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Ghazzal BZ, Kelli HM, Mehta A, Tahhan AS, Kim JH, Dong TA, Dhindsa DS, Sandesara PB, Hayek SS, Alkhoder AA, Liu C, Ko Y, Vaccarino V, Sperling LS, Quyyumi AA. P5479Educational attainment is an independent predictor of adverse outcomes in patients with coronary artery disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Educational attainment is an indicator of socioeconomic status and is inversely associated with cardiovascular risk factors and risk for incident coronary artery disease (CAD). Whether the level of educational attainment (EL) in patients with CAD influences outcomes remains understudied.
Purpose
To ascertain the relationship between EL and adverse outcomes in patients with CAD. We hypothesize that EL will be inversely associated with adverse outcomes in this high-risk patient population.
Methods
Subjects undergoing cardiac catheterization for known or suspected CAD were recruited in a cardiovascular biobank and had their highest level of educational attainment assessed using predefined options of elementary/middle school, high school, college, or graduate education. The primary outcome of interest was all-cause mortality and secondary outcomes included a composite of cardiovascular deaths and nonfatal myocardial infarction (MI) events, and nonfatal MI events during follow-up. Cox proportional hazards regression models were used to analyze the association between EL and adverse outcomes after adjustment for demographic characteristics, cardiovascular risk factors, cardiovascular medication use, and estimated zip code-based annual family income.
Results
Among the 6,318 subjects (mean age 64 years, 63% male, 23% black) enrolled, 998 (16%) had received graduate or a higher qualification, 2,689 (43%) had received a college education, 2,403 (38%) had received a high school education, and 228 (3%) had received elementary/middle school education. During a median follow-up of 3 years,there were 1,110 deaths from all causes, 851 cardiovascular deaths/nonfatal MI, and 286 nonfatal MI events. After adjusting for covariates and compared to patients with graduate education or higher, those with lower EL (elementary/middle school, high school, or college education) had a higher risk of all-cause mortality [hazard ratio 1.66, (95% CI 1.08, 2.54), 1.58 (95% CI 1.22, 2.04), and 1.45 (95% CI 1.13, 1.57), respectively]. Similar findings were observed for secondary outcomes. EL dichotomized at graduate education was associated with all-cause mortality (hazard ratio 1.48, 95% CI 1.16, 1.88), but this relationship was significantly modified by sex (p-interaction 0.023) and the association was attenuated among male patients (hazard ratio 1.23, 95% CI 0.94, 1.61) but not female patients (hazard ratio 2.70, 95% CI 1.53, 4.77).
Conclusions
Lower educational attainment is an independent predictor of adverse outcomes in patients with CAD. The causal link between low education level and increased CV risk needs further investigation.
Acknowledgement/Funding
Dr. Quyyumi is supported by NIH grants 5P01HL101398-02, 1P20HL113451-01, 1R56HL126558-01, 1RF1AG051633-01, R01 NS064162-01, R01 HL89650-01, HL095479-0
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Affiliation(s)
- B Z Ghazzal
- Emory University, Emory Clinical Cardiovascular Research Institute, Atlanta, United States of America
| | - H M Kelli
- Emory University School of Medicine, Division of Cardiology, Department of Medicine, Atlanta, United States of America
| | - A Mehta
- Emory University School of Medicine, Division of Cardiology, Department of Medicine, Atlanta, United States of America
| | - A S Tahhan
- Emory University School of Medicine, Division of Cardiology, Department of Medicine, Atlanta, United States of America
| | - J H Kim
- Emory University School of Medicine, Division of Cardiology, Department of Medicine, Atlanta, United States of America
| | - T A Dong
- Emory University School of Medicine, Department of Medicine, Atlanta, United States of America
| | - D S Dhindsa
- Emory University School of Medicine, Department of Medicine, Atlanta, United States of America
| | - P B Sandesara
- Emory University School of Medicine, Division of Cardiology, Department of Medicine, Atlanta, United States of America
| | - S S Hayek
- University of Michigan Medical School, Division of Cardiology, Department of Internal Medicine, Ann Arbor, United States of America
| | - A A Alkhoder
- Emory University, Emory Clinical Cardiovascular Research Institute, Atlanta, United States of America
| | - C Liu
- Emory University, Emory Clinical Cardiovascular Research Institute, Atlanta, United States of America
| | - Y Ko
- Emory University, Emory Clinical Cardiovascular Research Institute, Atlanta, United States of America
| | - V Vaccarino
- Emory University, Rollins School of Public Health, Atlanta, United States of America
| | - L S Sperling
- Emory University School of Medicine, Division of Cardiology, Department of Medicine, Atlanta, United States of America
| | - A A Quyyumi
- Emory University School of Medicine, Division of Cardiology, Department of Medicine, Atlanta, United States of America
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Bromfield SG, Hardy S, Sullivan S, Hammadah M, Shah A, Levantsevych O, Kaseer B, Elon L, Li L, Bremner JD, Quyyumi A, Vaccarino V, Lewis TT. 0705 Short Sleep Duration is Associated with Lower Stress-Induced Blood Pressure Reactivity in Young Women with Early-Onset Myocardial Infarction, But Not Men. Sleep 2018. [DOI: 10.1093/sleep/zsy061.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - S Hardy
- Emory University, Atlanta, GA
| | | | | | - A Shah
- Emory University, Atlanta, GA
| | | | | | - L Elon
- Emory University, Atlanta, GA
| | - L Li
- Emory University, Atlanta, GA
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Humphries KH, Izadnegahdar M, Sedlak T, Saw J, Johnston N, Schenck-Gustafsson K, Shah RU, Regitz-Zagrosek V, Grewal J, Vaccarino V, Wei J, Bairey Merz CN. Sex differences in cardiovascular disease - Impact on care and outcomes. Front Neuroendocrinol 2017; 46:46-70. [PMID: 28428055 PMCID: PMC5506856 DOI: 10.1016/j.yfrne.2017.04.001] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/31/2017] [Accepted: 04/13/2017] [Indexed: 02/07/2023]
Affiliation(s)
- K H Humphries
- Division of Cardiology, University of British Columbia, Vancouver, Canada; BC Centre for Improved Cardiovascular Health, Vancouver, Canada.
| | - M Izadnegahdar
- BC Centre for Improved Cardiovascular Health, Vancouver, Canada
| | - T Sedlak
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - J Saw
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - N Johnston
- Department of Medical Sciences, Cardiology, Uppsala University Hospital, Uppsala, Sweden
| | - K Schenck-Gustafsson
- Department of Medicine, Cardiac Unit and Centre for Gender Medicine, Karolinska University Hospital and Karolinska Institutet, Sweden
| | - R U Shah
- Division of Cardiovascular Medicine, University of Utah School of Medicine, USA
| | - V Regitz-Zagrosek
- Institute of Gender in Medicine (GIM) and Center for Cardiovascular Research (CCR) Charité, University Medicine Berlin and DZHK, Partner Site Berlin, Germany
| | - J Grewal
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - V Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - J Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - C N Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
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Kelli H, Haider M, Hammadah M, Awad M, Dubnar S, Lewis T, Sperling L, Vaccarino V, Gibbons G, Quyyumi A. PM041 Lower Income Is Associated With Increased Cardiovascular Risk Factors, Systemic Inflammation, Arterial Stiffness and Oxidative Stress. Glob Heart 2016. [DOI: 10.1016/j.gheart.2016.03.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Rooks C, Ibeanu I, Shah A, Pimple P, Murrah N, Shallenberger L, Bremner D, Vaccarino V, Raggi P. YOUNG WOMEN POST-MI HAVE HAVE HIGHER PLASMA CONCENTRATIONS OF INTERLEUKIN-6 BEFORE AND AFTER STRESS TESTING. Can J Cardiol 2015. [DOI: 10.1016/j.cjca.2015.07.589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Magruder K, Yeager D, Goldberg J, Forsberg C, Litz B, Vaccarino V, Friedman M, Gleason T, Huang G, Smith N. Diagnostic performance of the PTSD checklist and the Vietnam Era Twin Registry PTSD scale. Epidemiol Psychiatr Sci 2015; 24:415-22. [PMID: 24905737 PMCID: PMC5881392 DOI: 10.1017/s2045796014000365] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 04/14/2014] [Accepted: 04/16/2014] [Indexed: 11/06/2022] Open
Abstract
AIMS Self-report questionnaires are frequently used in clinical and epidemiologic studies to assess post-traumatic stress disorder (PTSD). A number of studies have evaluated these scales relative to clinician administered structured interviews; however, there has been no formal evaluation of their performance relative to non-clinician administered epidemiologic assessments such as the Composite International Diagnostic Interview (CIDI). We examined the diagnostic performance of two self-report PTSD scales, the PTSD checklist (PCL) and the Vietnam Era Twin Registry (VET-R) PTSD scale, compared to the CIDI. METHODS Data were derived from a large epidemiologic follow-up study of PTSD in 5141 Vietnam Era Veterans. Measures included the PCL, VET-R PTSD scale and CIDI. For both the PCL and VET-R PTSD scale, ROC curves, areas under the curve (AUC), sensitivity, specificity, % correctly classified, likelihood ratios, predictive values and quality estimates were generated based on the CIDI PTSD diagnosis. RESULTS For the PCL and VET-R PTSD scale the AUCs were 89.0 and 87.7%, respectively. Optimal PCL cutpoints varied from the 31-33 range (when considering sensitivity and specificity) to the 36-56 range (when considering quality estimates). Similar variations were found for the VET-R PTSD, ranging from 31 (when considering sensitivity and specificity) to the 37-42 range (when considering quality estimates). CONCLUSIONS The PCL and VET-R PTSD scale performed similarly using a CIDI PTSD diagnosis as the criterion. There was a range of acceptable cutpoints, depending on the metric used, but most metrics suggested a lower PCL cutpoint than in previous studies in Veteran populations.
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Affiliation(s)
- K. Magruder
- Mental Health Service, Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
- Department of Psychiatry, Medical University of South Carolina, Charleston, South Carolina, USA
| | - D. Yeager
- Mental Health Service, Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
- Department of Psychiatry, Medical University of South Carolina, Charleston, South Carolina, USA
| | - J. Goldberg
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - C. Forsberg
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - B. Litz
- Massachusetts Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - V. Vaccarino
- Departments of Epidemiology and Medicine, Emory University, Atlanta, Georgia, USA
| | - M. Friedman
- Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, White River Junction, Vermont, USA
- Departments of Psychiatry and Pharmacology & Toxicology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - T. Gleason
- Cooperative Studies Program, Clinical Science Research and Development, VA Office of Research and Development, Washington, DC, USA
| | - G. Huang
- Cooperative Studies Program, Clinical Science Research and Development, VA Office of Research and Development, Washington, DC, USA
| | - N. Smith
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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Bugiardini R, Badimon L, Manfrini O, Boytsov S, Bozidarka K, Daullxhiu I, Dilic M, Dorobantu M, Erglis A, Gafarov V, Gale CP, Goncalvesova E, Goudev A, Gustiene O, Hall A, Karpova I, Kedev S, Manak N, Milicic D, Ostojic M, Parkhomenko AN, Popovici M, Studenkan M, Toth K, Trninic D, Vasiljevic Z, Zakke I, Zaliunas R, Bugiardini R, Vaccarino V, Manfrini O, Badimon L, Manak N, Karpova I, Dilic M, Trninic D, Goudev A, Milicic D, Toth K, Daullxhiu I, Erglis A, Zakke I, Zaliunas R, Gustiene O, Kedev S, Popovici M, Knezevic B, Boytsov S, Gafarov V, Dorubantu M, Vasiljevic Z, Ojstoic M, Goncalvesova E, Studencan M, Parkhomenko AN, Hall A, Gale C, Karpova I, Manak N, Lovric M, Korac R, Mandic D, Vujovic V, Blagojevic M, Milekic J, Trendafilova E, Somleva D, Krivokapic L, Rajovic G, Sahmanovic O, Saranovic M, Radoman C, Tomic SC, Ljubic V, Velickovic M, Radojicic S, Arsenescu-Georfescu C, Garbea S, Radu C, Olinic D, Calin P, Chifor A, Babes K, lonescu DD, Craiu E, Petrescu H, Magda I, Luminita S, Benedek I, Marinescu S, Tiberiu N, Gheorghe G, Malaescu I, Trocan N, Doina D, Macarie C, Putnikovic B, Arandjelovic A, Nikolic NM, Zdravkovic M, Saric J, Radovanovic S, Matic I, Srbljak N, Davidovic G, Simovic S, Zivkovic S, Petkovic-Curic S, Studencan M, Parkhomenko AN. Perspectives: Rationale and design of the ISACS-TC (International Survey of Acute Coronary Syndromes in Transitional Countries) project. Eur Heart J Suppl 2014. [DOI: 10.1093/eurheartj/sut002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Karohl C, Veledar E, Raggi P, Su S, Vaccarino V, Kumari M, Tangpricha V. Reply to S-M Orton and GC Ebers. Am J Clin Nutr 2011. [DOI: 10.3945/ajcn.110.009944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Phillips LS, Ziemer DC, Kolm P, Weintraub WS, Vaccarino V, Rhee MK, Chatterjee R, Narayan KMV, Koch DD. Glucose challenge test screening for prediabetes and undiagnosed diabetes. Diabetologia 2009; 52:1798-807. [PMID: 19557386 DOI: 10.1007/s00125-009-1407-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Revised: 04/11/2009] [Accepted: 05/06/2009] [Indexed: 01/09/2023]
Abstract
AIMS/HYPOTHESIS Diabetes prevention and care are limited by lack of screening. We hypothesised that screening could be done with a strategy similar to that used near-universally for gestational diabetes, i.e. a 50 g oral glucose challenge test (GCT) performed at any time of day, regardless of meal status, with one 1 h sample. METHODS At a first visit, participants had random plasma and capillary glucose measured, followed by the GCT with plasma and capillary glucose (GCTplasma and GCTcap, respectively). At a second visit, participants had HbA(1c) measured and a diagnostic 75 g OGTT. RESULTS The 1,573 participants had mean age of 48 years, BMI 30.3 kg/m(2) and 58% were women and 58% were black. Diabetes (defined by WHO) was present in 4.6% and prediabetes (defined as impaired glucose tolerance [2 h glucose 7.8-11.1 (140-199 mg/dl) with fasting glucose <or=6.9 (125 mg/dl)] and/or impaired fasting glucose with plasma glucose 6.1-6.9 mmol/l [110-125 mg/dl]) in 18.7%. The GCTplasma provided areas under the receiver-operating-characteristic curves of 0.90, 0.82 and 0.79 for detection of diabetes, diabetes or prediabetes, and prediabetes, respectively, all of which were higher than GCTcap, random and capillary glucose, and HbA(1c) (p < 0.02 for all). The performance of GCTplasma was unaffected by time after meals or time of day, and was better in blacks than whites, but otherwise comparable in men and women, and in groups with differing prevalence of glucose intolerance. GCTplasma screening would cost approximately US$84 to identify one person with previously unrecognised diabetes or prediabetes. CONCLUSIONS/INTERPRETATION GCT screening for prediabetes and previously unrecognised diabetes would be accurate, convenient and inexpensive. Widespread use of GCT screening could help improve disease management by permitting early initiation of therapy aimed at preventing or delaying the development of diabetes and its complications.
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Affiliation(s)
- L S Phillips
- Division of Endocrinology and Metabolism, Emory University School of Medicine, 101 Woodruff Circle, WMRB Room 1027, Atlanta, GA 30322, USA.
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Krantz DS, Whittaker KS, Francis JL, Rutledge T, Johnson BD, Barrow G, McClure C, Sheps DS, York K, Cornell C, Bittner V, Vaccarino V, Eteiba W, Parashar S, Vido DA, Merz CNB. Psychotropic medication use and risk of adverse cardiovascular events in women with suspected coronary artery disease: outcomes from the Women's Ischemia Syndrome Evaluation (WISE) study. Heart 2009; 95:1901-6. [PMID: 19666461 DOI: 10.1136/hrt.2009.176040] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study investigated the relation between psychotropic medication use and adverse cardiovascular (CV) events in women with symptoms of myocardial ischaemia undergoing coronary angiography. METHOD Women enrolled in the Women's Ischemia Syndrome Evaluation (WISE) were classified into one of four groups according to their reported antidepressant and anxiolytic medication usage at study intake: (1) no medication (n = 352); (2) anxiolytics only (n = 67); (3) antidepressants only (n = 58); and (4) combined antidepressant and anxiolytics (n = 39). Participants were followed prospectively for the development of adverse CV events (for example, hospitalisations for non-fatal myocardial infarction, stroke, congestive heart failure and unstable angina) or all-cause mortality over a median of 5.9 years. RESULTS Use of antidepressant medication was associated with subsequent CV events (HR 2.16, 95% CI 1.21 to 3.93) and death (HR 2.15, 95% CI 1.16 to 3.98) but baseline anxiolytic use alone did not predict subsequent CV events and death. In a final regression model that included demographics, depression and anxiety symptoms, and risk factors for cardiovascular disease, women in the combined medication group (that is, antidepressants and anxiolytics) had higher risk for CV events (HR 3.98, CI 1.74 to 9.10, p = 0.001 and all-cause mortality (HR 4.70, CI 1.7 to 2.97, p = 0.003) compared to those using neither medication. Kaplan-Meier survival curves indicated that there was a significant difference in mortality among the four medication groups (p = 0.001). CONCLUSIONS These data suggest that factors related to psychotropic medication such as depression refractory to treatment, or medication use itself, are associated with adverse CV events in women with suspected myocardial ischaemia.
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Affiliation(s)
- D S Krantz
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
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Champney KP, Frederick PD, Bueno H, Parashar S, Foody J, Merz CNB, Canto JG, Lichtman JH, Vaccarino V. The joint contribution of sex, age and type of myocardial infarction on hospital mortality following acute myocardial infarction. Heart 2009; 95:895-9. [PMID: 19147625 DOI: 10.1136/hrt.2008.155804] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Younger, but not older, women have a higher mortality than men of similar age after a myocardial infarction (MI). We sought to determine whether this relationship is true for both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI). DESIGN Retrospective cohort study. SETTING 1057 USA hospitals participant in the National Registry of Myocardial Infarction between 2000 and 2006. PATIENTS 126 172 STEMI and 235 257 NSTEMI patients. MAIN OUTCOME MEASURE Hospital death. RESULTS For both STEMI and NSTEMI, the younger the patient's age, the greater the excess mortality risk for women compared with men, while older women fared similarly (STEMI) or better (NSTEMI) than men (p<0.0001 for the age-sex interaction). In STEMI, the unadjusted women-to-men RR was 1.68 (95% CI 1.41 to 2.01), 1.78 (1.59 to 1.99), 1.45 (1.34 to 1.57), 1.08 (1.02 to 1.14) and 1.03 (0.98 to 1.07) for age <50 years, age 50-59, age 60-69, age 70-79 and age 80-89, respectively. For NSTEMI, corresponding unadjusted RRs were 1.56 (1.31 to 1.85), 1.42 (1.27 to 1.58), 1.17 (1.09 to 1.25), 0.92 (0.88 to 0.96) and 0.86 (0.83 to 0.89). After adjusting for risk status, the excess risk for younger women compared with men decreased to approximately 15-20%, while a better survival of older NSTEMI women compared with men persisted. CONCLUSIONS Sex-related differences in short-term mortality are age-dependent in both STEMI and NSTEMI patients.
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Affiliation(s)
- K P Champney
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30306, USA
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Rhee MK, Musselman D, Ziemer DC, Vaccarino V, Kolm P, Weintraub WS, Caudle JM, Varughese RM, Irving JM, Phillips LS. Unrecognized glucose intolerance is not associated with depression. Screening for Impaired Glucose Tolerance study 3 (SIGT 3). Diabet Med 2008; 25:1361-5. [PMID: 19046230 PMCID: PMC2675874 DOI: 10.1111/j.1464-5491.2008.02543.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To understand the metabolic and temporal links in the relationship between diabetes and depression, we determined the association between depressive symptoms and unrecognized glucose intolerance. METHODS In a cross-sectional study, 1047 subjects without known diabetes were screened for diabetes or pre-diabetes using the oral glucose tolerance test and for depressive symptoms using the Patient Health Questionnaire (PHQ). RESULTS Mean age was 48 years, body mass index 30 kg/m(2); 63% were female, 54% black, 11% previously treated for depression and 10% currently treated; 5% had diabetes and 34% pre-diabetes. Median PHQ score was 2 (interquartile range 0-5). Depressive symptoms did not increase with worsening glucose tolerance, after adjusting for age, sex, ethnicity, body mass index, family history, exercise, education and depression treatment. CONCLUSIONS There is no association between depressive symptoms and unrecognized glucose intolerance. However, it remains possible that diagnosed diabetes, with its attendant health concerns, management issues, and/or biological changes, may be a risk for subsequent development of depression. Thus, patients with newly diagnosed diabetes should be counselled appropriately and monitored for the development of depression.
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Affiliation(s)
- M K Rhee
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, GA 30303, USA.
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Abstract
BACKGROUND Endothelial dysfunction assessed by brachial artery flow-mediated dilation (FMD) is a marker for early atherosclerotic vascular disease and future cardiovascular events. OBJECTIVE To estimate the heritability of brachial artery FMD using a twin design. METHODS We estimated the heritability of FMD using 94 middle-aged male twin pairs. FMD was measured by ultrasound, and traditional coronary heart disease risk factors were measured. Genetic modeling techniques were used to determine the relative contributions of genes and environment to the variation in FMD. RESULTS The mean age of the twin participants was 54.9 +/- 2.8 years. The mean FMD was 0.047 +/- 0.030. The intraclass correlation coefficient was higher in MZ twins [0.38, 95% confidence interval (CI) 0.32-0.43] than in DZ twins (0.19, 95% CI 0.11-0.26), suggesting a role of genetic influence in FMD variation. Structural equation modeling showed that both genetic and unique environmental factors contributed significantly to the variation in FMD. The crude FMD heritability was 0.37 (95% CI 0.15-0.54). After adjustment for traditional cardiovascular risk factors, including age, total cholesterol, blood pressure, and body mass index, the heritability of FMD was 39% (95% CI 0.18-0.56). The remaining variation in FMD could be explained by individual-specific environment. CONCLUSION This is the first study using twins to estimate the relative contributions of genetics and environment to the variation in FMD in a US population. Our results demonstrate a moderate genetic effect on brachial artery FMD, independent of traditional coronary risk factors. Our data also highlight the importance of unique environment on the variability in FMD.
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Affiliation(s)
- J Zhao
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, 1256 Briarcliff Road NE, Atlanta, GA 30306, USA
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Abstract
Coronary heart disease (CHD) remains the leading cause of mortality for US women, responsible for almost 250,000 deaths annually. Preventive heart-health behavioral changes by women and aggressive coronary risk reduction can decrease the number of women disabled and killed by CHD. Angina is the predominant initial and subsequent presentation of CHD in women; categorization of chest pain and risk stratification of women assume pivotal roles. A robust evidence-based algorithm can guide cardiovascular imaging techniques to evaluate women with suspected myocardial ischemia to detect those with worsened survival. Restricted functional capacity (<5 METs) is a consistent marker of worsened prognosis. Younger women have substantially higher mortality rates than men following myocardial infarction and coronary bypass surgery. Although these women have more comorbidity and risk factors, other issues including biological differences, treatment differences, and psychosocial factors require management strategies tailored to the unique needs of women.
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Affiliation(s)
- N K Wenger
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.
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15
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Bremmer J, Vaccarino V. We-P11:252 Plasma cholesterol concentrations in depression and posttraumatic stress disorder. ATHEROSCLEROSIS SUPP 2006. [DOI: 10.1016/s1567-5688(06)81605-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pryshchep S, Vaccarino V, Mallik S, Goronzy JJ, Weyand CM. 6 TISSUE-INJURIOUS EFFECTOR FUNCTIONS OF T LYMPHOCYTES IN THE UNSTABLE ATHEROSCLEROTIC PLAQUE. J Investig Med 2006. [DOI: 10.2310/6650.2005.x0008.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Vaccarino V, Goldberg J, Cheema F, Reddy U, Maisano C, Jones L, Murrah N, Quyyumi A, Bremner J. We-W39:5 Flow-mediated vasodilation predicts occult coronary artery disease detected by positron emission tomography. ATHEROSCLEROSIS SUPP 2006. [DOI: 10.1016/s1567-5688(06)81292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mallik S, Spertus J, Reid K, Lichtman J, Dawood N, Wenger N, Vaccarino V. Mo-P1:167 Younger menopause age predicts adverse outcome after myocardial infarction. ATHEROSCLEROSIS SUPP 2006. [DOI: 10.1016/s1567-5688(06)80300-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Smith G, Masoudi F, Vaccarino V, Radford M, Krumholz H. Outcomes in heart failure patients with preserved ejection fraction mortality, readmission and functional decline. ACTA ACUST UNITED AC 2003. [DOI: 10.1016/s1062-1458(03)00300-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
CONTEXT Many studies indicate that women are less likely than men to undergo cardiac procedures after an acute myocardial infarction (AMI), raising concerns of sexual bias in clinical care. However, no data exist regarding the relationship between patient sex, physician sex, and use of cardiac procedures. OBJECTIVE To determine whether sex differences in cardiac catheterization after AMI were greater when patients were treated by male attending physicians compared with female attending physicians. DESIGN, SETTING, AND PATIENTS Analysis of data from the Cooperative Cardiovascular Project, a retrospective medical record review. A total of 104 >231 Medicare fee-for-service beneficiaries who were hospitalized in US acute care hospitals for an AMI between January 1994 and February 1995. MAIN OUTCOME MEASURE Use of cardiac catheterization within 60 days of admission, compared between the 4 groups of patient sex-physician sex combinations. RESULTS Women underwent fewer cardiac catheterizations than men when treated by either male physicians (38.6% vs 50.8%; P =.001) or female physicians (34.8% vs 45.8%; P =.001). Sex differences in procedure use were not greater when a patient and physician were of different sexes (P for interaction =.85). After potential confounders in multivariable analysis were accounted for, women were less likely to undergo cardiac catheterization (risk ratio, 0.90 [95% confidence interval (CI), 0.88-0.92]), regardless of the treating physician's sex. Patients treated by male physicians were more likely to undergo cardiac catheterization (risk ratio, 1.06 [95%CI, 1.02-1.10]) than those treated by female physicians, regardless of patient sex. CONCLUSIONS Women who have had an AMI undergo a cardiac catheterization less often than men, whether treated by a male or female physician. These results suggest that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.
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Affiliation(s)
- S S Rathore
- Yale University School of Medicine, 333 Cedar St, PO Box 208025, New Haven, CT 06520-8025, USA
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Vaccarino V, Berger AK, Abramson J, Black HR, Setaro JF, Davey JA, Krumholz HM. Pulse pressure and risk of cardiovascular events in the systolic hypertension in the elderly program. Am J Cardiol 2001; 88:980-6. [PMID: 11703993 DOI: 10.1016/s0002-9149(01)01974-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pulse pressure has been related to higher risk of cardiovascular events in older persons. Isolated systolic hypertension is common among the elderly and is accompanied by elevated pulse pressure. Treatment of isolated systolic hypertension may further increase pulse pressure if diastolic pressure is lowered to a greater extent than systolic pressure. Little is known regarding pulse pressure as a predictor of cardiovascular outcomes in elderly persons with isolated systolic hypertension, and the influence of treatment on the pulse pressure effect. We assessed the relation between pulse pressure, measured throughout the follow-up period, and the incidence of coronary heart disease (CHD), heart failure (HF), and stroke in 4,632 participants in the Systolic Hypertension in the Elderly Program, a 5-year randomized, placebo-controlled clinical trial of treatment of isolated systolic hypertension in older adults. In the treatment group, a 10-mm Hg increase in pulse pressure was associated with a statistically significant 32% increase in risk of HF and a 24% increase in risk of stroke after controlling for systolic blood pressure and other known risk factors, as well as with a 23% increase in risk of HF and a 19% increase in risk of stroke after controlling for diastolic blood pressure and other risk factors. Pulse pressure was not significantly associated with HF or stroke in the placebo group, nor with incidence of CHD in either the placebo or treatment group. These results suggest that pulse pressure is a useful marker of risk for HF and stroke among older adults being treated for isolated systolic hypertension.
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Affiliation(s)
- V Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia 30306, USA.
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Affiliation(s)
- A L Arnold
- Yale University School of Medicine, New Haven, Connecticut, USA
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Abramson J, Berger A, Krumholz HM, Vaccarino V. Depression and risk of heart failure among older persons with isolated systolic hypertension. Arch Intern Med 2001; 161:1725-30. [PMID: 11485505 DOI: 10.1001/archinte.161.14.1725] [Citation(s) in RCA: 162] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Investigators have shown that depression is associated with an increased risk of coronary heart disease in general and myocardial infarction in particular. However, it is unknown whether depression, independent of its association with myocardial infarction, is a risk factor for heart failure. METHODS This study examined whether depression was a predictor of incident heart failure among 4538 persons aged 60 years and older with isolated systolic hypertension who were enrolled in the Systolic Hypertension in the Elderly Program (SHEP). Depression was defined as a score of 16 or more at baseline on the Center for Epidemiological Studies Depression Scale (CES-D). The relationship between depression and heart failure was assessed using Cox proportional hazards regression. RESULTS The average follow-up was 4.5 years. Heart failure developed in 138 (3.2%) of 4317 nondepressed persons and in 18 (8.1%) of 221 depressed persons. After controlling for age; sex; race; history of myocardial infarction, diabetes, or angina; blood pressure; cholesterol levels; electrocardiographic abnormalities; smoking; disability; and SHEP treatment group, depressed persons had more than a 2-fold higher risk of developing heart failure compared with nondepressed persons (hazard ratio, 2.59; 95% confidence interval, 1.57-4.27; P<.001). After additional adjustment for the occurrence of myocardial infarction during follow-up, depressed persons remained at elevated risk of heart failure (hazard ratio, 2.82; 95% confidence interval, 1.71-4.67; P<.001). CONCLUSIONS Depression is independently associated with a substantial increase in the risk of heart failure among older persons with isolated systolic hypertension. This association does not appear to be mediated by myocardial infarction.
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Affiliation(s)
- J Abramson
- Emory Center for Outcomes Research, Emory West, 1256 Briarcliff Rd NE, Suite 1 N, Atlanta, GA 30306, USA.
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Abstract
OBJECTIVES We sought to examine whether depressive symptoms are associated with poorer prognosis in patients with heart failure. BACKGROUND Depression is an established risk factor for poor outcome in patients with coronary heart disease (CHD). Little is known of its role in patients with heart failure. METHODS We prospectively followed 391 patients > or =50 years of age who met criteria for decompensated heart failure on hospital admission. The outcome of the study was death or decline in activities of daily living (ADL) at six months, relative to baseline. Depressive symptoms were measured at baseline by means of the Geriatric Depression Scale, Short-Form, with 6 to 7 symptoms, 8 to 10 symptoms and > or =11 symptoms indicating mild, moderate and severe levels of depressive symptoms, respectively. RESULTS There was a strong and graded association between the severity of depressive symptoms at baseline and the rate of the combined end point of either functional decline or death at six months. After adjustment for demographic factors, medical history, baseline functional status and clinical severity, patients with > or =11 depressive symptoms, compared with those with <6 depressive symptoms, had an 82% higher risk of either functional decline or death, whereas the intermediate levels of depressive symptoms showed intermediate risk (p = 0.003 for trend). A similar graded association was found for functional decline and death separately; however, after multivariate analysis, the association with mortality was less strong and no longer statistically significant. CONCLUSIONS An increasing number of depressive symptoms is a negative prognostic factor for patients with heart failure, just as it is for patients with CHD.
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Affiliation(s)
- V Vaccarino
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, Georgia 30306, USA.
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Abstract
BACKGROUND Symptoms, a key element in the patient's decision to seek care, are critical to appropriate triage, and influence decisions to pursue further evaluation and initiation of treatment. Although many studies have described symptoms associated with acute coronary syndromes (ACS), few, if any, have examined symptom predictors of ACS and whether they differ by patients' age. OBJECTIVES To explore symptom predictors of ACS in younger (< 70 years) and older (> or = 70 years) patients. To test the hypothesis that typical symptoms are predictive of ACS in younger patients, but are less predictive in older patients. METHOD Secondary analysis of observational data gathered on 531 patients presenting to the emergency department of a regional cardiac referral center in New England with symptoms suggestive of ACS. RESULTS Bivariate analyses revealed no symptoms significantly (p < .01) associated with ACS in older patients. In younger patients presence of chest symptoms and the total number of typical symptoms reported were significantly (p < .01) associated with ACS. After adjustment for age and gender, typical symptoms that were positive predictors of ACS in younger patients included chest symptoms (OR 2.37, 95% CI 1.32-4.27, p = .004) and arm pain (OR 1.78, 95% CI 1.03-3.09, p = .040). Additionally, the total number of typical symptoms reported (OR 1.68, 95% CI 1.31-2.15, p < .001) was a positive predictor of ACS in younger patients. The atypical symptom of fatigue (OR 2.52, 95% CI 1.10-5.81, p = .029) was a significant positive predictor of ACS, whereas dizziness/faintness (OR .50, 95% CI .26-.91, p = .024) was a significant negative predictor of ACS in younger patients. Logistic regression analysis using the entire sample revealed an interaction between age and number of typical symptoms indicating that younger patients had a 36% greater odds for ACS for each additional typical symptom present compared with older patients (OR 1.36, 95% CI 1.02-1.83, p = .038 for interaction between age and number of typical symptoms reported). The model with the interaction between age and chest symptoms revealed a borderline association (p = .10 for the interaction between age and chest symptoms), with younger patients being more likely than older patients to report chest symptoms. CONCLUSIONS Typical symptoms are predictive of ACS in younger patients and less predictive in older patients.
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Affiliation(s)
- K A Milner
- Yale University School of Nursing, New Haven, Connecticut 06536-0740, USA
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Heiat A, Vaccarino V, Krumholz HM. An evidence-based assessment of federal guidelines for overweight and obesity as they apply to elderly persons. Arch Intern Med 2001; 161:1194-203. [PMID: 11343442 DOI: 10.1001/archinte.161.9.1194] [Citation(s) in RCA: 289] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The US Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults set the body mass index (BMI; weight in kilograms divided by the square of height in meters) of 25 as the upper limit of ideal weight for all adults regardless of age. However, the prognostic importance of overweight and obesity in elderly persons (>/=65 years) is controversial. We sought to analyze the guidelines in the context of currently available evidence that is relevant to older adults. METHODS We searched MEDLINE for all English-language studies of the association between BMI and all-cause or cardiovascular mortality or coronary heart disease events from January 1966 through October 1999. Additional pertinent articles were identified through bibliographies of the MEDLINE articles. We selected studies for detailed review if they reported on the association between BMI and mortality for nonhospitalized subjects who were 65 years or older and had been followed up for at least 3 years. We controlled for age, smoking, and baseline health status. Of the 444 screened articles, 13 were selected to assess the guidelines. We extracted information regarding publication year, study design, population, recruitment period, follow-up duration, number of subjects, sex, age range, inclusion and exclusion criteria, and statistical models, including variables and end points. RESULTS These data do not support the BMI range of 25 to 27 as a risk factor for all-cause and cardiovascular mortality among elderly persons. The results were not substantially different for men and women. Most studies showed a negative or no association between BMI and all-cause mortality. Three studies indicated overweight (BMI >/=27) as a significant prognostic factor for all-cause and cardiovascular mortality among 65- to 74-year-olds, and one study showed a significant positive association between overweight (BMI >/=28) and all-cause mortality among those 75 years or older. Higher BMI values were consistent with a smaller relative mortality risk in elderly persons compared with young and middle-aged populations. CONCLUSIONS Federal guideline standards for ideal weight (BMI 18.7 to <25) may be overly restrictive as they apply to the elderly. Studies do not support overweight, as opposed to obesity, as conferring an excess mortality risk. Future guidelines should consider the evidence for specific age groups when establishing standards for healthy weight.
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Affiliation(s)
- A Heiat
- Yale University School of Medicine, 333 Cedar St, PO Box 208025, New Haven, CT 06520-8025, USA
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Abstract
CONTEXT Heavy consumption of alcohol can lead to heart failure, but the relationship between moderate alcohol consumption and risk of heart failure is largely unknown. OBJECTIVE To determine whether moderate alcohol consumption predicts heart failure risk among older persons, independent of the association of moderate alcohol consumption with lower risk of myocardial infarction (MI). DESIGN Prospective cohort study conducted from 1982 through 1996, with a maximum follow-up of 14 years. SETTING AND PARTICIPANTS Population-based sample of 2235 noninstitutionalized elderly persons (mean age, 73.7 years; 41.2% male; 21.3% nonwhite) residing in New Haven, Conn, who were free of heart failure at baseline. Persons who reported alcohol consumption of more than 70 oz in the month prior to baseline were excluded. MAIN OUTCOME MEASURE Time to first fatal or nonfatal heart failure event, according to the amount of alcohol consumed in the month prior to baseline. RESULTS Increasing alcohol consumption in the moderate range was associated with decreasing heart failure rates. For persons consuming no alcohol (50.0%), 1 to 20 oz (40.2%), and 21 to 70 oz (9.8%) in the month prior to baseline, crude heart failure rates per 1000 years of follow-up were 16.1, 12.2, and 9.2, respectively. After adjustment for age, sex, race, education, angina, history of MI and diabetes, MI during follow-up, hypertension, pulse pressure, body mass index, and current smoking, the relative risks of heart failure for those consuming no alcohol, 1 to 20 oz, and 21 to 70 oz in the month prior to baseline were 1.00 (referent), 0.79 (95% confidence interval [CI], 0.60-1.02), and 0.53 (95% CI, 0.32-0.88) (P for trend =.02). CONCLUSIONS Increasing levels of moderate alcohol consumption are associated with a decreasing risk of heart failure among older persons. This association is independent of a number of confounding factors and does not appear to be entirely mediated by a reduction in MI risk.
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Affiliation(s)
- J L Abramson
- Emory University School of Medicine, Department of Medicine, Division of Cardiology, 1256 Briarcliff Rd NE, Suite 1 North, Atlanta, GA 30306, USA.
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Abstract
BACKGROUND An interaction between sex and age is thought to affect hospital mortality after myocardial infarction; younger, but not older, women have been shown to have higher mortality rates than men. It is currently unknown whether findings are similar after hospital discharge. OBJECTIVE To determine whether an interaction between sex and age affects 2-year mortality after myocardial infarction. DESIGN Community-based prospective cohort study. SETTING 16 community hospitals serving the Worcester, Massachusetts, metropolitan area. PATIENTS 6826 patients who survived hospitalization for acute myocardial infarction during ten 1-year periods between 1975 and 1995. MEASUREMENTS Mortality 2 years after hospital discharge. RESULTS The overall 2-year mortality rate was higher in women (28.9%) than in men (19.6%). When patients were examined by age group, however, only women younger than 60 years of age had a higher mortality rate than men of similar age. The sex difference decreased with increasing age; among the oldest patients, women had a lower mortality rate than men (P = 0.009 for the interaction between sex and age). This relationship was not affected by adjustment for demographic characteristics and medical history, clinical characteristics, and hospital and discharge treatments; the hazard of 2-year death for women compared with men increased 15.4% (95% CI, 4.3% to 27.6%) for every 10-year decrease in age. In absolute terms, after adjustment for demographic characteristics and medical history, among patients younger than 60 years of age women were at greater risk than men (risk difference, 1.8 percentage points). At older ages, however, women were at lower risk than men. CONCLUSIONS Younger, but not older, women who survive hospitalization for myocardial infarction have a higher long-term mortality rate than men. This provides additional evidence that younger women with myocardial infarction are at greater risk for death than men.
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Affiliation(s)
- V Vaccarino
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory West, 1256 Briarcliff Road, Suite 1 North, Atlanta, GA 30306, USA
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Abstract
The purpose of this study was to determine to what extent a single measure, self-rated health (SRH), independently predicts long-term hospitalizations due to all causes and to cardiovascular diseases by using both the standard Cox proportional hazards model and a more robust events model. The study cohort consisted of 2,812 elderly subjects residing in New Haven, Connecticut, who were followed from 1982 to 1996 as part of the Established Populations for Epidemiologic Study of the Elderly. After adjustment for baseline risk factors, using the Cox model, a favorable SRH was associated with a significantly lowered risk for a first hospitalization for all causes (risk ratio (RR) = 0.850, 95% confidence interval (CI): 0.774, 0.934) and congestive heart failure (RR = 0.599, 95% CI: 0.426, 0.841) but not for myocardial infarction (RR = 0.882, 95% CI: 0.565, 1.379). With the adjusted robust events model, a positive SRH was associated with a decreased risk in both a first (RR = 0.813, 95% CI: 0.744, 0.889) and a second (RR = 0.870, 95% CI: 0.782, 0.968) hospitalization for any cause. These results indicate that a single measurement of SRH predicts long-term patterns of hospitalization, especially for heart failure, among older adults.
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Affiliation(s)
- B S Kennedy
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT, USA
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Robbins JM, Vaccarino V, Zhang H, Kasl SV. Socioeconomic status and type 2 diabetes in African American and non-Hispanic white women and men: evidence from the Third National Health and Nutrition Examination Survey. Am J Public Health 2001; 91:76-83. [PMID: 11189829 PMCID: PMC1446485 DOI: 10.2105/ajph.91.1.76] [Citation(s) in RCA: 242] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study examined the associations of poverty income ratio (PIR), education, and occupational status with type 2 diabetes prevalence among African American and non-Hispanic White (White) women and men aged 40 to 74 years. METHODS We analyzed cross-sectional data from the Third National Health and Nutrition Examination Survey, controlling for age and examination-related variables. RESULTS Among African American women, there was a strong, graded association between PIR and diabetes, which remained significant after other risk factors were adjusted for. All 3 variables were significantly associated with diabetes among White women. Among White men, only PIR was significantly associated with diabetes. Controlling for risk factors substantially attenuated these associations among White women. There were no significant associations for African American men. CONCLUSIONS Socioeconomic status is associated with type 2 diabetes prevalence among women, but not consistently among men. Diabetes prevalence is more strongly associated with PIR than with education or occupational status. These associations are largely independent of other risk factors, especially among African American women. Economic resources should be addressed in efforts to explain and reverse the increasing prevalence of diabetes in the United States.
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Affiliation(s)
- J M Robbins
- Department of Epidemiology and Public Health, Yale University, New Haven, Conn., USA.
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Abstract
Because of women's survival advantage, the impact of myocardial infarction (MI) on long-term mortality in women compared with men may be underestimated. The authors examined this issue in a community sample of 2,462 persons aged > or = 65 years living in New Haven, Connecticut, who were free of MI at baseline and were followed for 10 years (1982-1992). By using proportional hazards models with MI hospitalizations and the sex-MI interaction as time-dependent covariables, survival for the MI cases from the date of MI was compared with survival of persons who, at the same follow-up time, were still alive and free of MI. Women survived longer than men mainly in the absence of MI. The multivariable-adjusted hazard ratios of death were 0.53 in the absence and 0.87 in the presence of MI, and MI was associated with a greater risk of death in women (adjusted hazard ratio = 5.9) than in men (adjusted hazard ratio = 3.6) (p = 0.01 for the sex-MI interaction). When out-of-hospital fatal infarctions were considered, the impact of MI on survival in women compared with men increased. In conclusion, in this elderly cohort, when viewed from a population perspective, MI had a greater impact on mortality in women and significantly narrowed women's typical survival advantage over men.
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Affiliation(s)
- V Vaccarino
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8034, USA.
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Robbins JM, Vaccarino V, Zhang H, Kasl SV. Excess type 2 diabetes in African-American women and men aged 40-74 and socioeconomic status: evidence from the Third National Health and Nutrition Examination Survey. J Epidemiol Community Health 2000; 54:839-45. [PMID: 11027198 PMCID: PMC1731578 DOI: 10.1136/jech.54.11.839] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine whether socioeconomic status (SES) explains differences in the prevalence of type 2 diabetes between African-American and non-Hispanic white women and men. DESIGN Cross sectional study of diabetes prevalence, SES, and other risk factors ascertained by physical examination and interview. SETTING Interviews were conducted in subjects' homes; physical examinations were conducted in mobile examination centres. PARTICIPANTS 961 African-American women, 1641 non-Hispanic white women, 839 African-American men and 1537 non-Hispanic white men, aged 40 to 74 years, examined in the Third National Health and Nutrition Examination Survey (NHANES III), a representative sample of the non-institutionalised civilian population of the United States, 1988-1994. MAIN RESULTS Among women, African-American race/ethnicity was associated with an age adjusted odds ratio of 1.76 (95% confidence intervals 1.21, 2.57), which was reduced to 1.42 (95% confidence intervals 0.95, 2.13) when poverty income ratio was controlled. Controlling for education or occupational status had minimal effects on this association. When other risk factors were controlled, race/ethnicity was not significantly associated with type 2 diabetes prevalence. Among men, the age adjusted odds ratio associated with African-American race/ethnicity was 1.43 (95% confidence intervals 1.03, 1.99). Controlling for SES variables only modestly affected the odds ratio for African/American race/ethnicity among men, while adjusting for other risk factors increased the racial/ethnic differences. CONCLUSIONS Economic disadvantage may explain much of the excess prevalence of type 2 diabetes among African-American women, but not among men.
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Affiliation(s)
- J M Robbins
- Population Studies Center, University of Pennsylvania, 3718 Locust Walk, Philadelphia, PA 19104-6298, USA.
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Abstract
The evidence from research studies linking depression to excess risk for coronary heart disease (CHD) is strong and consistent. Depression is a risk factor for new cardiovascular events in individuals initially free of CHD, as well as for recurrent events and mortality among cardiac patients. The risk is not only limited to individuals who meet the criteria for a clinical diagnosis of major depression. Increasing levels of depressive symptoms, even in the absence of a major depressive episode, also carry higher CHD risk. What is less established, however, is the mechanism (or mechanisms) responsible for the effect of depression on CHD risk. Depression might increase CHD incidence by promoting or worsening coronary atherosclerosis (through effects on lipid profile, platelets and inflammatory factors), directly inducing cardiac ischemia, increasing the risk for cardiac arrhythmias and sudden death, and inducing unhealthy behaviors (cigarette smoking, decreased adherence to medications and other lifestyle factors). Depression is common in the U.S. and its prevalence is rising. It is important that individuals with depression are promptly identified and treated. This is likely to result in a reduction of CHD and related disability as well as health care costs among Americans.
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Affiliation(s)
- V Vaccarino
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut 06520-8034, USA
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Abstract
OBJECTIVES We sought to determine whether pulse pressure (PP), a measure of arterial stiffness, is an independent predictor of the incidence of coronary heart disease (CHD), congestive heart failure (CHF) and overall mortality among community-dwelling elderly. BACKGROUND Current hypertension guidelines classify cardiovascular risk on the basis of elevated systolic blood pressure (SBP) or diastolic blood pressure (DBP) without considering their combined effects. Recent studies suggest that PP is a strong predictor of cardiovascular end points, but few data are available among community elderly. METHODS The study sample included 2,152 individuals age > or =65 years, who were participants in the Established Populations for Epidemiologic Study of the Elderly program, free of CHD and CHF at baseline and still alive at one year after enrollment. Blood pressure was measured at baseline. Incidence of CHD, incidence of CHF and total mortality were monitored in the following 10 years. RESULTS There were 328 incident CHD events, 224 incident CHF events and 1,046 persons who died of any cause. Pulse pressure showed a strong and linear relationship with each end point. After adjusting for demographics, comorbidity and CHD risk factors, a 10-mm Hg increment in PP was associated with a 12% increase in CHD risk (95% confidence interval [CI], 2% to 22%), a 14% increase in CHF risk (95% CI, 5% to 24%), and a 6% increase in overall mortality (95% CI, 0% to 12%). While SBP and mean arterial pressure (MAP) also showed positive associations with the end points, PP yielded the highest likelihood ratio chi-square. When PP was entered in the model in conjunction with other blood pressure parameters (SBP, DBP, MAP or hypertension stage, respectively), the association remained positive for PP but became negative for the other blood pressure variables. The effect of PP persisted after adjusting for current medication use and was present in normotensive individuals and individuals with isolated systolic hypertension but not in individuals with diastolic hypertension. CONCLUSIONS Elevated PP is a powerful independent predictor of cardiovascular end points in the elderly.
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Affiliation(s)
- V Vaccarino
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut 06520-8034, USA.
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Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Impact of history of diabetes mellitus on hospital mortality in men and women with first acute myocardial infarction. The National Registry of Myocardial Infarction 2 Participants. Am J Cardiol 2000; 85:1486-9; A7. [PMID: 10856398 DOI: 10.1016/s0002-9149(00)00800-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- V Vaccarino
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA.
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Krumholz HM, Chen YT, Vaccarino V, Wang Y, Radford MJ, Bradford WD, Horwitz RI. Correlates and impact on outcomes of worsening renal function in patients > or =65 years of age with heart failure. Am J Cardiol 2000; 85:1110-3. [PMID: 10781761 DOI: 10.1016/s0002-9149(00)00705-0] [Citation(s) in RCA: 268] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
1.5 mg/dl. Based on the number of these factors, a patient's risk for developing worsening renal function ranged between 16% (< or =1 factor) and 53% (> or =5 factors). After adjusting for confounding effects, worsening renal function was associated with a significantly longer length of stay by 2.3 days, higher in-hospital cost by $1,758, and an increased risk of in-hospital mortality (odds ratio 2.72; 95% confidence interval 1.62 to 4.58). In conclusion, worsening renal function, an event that frequently occurs in elderly patients hospitalized with heart failure, confers a substantial burden to patients and the healthcare system and can be predicted by 6 admission characteristics.
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Affiliation(s)
- H M Krumholz
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT 06520-8025, USA.
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Balcezak TJ, Krumholz HM, Getnick GS, Vaccarino V, Lin ZQ, Cadman EC. Utilization and effectiveness of a weight-based heparin nomogram at a large academic medical center. Am J Manag Care 2000; 6:329-38. [PMID: 10977433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVE To determine the utilization rate of a weight-based heparin nomogram and to assess the performance of the nomogram outside of experimental conditions. STUDY DESIGN Prospective cohort analysis. PATIENTS AND METHODS A total of 747 consecutive patients treated with intravenous heparin therapy for any indication on an internal medicine service were evaluated for the utilization rate of the weight-based nomogram, the time needed to exceed heparin's therapeutic threshold (activated partial thromboplastin time [aPTT] of > 1.5 times the control value), and the time needed to achieve heparin's therapeutic range (aPTT of 1.5 to 2.4 times the control value). Physicians were encouraged to use the weight-based nomogram by using conventional continuing medical education techniques and by configuring the computerized order entry system to give physicians an equally easy and voluntary choice between choosing the weight-based nomogram or ordering heparin in the traditional fashion. RESULTS The study program had no effect in increasing the utilization rate of the nomogram; this rate remained the same as before the program was initiated (10%). Less time was needed both to exceed the therapeutic threshold and to achieve a therapeutic range with the weight-based nomogram compared with physician-guided dosing (P < .001 and P = .021, respectively). No difference was demonstrated between the weight-based and physician-guided groups in incidence of bleeding complications or in the proportion of patients with one or more supratherapeutic aPTTs. CONCLUSIONS The weight-based nomogram led to superior intermediate outcomes compared with physician-guided dosing. However, despite efforts intended to modify physician behavior, the utilization rate remained so low that it was ineffective. Further research into the reasons why physicians chose not to use the weight-based nomogram and further research into methods to translate efficacious therapies into effective patient care are indicated.
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Affiliation(s)
- T J Balcezak
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
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Abstract
BACKGROUND Readmission rates for patients discharged with heart failure approach 50% within 6 months. Identifying factors to predict risk of readmission in these patients could help clinicians focus resource-intensive disease management efforts on the high-risk patients. METHODS The study sample included patients 65 years of age or older with a principal discharge diagnosis of heart failure who were admitted to 18 Connecticut hospitals in 1994 and 1995. We obtained patient and clinical data from medical record review. We determined outcomes within 6 months after discharge, including all-cause readmission, heart failure-related readmission, and death, from the Medicare administrative database. We evaluated 2176 patients, including 1129 in the derivation cohort and 1047 in the validation cohort. RESULTS Of 32 patient and clinical factors examined, 4 were found to be significantly associated with readmission in a multivariate model. They were prior admission within 1 year, prior heart failure, diabetes, and creatinine level >2.5 mg/dL at discharge. The event rates according to number of risk predictors were similar in the derivation and the validation sets for all outcomes. In the validation cohort, rates for all-cause readmission and combined readmission or death were 26% and 31% in patients with no risk predictors, 48% and 54% in patients with 1 or 2 risk predictors, and 59% and 65% in patients with 3 or all risk predictors. CONCLUSIONS Few patient and clinical factors predict readmission within 6 months after discharge in elderly patients with heart failure. Although we were unable to identify a group of patients at very low risk, a group of high-risk patients were identified for whom resource-intensive interventions designed to improve outcomes may be justified.
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Affiliation(s)
- H M Krumholz
- Section of Cardiovascular Medicine, Department of Medicine, the Yale University School of Medicine, New Haven, Connecticut, USA.
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Abstract
BACKGROUND There is evidence for sex differences in treatment and outcome of ischemic heart disease. However, little and conflicting data exist about sex differences in the care and outcome of elderly patients with heart failure. METHODS We compared mortality rate, readmission, and use of selected treatments and procedures between women and men in a database of 2445 patients (1426 women) aged >/=65 admitted for heart failure to 18 Connecticut hospitals in 1994 and 1995. Demographic and clinical data were abstracted from the medical records. RESULTS Women were older and more likely to have a history of hypertension whereas men more often had previous coronary heart disease. Women had more preserved left ventricular systolic function and higher systolic blood pressure on presentation than men. Treatments on day 1 (aspirin, angiotensin-converting enzyme [ACE] inhibitors, and diuretics), procedures during admission (assessment of left ventricular function, coronary angiography, and revascularization), and use of ACE inhibitors among ideal candidates at discharge were similar in men and women. Six-month rehospitalization rates were also similar. Although 30-day mortality rate did not differ between men and women, 6-month and 1-year mortality rates were lower in women after age adjustment (relative risk for 6-month death 0.81, 95% confidence interval, 0.68-0.95). In multivariable analysis, sex differences in mortality rate were reduced (relative risk 0.90, 95% confidence intervals, 0.75-1.08). History of hypertension, systolic blood pressure on admission, and left ventricular function mostly explained the observed sex differences in mortality rate. CONCLUSIONS Female and male patients hospitalized for heart failure have a similar hospital course, treatment pattern, and readmission rates, but women live longer than men. When baseline differences are accounted for, the mortality risk of women and men becomes very similar.
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Affiliation(s)
- V Vaccarino
- Department of Epidemiology, Internal Medicine Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
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Abstract
This study explores gender differences in symptom presentation associated with coronary heart disease (CHD). In this prospective study, nurse data collectors directly observed 550 patients as they presented to the Emergency Department (ED) of Yale-New Haven Hospital. The final sample included 217 patients (41% women) diagnosed with CHD (acute coronary ischemia or myocardial infarction). Chest pain was the most frequently reported symptom in women (70%) and men (71%). Unadjusted analyses revealed that women were more likely than men to present with midback pain (odds ratio [OR] 9.61, 95% confidence interval [CI] 2.10 to 44.11, p = 0.001), nausea and/or vomiting (OR 2.29, 95% CI 1.19 to 4.42, p = 0.012), dyspnea (OR 1.82, 95% CI 1.05 to 3.16, p = 0.032), palpitations (OR 3.42, 95% CI 1.02 to 11.47, p = 0.036), and indigestion (OR 2.13, 95% CI 1.03 to 4.44, p = 0.040). After adjustment for age and diabetes, women were more likely to present with nausea and/or vomiting (OR 2.43, 95% CI 1.23 to 4.79, p = 0.011) and indigestion (OR 2.13, 95% CI 1.10 to 4.53, p = 0.048). Women (30%) and men (29%) were equally likely to present without chest pain, and dyspnea was the most common non-chest pain symptom. In the subgroup of patients without chest pain, unadjusted analyses revealed that women were more likely to report nausea and/or vomiting compared with men (OR 4.40, 95% CI 1.30 to 14.84, p = 0.013). Although we found some significant gender differences in non-chest pain symptoms, we conclude that there were more similarities than differences in symptoms in women and men presenting to the ED with symptoms suggestive of CHD who were later diagnosed with CHD.
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Affiliation(s)
- K A Milner
- The Yale University School of Nursing, The Yale-New Haven Hospital Center for Outcomes Research and Evaluation, Connecticut, USA.
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Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants. N Engl J Med 1999; 341:217-25. [PMID: 10413733 DOI: 10.1056/nejm199907223410401] [Citation(s) in RCA: 845] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is conflicting information about whether short-term mortality after myocardial infarction is higher among women than among men after adjustment for age and other prognostic factors. We hypothesized that younger, but not older, women have higher mortality rates during hospitalization than their male peers. METHODS We analyzed data on 384,878 patients (155,565 women and 229,313 men) who were 30 to 89 years of age and who had been enrolled in the National Registry of Myocardial Infarction 2 between June 1994 and January 1998. Patients who had been transferred from or to other hospitals were excluded. RESULTS The overall mortality rate during hospitalization was 16.7 percent among the women and 11.5 percent among the men. Sex-based differences in the rates varied according to age. Among patients less than 50 years of age, the mortality rate for the women was more than twice that for the men. The difference in the rates decreased with increasing age and was no longer significant after the age of 74 (P< 0.001 for the interaction between sex and age). Logistic-regression analysis showed that the odds of death were 11.1 percent greater for women than for men with every five-year decrease in age (95 percent confidence interval, 10.1 to 12.1 percent). Differences in medical history, the clinical severity of the infarction, and early management accounted for only about one third of the difference in the risk. After adjustment for these factors, women still had a higher risk of death for every five years of decreasing age (increase in the odds of death, 7.0 percent; 95 percent confidence interval, 5.9 to 8.1 percent). CONCLUSIONS After myocardial infarction, younger women, but not older women, have higher rates of death during hospitalization than men of the same age. The younger the age of the patients, the higher the risk of death among women relative to men. Younger women with myocardial infarction represent a high-risk group deserving of special study.
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Affiliation(s)
- V Vaccarino
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn. 06520-8034, USA.
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Abstract
PURPOSE The risk factors for the development of heart failure are not clearly defined, particularly for older adults. We undertook the current investigation to examine the associations of traditional cardiovascular risk factors, comorbidity, and psychosocial factors with the risk of heart failure during 10 years of follow-up in a community-based elderly population. SUBJECTS AND METHODS We evaluated 1,749 subjects, 65 years of age or older, free of heart failure, myocardial infarction, and angina at baseline, who were participating in the New Haven, Connecticut cohort of the Established Population for Epidemiologic Studies of the Elderly program. Cox proportional hazards regression models were used to determine risk ratios (RR) and 95% confidence intervals (CI). RESULTS During 13,811 person-years of follow-up, 173 subjects developed incident heart failure, as confirmed by chart review. Five factors were independent predictors of heart failure: male sex (RR = 1.7; CI, 1.3 to 2.4), older age (RR = 1.9; CI, 1.3 to 2.7 for age 75 to 84 years, RR = 3.0; CI, 1.7 to 5.5 for age 85 years and older, compared with < or = 74 years), diabetes (RR = 2.9; CI, 2.0 to 4.3), pulse pressure > or = 70 mm Hg (RR = 2.3; CI, 1.3 to 4.3, compared with <50 mm Hg), and body mass index > or = 28 kg/m2 (RR = 1.6; CI, 1.0 to 2.4, compared with <24 kg/ m2). Myocardial infarction occurred during follow-up in 8% of the cohort and was also an important predictor of heart failure (RR = 21; CI, 15 to 31). CONCLUSIONS Age and traditional cardiovascular risk factors are associated with the development of heart failure in the elderly. Preventive strategies should focus on the management of diabetes, blood pressure, and weight, in addition to the prevention and management of myocardial infarction.
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Affiliation(s)
- Y T Chen
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8025, USA
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Mendes de Leon CF, Krumholz HM, Seeman TS, Vaccarino V, Williams CS, Kasl SV, Berkman LF. Depression and risk of coronary heart disease in elderly men and women: New Haven EPESE, 1982-1991. Established Populations for the Epidemiologic Studies of the Elderly. Arch Intern Med 1998; 158:2341-8. [PMID: 9827785 DOI: 10.1001/archinte.158.21.2341] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Results of several recent studies suggest that depression is predictive of incident coronary disease. However, few studies have examined this relationship in the elderly, the age at which most coronary heart disease (CHD) becomes clinically manifest. METHODS AND RESULTS Data are from the New Haven, Conn, cohort (N = 2812) of the Established Populations for the Epidemiologic Studies of the Elderly project. Baseline information on depressive symptoms and CHD risk factors was collected during an in-person interview in 1982. Nonfatal myocardial infarctions were identified through monitoring of admissions to local hospitals and were validated by medical chart review. Cause of death was obtained from death certificates for all deceased participants. Outcomes were defined as CHD deaths (n = 255) and total incident CHD events (n = 391) between January 1, 1982, and December 31, 1991. There was no association between depressive symptoms and CHD outcomes in men. Among women, depressive symptoms were associated with an age-adjusted relative risk of 1.03 (per unit increase on the symptom scale) for CHD mortality (P=.001) and total CHD incidence (P=.002). These associations were largely unaffected by adjustment for established CHD risk factors but were reduced to nonsignificant levels after additional adjustment for impaired physical function. Additional analysis showed a significant association for depressive symptoms among women who had no physical function impairments or who survived at least 3 years without an event. CONCLUSION Depressive symptoms may not be independent risk factors for CHD outcomes in elderly populations in general but may increase risk among relatively healthy older women.
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Affiliation(s)
- C F Mendes de Leon
- Rush Institute for Healthy Aging, Rush-Presbyterian-St Luke's Medical Center, Chicago, Ill 60612, USA.
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Vaccarino V, Horwitz RI, Meehan TP, Petrillo MK, Radford MJ, Krumholz HM. Sex differences in mortality after myocardial infarction: evidence for a sex-age interaction. Arch Intern Med 1998; 158:2054-62. [PMID: 9778206 DOI: 10.1001/archinte.158.18.2054] [Citation(s) in RCA: 138] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Studies of sex differences in mortality after myocardial infarction (MI) have shown conflicting results. OBJECTIVES To test the hypothesis that sex differences in mortality after MI vary according to patients' age, with younger women, but not older women, having a higher mortality compared with men. METHODS We performed a retrospective cohort study of 1025 consecutive patients who met accepted criteria for MI in 1992 and 1993 in 15 Connecticut hospitals. Data for the study were abstracted from medical records. RESULTS Women had a 40% higher hospital mortality rate than men. Simple age adjustment eliminated the sex difference in mortality rate (odds ratio, 0.99; 95% confidence interval, 0.66-1.48). However, when the sample was subdivided into 2 age groups, women younger than 75 years showed twice as high a mortality rate as men in the same age group, while among older patients no difference in mortality was found. In multivariate analyses the interaction of sex with age was highly significant, even after adjusting for comorbid conditions, clinical severity, process of care, and hospital characteristics. In the fully adjusted model, this interaction indicated that among patients younger than 75 years women had 49% higher odds of hospital death than men, while in the age group 75 years or older women had 46% lower odds of death compared with men. CONCLUSIONS A higher mortality of women compared with men after MI is confined to the younger age groups. The sex-age interaction should be considered when examining sex differences in mortality after MI.
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Affiliation(s)
- V Vaccarino
- Department of Epidemiology, Yale University School of Medicine, New Haven, Conn 06520-8034, USA.
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Mendes de Leon CF, Krumholz HM, Vaccarino V, Williams CS, Glass TA, Berkman LF, Kas SV. A population-based perspective of changes in health-related quality of life after myocardial infarction in older men and women. J Clin Epidemiol 1998; 51:609-16. [PMID: 9674668 DOI: 10.1016/s0895-4356(98)00037-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This study analyzes changes in health-related quality-of-life (HQL) outcomes following myocardial infarction (MI) from a population-based perspective. Data came from a representative sample of 2812 men and women 65 years and older living in New Haven, CT. All subjects were interviewed at baseline in 1982, and again in 1985 and 1988. HQL outcomes included self-rated health, depressive symptoms, and physical and social functioning. Pooled logistic regression models were used to estimate the risk for decline in HQL outcomes due to MI. Of the 203 MIs during follow-up, 111 (55%) survived until the next interview to provide post-MI data on outcomes. In bivariate analysis, MI patients were more likely than subjects without MI to show a decline in physical functioning (26.4% vs. 11.9%, P = .001) and social functioning (31.4% vs. 20.8%), P = .06). There were no differences in self-rated health (26.3% vs. 26.9%), but MI patients were less likely to show an increase in depression (9.1%) vs. 15.8%, P = .08). These associations remained mostly unchanged after adjustment for CHD risk factors. The effect of MI on physical and social functioning was much stronger among patients with a recent MI (<1 year ago) than those whose MI had occurred more than a year before post-MI assessment. While a substantial proportion of MI patients experience a significant decline in quality of life-related outcomes, only some of these declines occur more frequently among MI patients than in the population at large. This effect may also be limited to the immediate post-MI period. Results from this analysis are discussed in terms of the "burden of illness" within a defined population due to MI.
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Affiliation(s)
- C F Mendes de Leon
- Rush Institute for Healthy Aging, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA
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Krumholz HM, Hennen J, Ridker PM, Murillo JE, Wang Y, Vaccarino V, Ellerbeck EF, Radford MJ. Use and effectiveness of intravenous heparin therapy for treatment of acute myocardial infarction in the elderly. J Am Coll Cardiol 1998; 31:973-9. [PMID: 9561996 DOI: 10.1016/s0735-1097(98)00022-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We sought to determine the use and association with 30-day mortality of intravenous heparin for the treatment of acute myocardial infarction in elderly patients not treated with a reperfusion strategy and without contraindications to anticoagulation. BACKGROUND The benefit of using full-dose intravenous heparin for the treatment of acute myocardial infarction in the elderly is not known. METHODS We conducted a retrospective cohort study using hospital medical records of all Medicare beneficiaries admitted to the hospital with an acute myocardial infarction in Alabama, Connecticut, Iowa and Wisconsin from June 1992 through February 1993. RESULTS Among the 6,935 patients > or = 65 years old who had no absolute chart-documented contraindications to heparin, 3,227 (47%) received early full-dose intravenous heparin therapy. After adjustment for baseline differences in demographic, clinical and treatment factors between patients with and without heparin, the use of heparin (odds ratio 1.02, 95% confidence interval 0.87 to 1.18) was not associated with a significantly better 30-day mortality rate. CONCLUSIONS Although intravenous heparin was commonly used for treatment of acute myocardial infarction in the elderly, it was not associated with an improved 30-day mortality rate. Although the findings of this observational study must be interpreted with care, they lead us to question whether the prevalent use of intravenous heparin has therapeutic effectiveness in this population.
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Affiliation(s)
- H M Krumholz
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, Yale-New Haven Hospital Center for Outcomes Research and Evaluation, Connecticut 06520-8025, USA.
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Krumholz HM, Philbin DM, Wang Y, Vaccarino V, Murillo JE, Therrien ML, Williams J, Radford MJ. Trends in the quality of care for Medicare beneficiaries admitted to the hospital with unstable angina. J Am Coll Cardiol 1998; 31:957-63. [PMID: 9561993 DOI: 10.1016/s0735-1097(98)00106-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We sought to 1) determine the proportion of appropriate elderly patients admitted to the hospital with unstable angina who are treated with aspirin and heparin; 2) identify patient factors associated with the Agency for Health Care Policy and Research (AHCPR) guideline-based use of aspirin and heparin; and 3) compare practice patterns and patient outcomes before and after publication of the AHCPR guidelines. BACKGROUND Improving the care of patients with unstable angina may provide immediate opportunities to mitigate the adverse consequences of unstable angina. However, despite the importance of this diagnosis, there is a paucity of information on the patterns of treatment and outcomes across diverse sites and recent trends in practice that have occurred, especially since the publication of the AHCPR practice guidelines. METHOD We performed a retrospective cohort study using data created from medical charts and administrative files. The sample included 300 consecutive patients admitted to one of three Connecticut hospitals in the period 1993 to 1994 and 150 consecutive patients admitted in 1995 with a principal discharge diagnosis of unstable angina or chest pain. RESULTS Of the 384 patients > or =65 years old who had no contraindications to aspirin on hospital admission, 276 (72%) received it. Of the 369 patients > or =65 years old who had no contraindications to heparin on admission, 88 (24%) received it. Among the 321 patients > or =65 years old who had no contraindications to aspirin at hospital discharge, 208 (65%) were prescribed it. When 1995 was compared with 1993 to 1994, the use of aspirin (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3 to 4.0) and heparin (OR 2.8, 95% CI 1.6 to 4.9) on hospital admission significantly increased, and the use of aspirin at discharge (OR 1.4, 95% CI 0.8 to 2.4) increased. Concomitantly, there was a significant reduction in 30-day readmission (OR 0.52, 95% CI 0.27 to 0.99). CONCLUSIONS Our results indicate an improvement in the care and outcomes of elderly patients with unstable angina, but there remain opportunities for further improvement.
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Affiliation(s)
- H M Krumholz
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale-New Haven Hospital, CT 06520-8025, USA.
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Krumholz HM, Butler J, Miller J, Vaccarino V, Williams CS, Mendes de Leon CF, Seeman TE, Kasl SV, Berkman LF. Prognostic importance of emotional support for elderly patients hospitalized with heart failure. Circulation 1998; 97:958-64. [PMID: 9529263 DOI: 10.1161/01.cir.97.10.958] [Citation(s) in RCA: 237] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several studies have indicated that a variety of social relationships are important predictors of morbidity and mortality in patients with coronary artery disease, but little attention has been focused on the prognostic importance of these factors in the growing population of elderly patients with heart failure. To address this issue, we sought to determine whether emotional support is associated with fatal and nonfatal cardiovascular events in elderly patients hospitalized with heart failure. METHODS AND RESULTS We reviewed the medical records of 292 subjects aged > or =65 years who were hospitalized with clinical heart failure and were part of the New Haven, Conn, cohort of the Established Population for the Epidemiologic Study of the Elderly, a longitudinal, community-based study of aging that included a comprehensive assessment of psychosocial support. In the unadjusted analysis, lack of emotional support was significantly associated with the 1-year risk of fatal and nonfatal cardiovascular outcomes [odds ratio, 2.4; 95% confidence interval, 1.1 to 4.9]. After adjustment for demographic factors, clinical severity, comorbidity and functional status, social ties, and instrumental support, the absence of emotional support remained associated with a significantly higher risk (odds ratio, 3.2; 95% confidence interval, 1.4 to 7.8). The test for interaction between emotional support and sex was significant (P=.01). In the fully adjusted model, the odds ratio for women was 8.2 (95% confidence interval, 2.5 to 27.2) compared with 1.0 (95% confidence interval, 0.3 to 3.3) for men. CONCLUSIONS Among elderly patients hospitalized with clinical heart failure, the absence of emotional support, measured before admission, is a strong, independent predictor of the occurrence of fatal and nonfatal cardiovascular events in the year after admission. In this cohort, the association is restricted to women.
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Affiliation(s)
- H M Krumholz
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut 06520-8025, USA.
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Abstract
Several studies have indicated that women sustaining a myocardial infarction have a higher unadjusted short-term (i.e., in-hospital or 30-day) mortality than men. The advanced age of women at the time of presentation appears to be the major factor contributing to their worse prognosis relative to men. Controlling for age eliminates the association between female gender and increased mortality in most, but not all studies. This article reviews the data on age and other factors that might explain why women with a myocardial infarction fare worse then men.
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Affiliation(s)
- A Nohria
- Department of Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
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