent a therapeutic alternative but has not been tested in this population.

OBJECTIVES

To evaluate the effect of snacks containing a compendium of functional bioactives on fasting LDL cholesterol in statin candidates unwilling to use or intolerant to ≥1 statin drug. Secondary outcomes included changes in circulating total cholesterol (TC), triglycerides, HDL cholesterol, fasting glucose, insulin, and high-sensitivity C-reactive protein concentrations, as well as effects of single-nucleotide polymorphisms (SNPs) on outcome.

METHODS

This multicenter, randomized, double-blind, free-living crossover study was composed of 2 regimented phases of 4 wk each, separated by a 4-wk washout. Eighteen men and 36 women, with a mean ± SD age of 49 ± 12 y and mean ± SD LDL cholesterol of 131 ± 32.1 mg/dL,  were instructed to ingest a variety of ready-to-eat snacks twice daily as a substitute for something they were consuming already. Other behavior changes were actively discouraged. Treatment products provided ≥5 g fiber, 1000 mg ω-3 (n-3) fatty acids, 1000 mg phytosterols, and 1800 μmol antioxidants per serving. Control products were calorie-matched like-items drawn from the general grocery marketplace. Serum lipids were measured at baseline and the end of each phase and compared using the ANOVA model. Compliance to study foods was confirmed by serum 18:3n-3 concentration assessment.

RESULTS

Comparing intervention phase endpoints, LDL cholesterol was reduced a mean ± SD of 8.80 ± 1.69% (P < 0.0001), and TC was reduced a mean ± SD of 5.08 ± 1.12% (P < 0.0001) by treatment foods compared with control foods, whereas effects on other analytes did not differ between treatments. SNPs were not significantly related to outcomes (P ≥ 0.230). Compliance with study foods was 95%.

CONCLUSIONS

Consumption of hedonically acceptable snacks containing a compendium of cholesterol-lowering bioactive compounds can rapidly and meaningfully reduce LDL cholesterol in adult patients unable or unwilling to take statin drugs. This trial was registered at clinicaltrials.gov as NCT02341924.

Clinical evaluation and diagnostic yield following evaluation of abnormal pulse detected using Apple Watch

Objective

The study sought to characterize the evaluation of patients who present following detection of an abnormal pulse using Apple Watch.

Materials and Methods

We conducted a retrospective review of patients evaluated for abnormal pulse detected using Apple Watch over a 4-month period.

Results

Among 264 included patients, clinical documentation for 41 (15.5%) explicitly noted an abnormal pulse alert. Preexisting atrial fibrillation was noted in 58 (22.0%). Most commonly performed testing included 12-lead echocardiography (n = 158; 59.8%), Holter monitor (n = 77; 29.2%), and chest x-ray (n = 64; 24.2%). A clinically actionable cardiovascular diagnosis of interest was established in only 30 (11.4%) patients, including 6 of 41 (15%) patients who received an explicit alert.

Discussion

False positive screening results may lead to overutilization of healthcare resources.

Conclusions

The Food and Drug Administration and Apple should consider the unintended consequences of widespread screening for asymptomatic (“silent”) atrial fibrillation and use of the Apple Watch abnormal pulse detection functionality by populations in whom the device has not been adequately studied.

Ceramides improve atherosclerotic cardiovascular disease risk assessment beyond standard risk factors

Ceramides are bioactive lipids that act as secondary messengers for both intra- and inter-cellular signaling. Elevated plasma concentrations of ceramides are associated with multiple risk factors of atherosclerotic cardiovascular diseases and comorbidities including obesity, insulin resistance and diabetes mellitus. Furthermore, atherosclerotic plaques have been shown to be highly enriched with ceramides. Increases in ceramide content may accelerate atherosclerosis development by promoting LDL infiltration to the endothelium and aggregation within the intima of artery walls. Thus, ceramides appear to play a key role in the development of cardiometabolic disease due to their central location in major metabolic pathways that intersect lipid and glucose metabolism. Recently published data have shown that ceramides are not only of scientific interest but may also have diagnostic value. Their independent prognostic value for future cardiovascular outcomes over and above LDL cholesterol and other traditional risk factors have consistently been shown in numerous clinical studies. Thus, ceramide testing with a mass spectrometer offers a simple, reproducible and cost-effective blood test for risk stratification in atherosclerotic cardiovascular diseases.

Effect of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors on Plasma Ceramide Levels

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are novel drugs that provide striking lowering of low-density lipoprotein cholesterol (LDL-C) when added to maximum tolerated therapy in patients with hypercholesterolemia. Ceramides, novel cardiac risk markers, have been associated with increased cardiovascular mortality, independent of traditional cardiovascular risk factors. The Ceramide Risk Score (CRS) predicts the likelihood of adverse cardiovascular events within 1 to 3 years in patients with coronary artery disease. The effect of PCSK9 inhibition on plasma ceramides is not well known. The study examines the effect of PCSK9 inhibitors on plasma ceramides and CRS in patients with clinical indication for this therapy. Retrospective chart review of consecutive patients with hypercholesterolemia on PCSK9 inhibitors was conducted (n = 24; Mayo Clinic 2015 to 2018). Plasma ceramides were measured before the initiation of PCSK9 inhibitors and 2 to 12 months after treatment. CRS was calculated before and after therapy based on individual plasma concentrations of 4 ceramides. Treatment with PCSK9 inhibitors was associated with significant reduction in mean CRS and individual ceramides levels (p <0.0001). CRS significantly improved with PCSK9 therapy. PCSK9 inhibitors significantly decreased LDL-C levels by 63% (p <0.0001). The absolute reduction in CRS did not correlate with the absolute reduction in LDL-C (r = 0.31; confidence interval -0.10 to 0.64), indicating that CRS may evaluate a different pathway for risk reduction beyond LDL-C lowering. In conclusion, treatment with PCSK9 inhibitors is associated with significant reduction in CRS and distinct ceramide levels.

Cardiovascular Health and Outcomes in Cancer Patients Receiving Immune Checkpoint Inhibitors

Whether cardiovascular (CV) disease is associated with clinical outcomes in cancer patients receiving immunotherapy is unknown. We reviewed the Mayo Clinic database for all cancer patients who received an immune checkpoint inhibitor (ICI). Multivariate logistic regression analysis, survival analyses, and Cox proportional-hazards models were formulated. Between March, 2010 and July, 2019, 3,326 patients received ICI. Mean patient age was 63.5 years (range: 16 to 96 years). In a Cox proportional-hazards model, obesity (hazard ratio [HR] 0.65, 95% confidence level [CI] 0.55 to 0.77, p < 0.001) and hypercholesterolemia (HR 0.80, 95% CI 0.72 to 0.89, p < 0.001) were associated with lower all-cause mortality while hypertension (HR 1.32, 95% CI 1.17 to 1.49, p < 0.001) and smoking (HR 1.17, 95% CI 1.06 to 1.29, p = 0.002) were associated with higher overall mortality. Among patients with lung cancer, multivariable-adjusted hazard ratios for death from any cause for beta blocker users, as compared with patients who had never used a beta blocker, were 1.39 (95% CI 1.10 to 1.76, p = 0.006). A total of 80 patients (2.4%) experienced CV immune-related adverse events. Event-related morality for ICI-induced myocarditis was 41.7% (5/12). Multivariable-adjusted hazard ratios for ICI-induced myocarditis were 5.2 (95% CI 1.4 to 18.7, p = 0.01) for history of heart failure, 4.06 (95% CI 1.15 to 14.3, p = 0.03) for history of acute coronary syndrome, and 1.07 (per each 1-year increase, 95% CI 1.01 to 1.14, p = 0.02) for age. In conclusion, our study shows that CV factors are associated with clinical outcomes in cancer patients receiving ICI and could be used to predict mortality. In patients with lung cancer, pretreatment beta blocker use is associated with higher all-cause mortality. Three clinical factors-history of heart failure, history of acute coronary syndrome, and age greater than 80 years-help identify patients at higher risk of ICI-induced myocarditis who might benefit from more intensive cardiac surveillance.

Characteristics and Outcomes of Patients Treated With Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors (The Mayo Clinic Experience)

Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors represent a novel addition to the lipid-lowering armamentarium. We attempted to characterize a real-world group of patients with a clinical indication for PCSK9 inhibitors and describe their clinical outcomes and adverse effect profile. A retrospective chart review was conducted, evaluating all patients referred to preventive cardiology at the Mayo Clinic (Minnesota) between September, 2015 and December, 2018 for management of severe dyslipidemia. A total of 222 patients were referred and a recommendation to start a PCSK9 inhibitor was given to 164 patients (73.9%). Of these, 28 patients (17.1%) declined the use of a PCSK9 inhibitor. A total of 136 previous authorizations were submitted. Of these applications, 96 (70.6%) were approved and 17 (12.5%) were rejected. The cohort's mean age was 64.1 years (range 39 to 91). High-intensity statins and ezetimibe were used in 50 (52.1%) and 80 (83.3%) of the treated patients. Mean pretreatment low-density lipoprotein cholesterol was 167.9 mg/dl. At a median follow-up of 19.0 months, the mean low-density lipoprotein reduction was 60.9% (range 0 to 90.3%). Higher low-density lipoprotein cholesterol percent reductions were seen in younger patients (p value 0.048), patients on high-intensity statins (p value 0.027), those with statin intolerance (p value 0.046), and individuals with a higher baseline triglycerides (p value 0.047). Two (2.1%) patients underwent coronary revascularization, and 1 (1.0%) patient was hospitalized for unstable angina. No cardiovascular deaths occurred. Adverse events were reported in 12 (12.5%) patients, and were all minor (injection site reactions, myalgias, and flu-like illness). In conclusion, our study shows an efficacy and safety profile that is concordant with previous investigations. The use of a standardized application form was associated with a high insurance approval rate.

Cardiorespiratory Fitness and Coronary Artery Calcification in a Primary Prevention Population

Objective

To elucidate whether cardiorespiratory fitness (CRF) is protective or contributory to coronary artery disease plaque burden.

Patients and Methods

Study participants were working middle-aged men from the Mayo Clinic Executive Health Program who underwent coronary artery calcium (CAC) assessment and exercise treadmill testing for risk stratification. Data from January 1, 1995, through December 31, 2008, were considered. The CAC assessment score was used for lifelong plaque burden analysis; functional aerobic capacity (FAC) from treadmill testing was analyzed as 4 ranked categories of CRF. Known risk factors for cardiovascular disease, including family history, were also considered.

Results

In 2946 male patients in this retrospective, cross-sectional, observational study, known cardiovascular risk factor profiles and risk calculations tended to uniformly improve with increasing CRF, defined by the FAC level. Only the above-average group, or the third of 4 levels, was found consistently lower than other levels of FAC for CAC scores. The above-average group also had statistical significance after controlling for age, body mass index, and family history of coronary artery disease in a U-shaped distribution rather than the expected linear dose-response relationship. Plaque burden was significantly increased in patients with the highest FAC level (P=.005) compared with the above-average group despite the observed maximal risk factor optimization in all known conventional cardiovascular risk factors.

Conclusion

For men, maximal CRF is associated with increased atherosclerosis, established with CAC scores. By comparison, average-to-moderate CRF appears to be cardioprotective regardless of either age or the influence of other contributing, recognized cardiac risk factors.

Impact of Cardiorespiratory Fitness on Frequency of Atrial Fibrillation, Stroke, and All-Cause Mortality

Benefits of cardiorespiratory fitness on cardiovascular health are well recognized, but the impact on incidence of atrial fibrillation (AF) and stroke, and, particularly, risk of stroke and mortality in patients with AF is less clear. From 1993 to 2010, patients referred for a treadmill exercise test (TMET) at the Mayo Clinic Rochester, MN, were retrospectively identified (N = 76,857). From this, 14,094 local residents were selected. Exclusions were age <18 years; history of heart failure, structural or valvular heart disease, AF or flutter, or stroke. Subjects were divided into 4 groups at baseline based on quartiles of functional aerobic capacity (FAC) and followed through January 2016. The final study cohort included 12,043 patients. During median follow-up of 14 (9 to 17) years, 1,222 patients developed incident AF, 1,128 developed stroke, and 1,590 patients died. Each 10% increase in FAC was associated with decreased risk of incident AF, stroke, and mortality by 7% (0.93 [0.91 to 0.96, p < 0.001]), 8% (0.92 [0.89 to 0.94, p < 0.001]), and 16% (0.84 [0.82 to 0.86, p < 0.001]), respectively. In patients who developed incident AF with baseline FAC <75% versus ≥105%, risks of both stroke (1.40 [1.04 to 1.90, p = 0.01]) and mortality (3.20 [2.11 to 4.58, p < 0.001]) were significantly higher. In conclusion, better cardiorespiratory fitness is associated with lower risk of incident AF, stroke, and mortality. Similarly, risk of stroke and mortality in patients with AF is also inversely associated with cardiorespiratory fitness.

Genetic variation in statin intolerance and a possible protective role for UGT1A1

The etiology of statin intolerance is hypothesized to be due to genetic variants that impact statin disposition and clearance. We sought to determine whether genetic variants were associated to statin intolerance. The studied cohort consisted of hyperlipidemic participants (n = 90) clinically diagnosed with statin intolerance by a cardiologist and matched controls without statin intolerance. Creatine kinase activity, lipid profiles and genetic analyses were performed on genes involved in statin metabolism and included UGT1A1 and UGT1A3 sequencing and targeted analyses of CYP3A4*22, CYP3A5*3, SLCO1B1*5 and *1b, ABCB1 c.3435C>T, ABCG2 c.421C>A and GATM rs9806699. Although lipids were higher in cases, genetic variant minor allele frequencies were similar between cases and controls, except for UGT1A1*28, which was less prevalent in cases than controls.

Contemporary Primary Prevention Aspirin Use by Cardiovascular Disease Risk: Impact of US Preventive Services Task Force Recommendations, 2007-2015: A Serial, Cross-sectional Study

BACKGROUND

No previous study has evaluated the impact of past US Preventive Services Task Force statements on primary prevention (PP) aspirin use in a primary care setting. The aim of this study was to evaluate temporal changes in PP aspirin use in a primary care population, stratifying patients by their 10-year global cardiovascular disease risk, in response to the 2009 statement.

METHODS AND RESULTS

This study estimated biannual aspirin use prevalence using electronic health record data from primary care clinics within the Fairview Health System (Minnesota) from 2007 to 2015. A total of 94 270 patient encounters had complete data to estimate a 10-year cardiovascular disease risk score using the 2013 American College of Cardiology/American Heart Association global risk estimator. Patients were stratified into low- (<10%), intermediate- (10-20%), and high- (≥20%) risk groups. Over the 9-year period, PP aspirin use averaged 43%. When stratified by low, intermediate and high risk, average PP aspirin use was 41%, 63%, and 73%, respectively. Average PP aspirin use decreased after the publication of the 2009 US Preventive Services Task Force recommendation statement: from 45% to 40% in the low-risk group; from 66% to 62% in the intermediate-risk group; and from 76% to 73% in the high-risk group, before and after the guideline.

CONCLUSIONS

Publication of the 2009 US Preventive Services Task Force recommendation was not associated with an increase in aspirin use. High risk PP patients utilized aspirin at high rates. Patients at intermediate risk were less intensively treated, and patients at low risk used aspirin at relatively high rates. These data may inform future aspirin guideline dissemination.

No decline in the risk of heart failure after incident atrial fibrillation: A community study assessing trends overall and by ejection fraction

BACKGROUND

Patients with atrial fibrillation (AF) experience an increased risk of heart failure (HF). However, data are lacking on current trends in the risk of HF after AF.

OBJECTIVE

The purpose of this study was to describe the temporal trends in HF occurrence after AF in a community cohort of patients with incident AF from 2000 to 2013.

METHODS

Cox regression was used to examine the association of year of AF diagnosis with HF and the predictors of developing HF after AF.

RESULTS

Among 3491 AF patients without prior HF, 750 (21%) developed incident HF over mean follow-up of 3.7 years. Among those with an echocardiogram, 422 (61%) had HF with preserved ejection fraction (HFpEF), and 270 (39%) had HF with reduced ejection fraction (HFrEF). After adjusting for demographics and comorbidities, the risk of developing HF did not change over time (hazard ratio [HR] (95% confidence interval [CI]) per year of AF diagnosis: 1.01 (0.98-1.03) overall; 1.00 (0.98-1.03) for HFpEF; 1.00 (0.96-1.03) for HFrEF). Increasing age, obesity, smoking, diabetes, chronic pulmonary disease, and renal disease were predictors of developing HF. Compared to the Olmsted County, Minnesota, population, a substantial excess risk of developing HF was observed after AF diagnosis [standardized morbidity ratio (95% CI): 9.60 (7.44-12.19), 2.13 (1.56-2.84), and 1.70 (1.34-2.14) at 90 days, 1 year, and 3 years after diagnosis].

CONCLUSION

In the community, HF is a frequent adverse outcome among patients with AF, and HFpEF is more common than HFrEF. The rates of HF after AF have not declined, thus highlighting the importance of continued efforts to improve outcomes in AF.

Lack of Evidence Linking Calcium With or Without Vitamin D Supplementation to Cardiovascular Disease in Generally Healthy Adults: A Clinical Guideline From the National Osteoporosis Foundation and the American Society for Preventive Cardiology

DESCRIPTION

Calcium is the dominant mineral present in bone and a shortfall nutrient in the American diet. Supplements have been recommended for persons who do not consume adequate calcium from their diet as a standard strategy for the prevention of osteoporosis and related fractures. Whether calcium with or without vitamin D supplementation is beneficial or detrimental to vascular health is not known.

METHODS

The National Osteoporosis Foundation and American Society for Preventive Cardiology convened an expert panel to evaluate the effects of dietary and supplemental calcium on cardiovascular disease based on the existing peer-reviewed scientific literature. The panel considered the findings of the accompanying updated evidence report provided by an independent evidence review team at Tufts University.

RECOMMENDATION

The National Osteoporosis Foundation and American Society for Preventive Cardiology adopt the position that there is moderate-quality evidence (B level) that calcium with or without vitamin D intake from food or supplements has no relationship (beneficial or harmful) to the risk for cardiovascular and cerebrovascular disease, mortality, or all-cause mortality in generally healthy adults at this time. In light of the evidence available to date, calcium intake from food and supplements that does not exceed the tolerable upper level of intake (defined by the National Academy of Medicine as 2000 to 2500 mg/d) should be considered safe from a cardiovascular standpoint.

Non-ischemic cardiomyopathy after rituximab treatment for membranous nephropathy

Rituximab is an anti-CD20 monoclonal antibody frequently used for the treatment of non-Hodgkin's lymphoma, chronic lymphocytic leukemia (CLL), rheumatoid arthritis (RA), and anti-neutrophilic cytoplasmic antibody (ANCA)-associated vasculitis. In addition, rituximab has recently been increasingly used as an off-label treatment in a number of inflammatory and systemic autoimmune diseases. It is advised that rituximab infusion may cause infusion reactions and adverse cardiac effects including arrhythmia and angina, especially in patients with prior history of cardiovascular diseases. However, its detailed cardiotoxicity profile and effects on cardiac function were not well described. We report a 51-year-old man who developed non-ischemic cardiomyopathy after rituximab treatment for membranous nephropathy. The patient experienced reduced cardiac functions within 48 hours after the initial infusion, which remained markedly reduced at 9-month follow-up. As the utility of rituximab expands, physicians must be aware of this serious cardiovascular adverse effect.

Side Effects of CV Medications Following Hospitalization for ACS Are Associated With More Frequent Health-Care Contacts

Background:

Patients hospitalized for first acute coronary syndrome (ACS) are frequently discharged on multiple new medications. The short-term tolerability of these medications is unknown.

Methods:

This single-center cohort study assessed 30-day health-care utilization and how it may be impacted by medication prescribing trends. We included Olmsted County patients presenting with ACS and previously undiagnosed coronary artery disease in 2008 to 2009. All health-care contacts were reviewed 30 days after index hospital discharge for potential adverse medication effects including documented hypotension or bradycardia, or symptoms likely attributed to the medications.

Results:

The study included 86 patients; their mean age was 63 (standard deviation: 15.5 years). Antianginal or antihypertensive cardiovascular (CV) medications were prescribed to 98% of patients at discharge; 76% were prescribed 2 or more. There were 233 health-care contacts in 30 days; 90 (39%) of these contacts were unscheduled. More CV medications tended to be prescribed to patients with unscheduled contacts, both pre-ACS ( P = .045) and upon hospital discharge ( P = .051). Hypotension and/or bradycardia at follow-up occurred in 52 patients (60%). Surprisingly, there was no association between hypotension and/or bradycardia at follow-up and increased health-care utilization ( P = .12). Potential adverse drug effects were reported in 34 (40%) patients. These patients had significantly more total health-care contacts ( P < .001) and unscheduled health-care contacts (median 0 vs 1.5; P < .001).

Conclusions:

Symptoms of adverse drug effects were associated with more frequent health-care utilization after ACS. Clinicians need to consider this while striving to increase patient compliance with post-ACS medications and optimize care transitions.

Comparative Trends and Downstream Outcomes of Coronary Computed Tomography Angiography and Cardiac Stress Testing in Emergency Department Patients With Chest Pain: An Administrative Claims Analysis

OBJECTIVES

Coronary computerized tomography angiography (CCTA) is a rapidly emerging technology for the evaluation of chest pain in the emergency department (ED). We assessed trends in CCTA use and compared downstream healthcare utilization between CCTA and cardiac stress testing modalities.

METHODS

Using administrative claims data (Optum Labs Data Warehouse) from over 100 million geographically diverse privately insured and Medicare Advantage enrollees across the United States, we identified 2,047,799 ED patients from January 2006 to December 2013 who presented with chest pain and had a CCTA or cardiac stress test within 72 hours. Cohorts were established based on CCTA or functional stress testing (myocardial perfusion scintigraphy [MPS], stress echocardiogram [SE], or treadmill exercise electrocardiogram [TMET]) performed within 72 hours of the ED visit. We tracked subsequent invasive cardiac procedures (invasive coronary angiography [ICA], percutaneous coronary intervention [PCI], and coronary artery bypass grafting [CABG]), repeat noninvasive testing, return ED visits, hospitalization, and the rate of acute myocardial infarction (AMI) within 30 days. We used propensity-score matching to adjust for coronary artery disease (CAD) risk factors, Charlson-Deyo comorbidity index, and baseline differences between patients selected for CCTA or cardiac stress testing. Logistic regression was used to measure adjusted associations between testing modality and outcomes.

RESULTS

During the study period, CCTA use increased from 0.8% to 4.5% of all cardiac testing within 72 hours, a change of 434% (p-value for trend < 0.001), while rates of other cardiac stress testing modalities decreased (-22% for TMET [p < 0.001]; -11% for SE [p = 0.11]; -6% for MPS [p = 0.04]. After matching, there was no difference in the 30-day rate of AMI between testing modalities. Compared to MPS, CCTA was associated with higher rates of PCI (odds ratio [OR] = 1.25, 95% confidence interval [CI] = 1.04 to 1.51), and CABG (OR = 1.47; 95% CI = 1.03 to 2.13). Compared to SE and treadmill stress testing, CCTA was associated with more invasive procedures, hospitalizations, return ED visits, and repeat noninvasive testing.

CONCLUSIONS

CCTA use increased fourfold during the study period and was associated with higher rates of PCI, CABG, repeat noninvasive testing, hospitalization, and return ED visits. The authors have no relevant financial information or potential conflicts to disclose.

Impact of an Emergency Department Observation Unit Management Algorithm for Atrial Fibrillation

Background

Atrial fibrillation (AF) is a common, growing, and costly medical condition. We aimed to evaluate the impact of a management algorithm for symptomatic AF that used an emergency department observation unit on hospital admission rates and patient outcomes.

Methods and Results

This retrospective cohort study compared 563 patients who presented consecutively in the year after implementation of the algorithm, from July 2013 through June 2014 (intervention group), with 627 patients in a historical cohort (preintervention group) who presented consecutively from July 2011 through June 2012. All patients who consented to have their records used for chart review were included if they had a primary final emergency department diagnosis of AF. We observed no significant differences in age, sex, vital signs, body mass index, or CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke or transient ischemic attack) score between the preintervention and intervention groups. The rate of inpatient admission was significantly lower in the intervention group (from 45% to 36%; P<0.001). The groups were not significantly different with regard to rates of return emergency department visits (19% versus 17%; P=0.48), hospitalization (18% versus 16%; P=0.22), or adverse events (2% versus 2%; P=0.95) within 30 days. Emergency department observation unit admissions were 40% (P<0.001) less costly than inpatient hospital admissions of ≤1 day's duration.

Conclusions

Implementation of an emergency department observation unit AF algorithm was associated with significantly decreased hospital admissions without increasing the rates of return emergency department visits, hospitalization, or adverse events within 30 days.

Efficacy and safety of alirocumab vs ezetimibe in statin-intolerant patients, with a statin rechallenge arm: The ODYSSEY ALTERNATIVE randomized trial

BACKGROUND

Statin intolerance limits many patients from achieving optimal low-density lipoprotein cholesterol (LDL-C) concentrations. Current options for such patients include using a lower but tolerated dose of a statin and adding or switching to ezetimibe or other non-statin therapies.

METHODS

ODYSSEY ALTERNATIVE (NCT01709513) compared alirocumab with ezetimibe in patients at moderate to high cardiovascular risk with statin intolerance (unable to tolerate ≥2 statins, including one at the lowest approved starting dose) due to muscle symptoms. A placebo run-in and statin rechallenge arm were included in an attempt to confirm intolerance. Patients (n = 361) received single-blind subcutaneous (SC) and oral placebo for 4 weeks during placebo run-in. Patients reporting muscle-related symptoms during the run-in were to be withdrawn. Continuing patients were randomized (2:2:1) to double-blind alirocumab 75 mg SC every 2 weeks (Q2W; plus oral placebo), ezetimibe 10 mg/d (plus SC placebo Q2W), or atorvastatin 20 mg/d (rechallenge; plus SC placebo Q2W) for 24 weeks. Alirocumab dose was increased to 150 mg Q2W at week 12 depending on week 8 LDL-C values. Primary end point was percent change in LDL-C from baseline to week 24 (intent-to-treat) for alirocumab vs ezetimibe.

RESULTS

Baseline mean (standard deviation) LDL-C was 191.3 (69.3) mg/dL (5.0 [1.8] mmol/L). Alirocumab reduced mean (standard error) LDL-C by 45.0% (2.2%) vs 14.6% (2.2%) with ezetimibe (mean difference 30.4% [3.1%], P < .0001). Skeletal muscle-related events were less frequent with alirocumab vs atorvastatin (hazard ratio 0.61, 95% confidence interval 0.38-0.99, P = .042).

CONCLUSIONS

Alirocumab produced greater LDL-C reductions than ezetimibe in statin-intolerant patients, with fewer skeletal-muscle adverse events vs atorvastatin.

Pathways Forward in Cardiovascular Disease Prevention One and a Half Years After Publication of the 2013 ACC/AHA Cardiovascular Disease Prevention Guidelines

The 2013 American College of Cardiology/American Heart Association cardiovascular disease prevention guidelines represent an important step forward in the risk assessment and management of atherosclerotic cardiovascular disease in clinical practice. Differentiated risk prediction equations for women and black individuals were developed, and convenient 10-year and lifetime risk assessment tools were provided, facilitating their implementation. Lifestyle modification was portrayed as the foundation of preventive therapy. In addition, based on high-quality evidence from randomized controlled trials, statins were prioritized as the first lipid-lowering pharmacologic treatment, and a shared decision-making model between the physician and the patient was emphasized as a key feature of personalized care. After publication of the guidelines, however, important limitations were also identified. This resulted in a constructive scientific debate yielding valuable insights into potential opportunities to refine recommendations, fill gaps in guidance, and better harmonize recommendations within and outside the United States. The latter point deserves emphasis because when guidelines are in disagreement, this may result in nonaction on the part of professional caregivers or nonadherence by patients. In this review, we discuss the key scientific literature relevant to the guidelines published in the year and a half after their release. We aim to provide cohesive, evidence-based views that may offer pathways forward in cardiovascular disease prevention toward greater consensus and benefit the practice of clinical medicine.

Phosphodiesterase 5 Inhibitor Use in Men With Hypertrophic Cardiomyopathy

The prevalence of sexual dysfunction (SD) in men with hypertrophic cardiomyopathy (HC) remains unknown, yet its clinical relevance may be high given that its treatment-phosphodiesterase 5 inhibitors (PDE5i)-can increase the left ventricular outflow tract pressure gradient. In this retrospective study, we evaluated the medical records of consecutively seen men with HC for the evidence of SD (defined as SD diagnosis noted in the medical record, the use of medications unique for SD, or SD reported by the patient on a routine clinical questionnaire). Of the 283 consecutively seen men with HC (mean age 52.9 ± 14.1 years), 63 patients (22%) with SD were identified. Of those with SD, 38% were recorded as regularly using PDE5i. In conclusion, SD and the use of PDE5i present a relatively common occurrence in men with HC, and further studies are needed to develop an evidence-guided algorithm for safe implementation of SD therapies in this most common inherited cardiomyopathy.

An assessment by the Statin Muscle Safety Task Force: 2014 update

The National Lipid Association's Muscle Safety Expert Panel was charged with the duty of examining the definitions for statin-associated muscle adverse events, development of a clinical index to assess myalgia, and the use of diagnostic neuromuscular studies to investigate muscle adverse events. We provide guidance as to when a patient should be considered for referral to neuromuscular specialists and indications for the performance of a skeletal muscle biopsy. Based on this review of evidence, we developed an algorithm for the evaluation and treatment of patients who may be intolerant to statins as the result of adverse muscle events. The panel was composed of clinical cardiologists, clinical lipidologists, an exercise physiologist, and a neuromuscular specialist.

A perspective on the New American College of Cardiology/American Heart Association guidelines for cardiovascular risk assessment

The recently published American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for cardiovascular risk assessment provide equations to estimate the 10-year and lifetime atherosclerotic cardiovascular disease (ASCVD) risk in African Americans and non-Hispanic whites, include stroke as an adverse cardiovascular outcome, and emphasize shared decision making. The guidelines provide a valuable framework that can be adapted on the basis of clinical judgment and individual/institutional expertise. In this review, we provide a perspective on the new guidelines, highlighting what is new, what is controversial, and potential adaptations. We recommend obtaining family history of ASCVD at the time of estimating ASCVD risk and consideration of imaging to assess subclinical disease burden in patients at intermediate risk. In addition to the adjuncts for ASCVD risk estimation recommended in the guidelines, measures that may be useful in refining risk estimates include carotid ultrasonography, aortic pulse wave velocity, and serum lipoprotein(a) levels. Finally, we stress the need for research efforts to improve assessment of ASCVD risk given the suboptimal performance of available risk algorithms and suggest potential future directions in this regard.

A summary and critical assessment of the 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults: filling the gaps

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines has recently released the new cholesterol treatment guideline. This update was based on a systematic review of the evidence and replaces the previous guidelines from 2002 that were widely accepted and implemented in clinical practice. The new cholesterol treatment guideline emphasizes matching the intensity of statin treatment to the level of atherosclerotic cardiovascular disease (ASCVD) risk and replaces the old paradigm of pursuing low-density lipoprotein cholesterol targets. The new guideline also emphasizes the primacy of the evidence base for statin therapy for ASCVD risk reduction and lists several patient groups that will not benefit from statin treatment despite their high cardiovascular risk, such as those with heart failure (New York Heart Association class II-IV) and patients undergoing hemodialysis. The guideline has been received with mixed reviews and significant controversy. Because of the evidence-based nature of the guideline, there is room for several questions and uncertainties on when and how to use lipid-lowering therapy in clinical practice. The goal of the Mayo Clinic Task Force in the assessment, interpretation, and expansion of the ACC/AHA cholesterol treatment guideline is to address gaps in information and some of the controversial aspects of the newly released cholesterol management guideline using additional sources of evidence and expert opinion as needed to guide clinicians on key aspects of ASCVD risk reduction.

Echocardiographic determinants of peak aerobic capacity and breathing efficiency in patients with undifferentiated dyspnea

Diastolic function and E/e' correlate with peak aerobic capacity (VO2) in patients with heart failure, but the echocardiographic correlates of abnormal gas exchange in patients without heart failure are not well defined. We sought to determine the echocardiographic correlates of peak VO2 and breathing efficiency (estimated using the ratio of minute ventilation to carbon dioxide production, or VE/VCO2 nadir) in patients with unexplained dyspnea. We identified 232 patients with unexplained dyspnea who underwent echocardiography at rest followed by stress echocardiography with simultaneous measurement of peak VO2 and VE/VCO2 nadir. At baseline, 17 patients (5%) had an E/e' of ≥15 while 31 patients (17%) had a right ventricular systolic pressure (RVSP) of >35 mm Hg. E/e' ≥15 and RVSP >35 mm Hg were associated with lower peak VO2 (14.1 ± 4.4 vs 21.0 ± 6.9 and 15.2 ± 3.6 vs 21.8 ± 6.8 ml/kg/min, respectively, p <0.0001). E/e' ≥15 (sensitivity 0.13, specificity 0.99, area under the curve 0.64) and RVSP >35 mm Hg (sensitivity 0.38, specificity 0.93, area under the curve 0.76) were highly specific for predicting limited peak VO2. Age and RVSP at rest were independent correlates with VE/VCO2, but diastolic function was not. However, the risk of having abnormal VE/VCO2 nadir was only elevated in subjects with elevated RVSP in the setting of abnormal diastolic function (hazard ratio 2.4, 95% confidence interval 1.3 to 4.6, p = 0.02). In conclusion, both E/e' ≥15 and RVSP >35 mm Hg are highly specific markers of exercise limitation in patients without heart failure, but RVSP at rest may offer better overall diagnostic power than E/e' to predict low peak VO2 in this group.

Cardiopulmonary fitness and heart rate recovery as predictors of mortality in a referral population

BACKGROUND

Exercise testing provides valuable information in addition to ST-segment changes. The present study evaluated the associations among exercise test parameters and all-cause mortality in a referral population.

METHODS AND RESULTS

We examined conventional cardiovascular risk factors and exercise test parameters in 6546 individuals (mean age 49 years, 58% men) with no known cardiovascular disease who were referred to our clinic for exercise stress testing between 1993 and 2003. The association of exercise parameters with mortality was assessed during a follow-up of 8.1±3.7 years. A total of 285 patients died during the follow-up period. Adjusting for age and sex, the variables associated with mortality were: smoking, diabetes, functional aerobic capacity (FAC), heart rate recovery (HRR), chronotropic incompetence, and angina during the exercise. Adjusting for cardiovascular risk factors (diabetes, smoking, body mass index, blood pressure, serum total, HDL, LDL cholesterol, and triglycerides) and other exercise variables in a multivariable model, the only exercise parameters independently associated with mortality were lower FAC (adjusted hazard ratio [HR] per 10% decrease in FAC, 1.21; 95% confidence interval [CI], 1.13 to 1.29; P<0.001), and abnormal HRR, defined as failure to decrease heart rate by 12 beats at 1 minute recovery (adjusted HR per 1-beat decrease, 1.05; 95% CI, 1.03 to 1.07; P<0.001). The additive effects of FAC and HRR on mortality were also highly significant when considered as categorical variables.

CONCLUSION

In this cohort of patients with no known cardiovascular disease who were referred for exercise electrocardiography, FAC and HRR were independently associated with all-cause mortality.

Use of functional aerobic capacity based on stress testing to predict outcomes in normal, overweight, and obese patients

OBJECTIVE

To determine the poorly studied relationship between functional aerobic capacity (FAC) as measured by treadmill stress testing and mortality in normal, overweight, and obese patients.

PATIENTS AND METHODS

Patients were identified retrospectively from the stress testing database at Mayo Clinic in Rochester, Minnesota. We selected 5328 male nonsmokers (mean ± SD age, 51.8±11.5 years) without baseline cardiovascular disease who were referred for treadmill exercise testing between January 1, 1986, and December 31, 1991, and classified them by body mass index (BMI) into normal-weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), and obese (≥30 kg/m(2)) categories. Functional aerobic capacity was assessed by maximal exercise test results based on age- and sex-specific metabolic equivalents, and patients were stratified into fitness quintiles. Cox proportional hazards analysis was used to determine the relationship of all-cause mortality to fitness in each BMI category.

RESULTS

There were 322 deaths during 14 years of follow-up. After adjustment for age and exercise confounders, FAC predicted mortality in the 3 BMI groups. Hazard ratios for FAC less than 80% of predicted vs a reference group with normal BMI and fitness (FAC ≥100%) were 1.754 (95% CI, 0.874-3.522), 1.962 (1.356-2.837), and 1.518 (1.056-2.182) for the normal, overweight, and obese groups, respectively. The CIs of the hazard ratios overlapped with no statistically significant differences (P>.05).

CONCLUSION

A significant increase in mortality occurs with FAC below 80% of predicted for overweight and obese subjects and below 70% for normal weight subjects. Our results suggest that clinicians need not adjust the standard for low fitness in obese patients.

Questions and answers on proper peri-operative management of antiplatelet therapy after coronary stent implantation to prevent stent thrombosis

Stent thrombosis (ST) is a rare but life-threatening complication of coronary artery stenting. Although dual-antiplatelet therapy is an effective management strategy in reducing the risk for ST, some patients may need to interrupt their regimens because of unforeseen circumstances, such as the requirement for surgery. In conclusion, this case presentation highlights some pertinent issues related to ST, including its risk factors, the perioperative management of antiplatelet agents, and treatment for ST.

Safety of symptom-limited cardiopulmonary exercise testing in patients with aortic stenosis

BACKGROUND

There are no published data on the safety of cardiopulmonary exercise testing in patients with aortic stenosis.

METHODS

In this retrospective descriptive study, we examined 347 consecutive patients with aortic stenosis who underwent cardiopulmonary exercise testing at a tertiary referral center. We recorded major events including death, nonfatal major events (cardiac arrest, symptomatic or sustained ventricular or supraventricular tachycardia, myocardial infarction, and syncope), and minor events such as hypotension, nonsustained supraventricular and ventricular arrhythmias, positive electrocardiographic changes, and angina.

RESULTS

Of 347 patients, 65 (19%) had mild, 145 (42%) had moderate, and 137 (40%) had severe aortic stenosis by echocardiographic criteria. No major events occurred during the tests. Minor events occurred in a total of 97 patients (28%), including 10 patients who developed supraventricular arrhythmias without hypotension; and one who had asymptomatic nonsustained ventricular tachycardia.

CONCLUSION

Symptom-limited cardiopulmonary exercise testing in cardiology-referred patients with aortic stenosis with preserved systolic function appears to be associated with very low risk of major adverse cardiovascular events during testing.

Abstract P278: Safety of Symptom-Limited Cardiopulmonary Exercise Testing in Asymptomatic Patients With Aortic Stenosis

Background: We conducted this study to assess the safety of symptom-limited cardiopulmonary exercise testing (CPX) in patients with varying severity of aortic stenosis (AS). We hypothesized that exercise testing would be safe, as defined by a rates for all-cause death of <0.01% and rate of nonfatal major cardiovascular (CV) events <0.1% within 24 hours of CPX. Secondary purpose of this study was to determine the frequency of complications during CPX.

Methods: This cohort study was carried out with 308 consecutive patients with varying degree of AS (as determined by standard echocardiographic criteria) with no or equivocal symptoms who were referred for clinically indicated cardiopulmonary testing between 1994 and 2009. We did not include patients with pending or completed heart transplant, or ventricular assist device implantation. These patients underwent standard symptom limited CPX, and continuous monitoring of heart rate, blood pressure, and electrocardiogram was performed. Complications recorded included death, non-fatal major CV events (cardiac arrest, symptomatic and sustained ventricular or atrial tachycardia, and syncope), and minor events such as hypotension, non-sustained atrial and ventricular arrhythmias, positive exercise ECG and anginal pain.

Results: The mean age of patients was 66 ± 14 years, and 252 (82%) were males. The number of patients with mild, moderate and severe AS were 44 (14%), 138 (49%), and 126 (41%) respectively. No death or major CV event occurred during or within 24 hours of CPX. Eleven patients developed supraventricular arrhythmias without compromising hemodynamic status, and one had asymptomatic non-sustained ventricular tachycardia. Detailed description of complications is presented in the Table 1 .

Conclusion: Our results show that symptom-limited CPX is safe among AS patients with no or equivocal symptoms based on no deaths or major CV events in our cohort. Minor complications occurred in 110 patients (36%).

Table 1 Mild AS (n=44) Moderate AS (n=138) Severe AS (n=126) Age 61.7 ± 15.3 66.5 ± 13.86 67.89 ± 12.74 Males 36 (81%) 128 (83%) 96 (85%) Test protocol O2 protocol 39 (86%) 123 (89%) 104 (82%) Other 5 15 22 Reason for termination Symptom-limited 41 (93%) 114 (82%) 96 (76%) Other 3 24 30 Chest pain None 41 (93%) 122 (88%) 117 (93%) Non-cardiac 0 2 0 Non-anginal 0 2 0 Anginal 2 14 9 Treadmill ECG interpretation Negative 27 (61%) 67 (49%) 45 (37%) Non-diagnostic 14 48 58 Positive 3 23 23 Ventricular arrhythmia None 42 (95%) 134 (97%) 122 (97%) 3-5 beats VT 2 3 4 NSVT 0 1 0 Supraventricular arrhythmia None 42 (95%) 135 (97%) 120 (95%) SVT ≤ 30 sec 2 3 4 SVT > 30 sec 0 0 1 Afib 0 0 1 BP response Normal 41 (93%) 117 (85%) 93 (74%) Hypotensive 3 21 33

Abstract P137: Recognition of Cardiovascular Risk Factors and Implementation of Primary Prevention Interventions with Utilization of an On-Line Form

Purpose: Awareness, documentation and management of Cardiovascular Risk Factors (CVRF) are measures of quality of care in primary and secondary prevention of Cardiovascular Disease (CVD). We measured the recognition, documentation and management of CVRF in patients at a preventive cardiology clinic with the use of a standardized on-line form.

Background and Methods: An on-line “Risk Profile Form” was created by the Cardiovascular Health Clinic at the Mayo Clinic. The form automatically populates height, weight, laboratory values including lipids, fasting blood glucose, novel risk factors, and results of cardiac stress testing. Clinicians enter information on hypertension, diabetes, smoking, family history, depression, self-reported stress level, quality of life, diet and physical activity. The form uses computerized algorithms to calculate BMI, identify metabolic syndrome, calculate Framingham Risk Score, and generate recommendations for exercise, diet, and other aspects of CV prevention. The form is reviewed with the patient and added to the medical record in addition to the consultation note. We assessed a random sample of 210 preventive cardiology consultations for 2007, 2008 and 2009 and compared the recognition, documentation and management of CVRF in patients in whom the form was and was not used.

Results: The “Risk Profile Form” was used for 92 of the 210 patient encounters reviewed. Detailed results are reported in Table 1 .

Conclusions: Use of a simple, standardized on-line form with incorporated computerized algorithms improves identification, documentation and management of CVRF and total CVD risk.

Table 1:

The effect of lifestyle modification and cardiovascular risk factor reduction on erectile dysfunction: a systematic review and meta-analysis

BACKGROUND

Erectile dysfunction (ED) shares similar modifiable risks factors with coronary artery disease (CAD). Lifestyle modification that targets CAD risk factors may also lead to improvement in ED. We conducted a systematic review and meta-analysis of randomized controlled trials evaluating the effect of lifestyle interventions and pharmacotherapy for cardiovascular (CV) risk factors on the severity of ED.

METHODS

A comprehensive search of multiple electronic databases through August 2010 was conducted using predefined criteria. We included randomized controlled clinical trials with follow-up of at least 6 weeks of lifestyle modification intervention or pharmacotherapy for CV risk factor reduction. Studies were selected by 2 independent reviewers. The main outcome measure of the study is the weighted mean differences in the International Index of Erectile Dysfunction (IIEF-5) score with 95% confidence intervals (CIs) using a random effects model.

RESULTS

A total of 740 participants from 6 clinical trials in 4 countries were identified. Lifestyle modifications and pharmacotherapy for CV risk factors were associated with statistically significant improvement in sexual function (IIEF-5 score): weighted mean difference, 2.66 (95% CI, 1.86-3.47). If the trials with statin intervention (n = 143) are excluded, the remaining 4 trials of lifestyle modification interventions (n = 597) demonstrate statistically significant improvement in sexual function: weighted mean difference, 2.40 (95% CI, 1.19-3.61).

CONCLUSION

The results of our study further strengthen the evidence that lifestyle modification and pharmacotherapy for CV risk factors are effective in improving sexual function in men with ED.

Exercise DVD improves exercise expectations in cardiovascular outpatients

OBJECTIVE

To assess impact of exercise education intervention on exercise frequency and attitudes.

METHODS

Cardiovascular outpatients (N=509) were randomized to receive an education DVD or standard care. Outcome measures (baseline and 6 weeks) assessed exercise frequency and cognitive variables.

RESULTS

There was no difference between groups on exercise frequency change from baseline, but DVD group reported greater exercise outcome expectations than control group (P=0.01). There was a greater increase in relapse-prevention behavior in the DVD group, compared to control, for those with low relapse-prevention behavior at baseline (P=0.02).

CONCLUSION

A minimal intervention improves outcome expectations for exercise.

Impact of ezetimibe on atherosclerosis: is the jury still out?

Ezetimibe is a new lipid-lowering agent that inhibits intestinal absorption of dietary cholesterol. It substantially lowers low-density lipoprotein cholesterol levels when used alone or in combination with statins. However, its effect on cardiovascular mortality remains unknown. We reviewed peer-reviewed published literature on the effect of ezetimibe on different phases of atherosclerosis. MEDLINE, EMBASE, BIOSIS, and other Web of Knowledge databases were searched for relevant abstracts and articles published in the English language that compared ezetimibe and statins as modulators of atherosclerosis. On the basis of the available evidence, ezetimibe appears to reduce inflammation when used in combination with statins, but its effect on endothelial function is mixed and less clear. The effect of ezetimibe on coronary disease progression or prevention of cardiovascular events is currently unknown. Use of ezetimibe as a second- or third-line agent to achieve low-density lipoprotein cholesterol treatment goals seems appropriate on the basis of the available evidence.

Improved survival after acute myocardial infarction in patients with advanced Killip class

BACKGROUND

The continuing applicability of the Killip classification system to the effective stratification of long-term and short-term outcome in patients with acute myocardial infarction (MI) and its influence on treatment strategy calls for reanalysis in the setting of today's primary reperfusion treatments.

HYPOTHESIS

Our study sought to test the hypothesis that Killip classification, established on admission in patients with acute MI, is an effective tool for early prediction of in-hospital mortality and long-term survival.

METHODS

A series of 909 consecutive Olmsted County patients admitted with acute MI to St. Marys Hospital, Mayo Clinic, between January 1988 and March 1998 was analyzed. Killip classification was the primary variable. Endpoints were in-hospital death, major in-hospital complications, and post-hospital death.

RESULTS

Patients analyzed included 714 classified as Killip I, 170 classified as Killip II/III, and 25 classified as Killip IV. Increases in in-hospital mortality and prevalence of in-hospital complications correspond significantly with advanced Killip class (p < 0.01), with in-hospital mortality 7% in class I, 17.6% in classes II/III, and 36% in class IV patients (p < 0.001). Killip classification was strongly associated with mode of therapy administered within 24 h of admission (p < 0.01). Killip IV patients underwent primary angioplasty most commonly and were less likely to receive medical therapy.

CONCLUSIONS

Killip classification remains a strong independent predictor of in-hospital mortality and complications, and of long-term survival. Early primary angioplasty has contributed to a decrease in mortality in Killip IV patients, but effective adjunctive medical therapy is underutilized.

Obesity is associated with premature occurrence of acute myocardial infarction

BACKGROUND

The American Heart Association has classified obesity as a major modifiable risk factor for coronary artery disease, but its relationship with age at presentation with acute myocardial infarction (AMI) is poorly documented.

HYPOTHESIS

The study was undertaken to evaluate the impact of obesity on age at presentation, and on in-hospital morbidity and mortality in patients with AMI.

METHODS

Our analysis includes a consecutive series of 906 Olmsted County patients (mean age 67.7 years, 51% male) admitted with AMI to the Mayo Clinic Coronary Care Unit (CCU). The patients were entered into the Mayo CCU Database, a prospective registry of data pertaining to patients admitted to the Mayo Clinic CCU with AMI. Age at AMI occurrence and in-hospital morbidity and mortality were noted.

RESULTS

Obese patients (body mass index [BMI] >30) with AMI were significantly younger than patients with AMI in the overweight (BMI 25-30) and normal-weight (BMI < 30) groups (62.3+/-13.1 vs. 66.9+/-13.2 and 72.9+/-13.4, respectively. p < 0.001). Obesity and overweight status were associated with male gender, diabetes mellitus, hypercholesterolemia, and smoking history; however, after multivariate adjustment for these risk factors, excess weight and premature AMI remained significantly associated. Compared with normal-weight patients, overweight patients presenting with AMI were 3.6 years younger (p < 0.001, confidence interval [CI] 1.9-5.4) and obese patients 8.2 years younger (p < 0.001, Cl 6.2-10.1). No significant increase in in-hospital morbidity and mortality was seen.

CONCLUSION

In this population-based study, overweight and obese status are independently associated with the premature occurrence of AMI, but not with an increased incidence of in-hospital complications.

Long-term mortality with multiple treadmill exercise test abnormalities: comparison between patients with and without cardiovascular disease

BACKGROUND

Poor exercise capacity, abnormal heart rate responses, and electrocardiographic abnormalities during treadmill exercise testing independently predict mortality. The combined relationship of these 3 variables to determine the incremental increase in mortality was compared in groups with and without known cardiovascular disease (CVD).

METHODS

Patients referred for treadmill exercise testing during 1986 to 1991 were included. Exercise capacity <74% (of age- and gender-predicted value), heart rate reserve of <68 beat/min, and horizontal or down-sloping ST depression of > or =1 mm were considered abnormal. Cox proportional hazards regression was used to determine all-cause mortality (average follow-up of 16 years) based on the number of exercise test abnormalities (0, 1, 2, or all 3).

RESULTS

Among 10,897 patients, 20.9% (n = 2,277) had CVD. Poor exercise capacity and limited heart rate reserve were associated with increased risk of mortality (P < .0001) in both groups; however, abnormal exercise electrocardiogram was associated with an increased risk of mortality in the no-CVD group only (P < .0001). A graded increase in mortality was observed with increase in number of abnormal exercise test results in both groups. Patients without CVD having 2 or 3 abnormal exercise test results had a similar age-adjusted risk of long-term mortality as those with CVD but normal exercise test results, with a hazard ratio comparing these groups = 1.01 (95% CI 0.79-1.28).

CONCLUSIONS

The combinatorial approach validates the prognostic significance of multiple exercise test variables. The presence of > or =2 exercise test abnormalities may constitute a "CVD risk equivalent" in patients without CVD.

Long-Term Progression and Outcomes With Aging in Patients With Lone Atrial Fibrillation

BACKGROUND

The long-term natural history of lone atrial fibrillation is unknown. Our objective was to determine the rate and predictors of progression from paroxysmal to permanent atrial fibrillation over 30 years and the long-term risk of heart failure, thromboembolism, and death compared with a control population.

METHODS AND RESULTS

A previously characterized Olmsted County, Minnesota, population with first episode of documented atrial fibrillation between 1950 and 1980 and no concomitant heart disease or hypertension was followed up long term. Of this unique cohort, 76 patients with paroxysmal (n=34), persistent (n=37), or permanent (n=5) lone atrial fibrillation at initial diagnosis met inclusion criteria (mean age at diagnosis, 44.2+/-11.7 years; male, 78%). Mean duration of follow-up was 25.2+/-9.5 years. Of 71 patients with paroxysmal or persistent atrial fibrillation, 22 had progression to permanent atrial fibrillation. Overall survival of the 76 patients with lone atrial fibrillation was 92% and 68% at 15 and 30 years, respectively, similar to 86% and 57% survival for the age- and sex-matched Minnesota population. Observed survival free of heart failure was slightly worse than expected (P=0.051). Risk for stroke or transient ischemic attack was similar to the expected population risk during the initial 25 years of follow-up but increased thereafter (P=0.004), although CIs were wide. All patients who had a cerebrovascular event had developed > or = 1 risk factor for thromboembolism.

CONCLUSIONS

Comorbidities significantly modulate progression and complications of atrial fibrillation. Age or development of hypertension increases thromboembolic risk.

Influence of preoperative lipid-lowering therapy on postoperative outcome in patients undergoing coronary artery bypass grafting

Statin therapy has recently been shown to decrease adverse perioperative events in patients undergoing vascular surgery. The potential beneficial effect of lipid-lowering therapy in patients undergoing coronary artery bypass grafting (CABG) is not well known. This was an observational analysis of 4,739 patients who underwent first-time isolated CABG at a single institution from 1995 to 2001. Patients were categorized into 2 groups based on treatment with a lipid-lowering agent within 30 days before surgery. Univariate and multivariate analyses were used to determine the association between lipid-lowering therapy and survival to hospital discharge. Patients in the lipid-lowering group (n = 2,334) tended to be younger (mean age 66 +/- 10 vs 68 +/- 10 years), were more likely to be diabetic (31% vs 28%), and on beta blockers (77% vs 70%) than patients in the nonlipid-lowering group (n = 2,405). In-hospital mortality was significantly lower in the lipid-lowering group than in the nonlipid-lowering therapy group (1.4% vs 2.2%, odds ratio 0.62, 95% confidence interval 0.40 to 0.96, p = 0.03). A multivariable model demonstrated a loss of statistical significance for the effect of lipid-lowering therapy on in-hospital mortality (adjusted odds ratio 0.83, 95% confidence interval 0.5 to 1.37, p = 0.46). In conclusion, preoperative use of lipid-lowering therapy in patients undergoing CABG appears safe and is associated with improved survival to hospital discharge compared with patients not receiving lipid-lowering therapy. However, patient risk factors and other cardioprotective medication use associated with the use of preoperative lipid-lowering therapy appear to explain the association with improved survival.

Functional profile of activated dendritic cells in unstable atherosclerotic plaque

BACKGROUND

Unstable atherosclerotic plaque typically contains an infiltrate of activated macrophages and activated T cells. This study established a functional profile of plaque-residing dendritic cells (DC) to examine whether they can function as Ag-presenting cells to facilitate in situ T-cell activation.

METHODS

Carotid artery plaque tissues were collected from 19 asymptomatic and 38 symptomatic patients undergoing endarterectomy. Matched samples of normal coronary artery wall, stable nonruptured plaque, and eroded unstable plaque were harvested from patients with fatal myocardial infarction. Quantitative PCR and immunohistochemistry were used to analyze the tissues for markers of DC activation (CD83, CD86, CCL19,CCL21) and correlate them with T-cell activation (IFN-gamma,TNF-alpha).

RESULTS

Carotid artery plaques from patients with ischemic symptoms compared to asymptomatic patients were characterized by the presence of high amount of T-cells (P<0.01) and tissue production of high levels of the T-cell cytokines IFN-gamma (P=0.001) and TNF-alpha (P=0.006). Plaque tissues from patients with ischemic complications contained elevated levels of CD83 (P<0.001), a marker of DC activation, and the DC chemokines CCL19 (P=0.001) and CCL21 (P<0.02). Unstable coronary artery plaques were similarly correlated compared to carotid plaques from symptomatic patients with the accumulation of T cells (P=0.001) and the production of T cell chemokines IFN-gamma (P=0.001) and TNF-alpha (P=0.002). Immunohistochemistry confirmed the presence of CD83(+) DC in the shoulder region of unstable plaques, where they produced the T cell-attracting chemokines CCL19 and CCL21. Mapping of activated DC demonstrated close contact between mature DC and T cells expressing the activation marker CD40 ligand (CD40L).

CONCLUSION

Activated and fully mature DC are represented in the inflammatory infiltrate characteristic for unstable carotid and coronary atheroma. Such DC produce chemokines, and thus can regulate the cell traffic into the lesion. Through the expression of the costimulatory ligand CD86, plaque-residing DC can augment T-cell stimulation and provide optimal stimulation conditions for T lymphocytes, resembling the microenvironment in organized lymphoid tissues.