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Data on the epidemiology of aortic stenosis (AS) are primarily derived from single center experiences and administrative claims data that do not delineate by degree of disease severity. An observational cohort study of adults with echocardiographic AS was conducted January 1st, 2013-December 31st, 2019 at an integrated health system. The presence/grade of AS was based on physician interpretation of echocardiograms. A total of 66,992 echocardiogram reports for 37,228 individuals were identified. The mean ± standard deviation (SD) age was 77.5 ± 10.5, 50.5% (N = 18,816) were women, and 67.2% (N = 25,016) were non-Hispanic whites. The age-standardized AS prevalence increased from 589 (95% Confidence Interval [CI] 580–598) to 754 (95% CI 744–764) cases per 100,000 during the study period. The age-standardized AS prevalences were similar in magnitude among non-Hispanic whites (820, 95% CI 806–834), non-Hispanic blacks (728, 95% CI 687–769), and Hispanics (789, 95% CI 759–819) and substantially lower for Asian/Pacific Islanders (511, 95% CI 489–533). Finally, the distribution of AS by degree of severity remained relatively unchanged over time. The population prevalence of AS has grown considerably over a short timeframe although the distribution of AS severity has remained stable. • The prevalence of aortic stenosis has grown substantially. • The prevalence of aortic stenosis is lower for Asian/Pacific Islanders. • The distribution of aortic stenosis severity has not changed over time. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) is commonly treated with oral anticoagulants, including warfarin or direct oral anticoagulants (DOACs). Although DOACs are associated with favorable treatment satisfaction, few studies have assessed whether quality of life differs between DOAC and warfarin users. We invited adults enrolled in two California-based integrated health care delivery systems and with a history of VTE between January 1, 2015 and June 30, 2018 to complete a survey on their experience with anticoagulants. Health-related quality of life (QOL) was assessed using the RAND 36-item Short Form Health Survey (SF-36), which measures QOL in 2 general component scores (physical and mental). We used multivariable linear regression to compare mean QOL component scores between DOAC-users and warfarin-users, adjusting for patient and clinical characteristics. Overall, 2230 patients (43.1 % women and 31.8 % >75 years of age) taking anticoagulants answered at least 1 question on the SF-36, 975 taking DOACs and 1255 taking warfarin. After adjustment for patient-level factors, there were no significant differences in either physical component scores (39.2 v 38.3, p = 0.24) or mental component scores (48.5 v 49.0, p = 0.42) between DOAC and warfarin users. Health-related QOL did not significantly differ between DOAC and warfarin users with a history of VTE. • Health-related quality of life (QOL) is a key outcome measure in venous thromboembolism (VTE). • Little is known about differences in QOL for patients prescribed warfarin versus direct oral anticoagulants (DOACs). • We assessed QOL using RAND 36-item Short Form Health Survey (SF-36) in patients with VTE in Kaiser integrated healthcare system. • Among 2230 patients, there were no significant differences in physical or mental QOL scores between warfarin and DOAC users. [ABSTRACT FROM AUTHOR]

Background: Limited existing data suggest that the novel COVID-19 may increase risk of VTE, but information from large, ethnically diverse populations with appropriate control participants is lacking.Research Question: Does the rate of VTE among adults hospitalized with COVID-19 differ from matched hospitalized control participants without COVID-19?Study Design and Methods: We conducted a retrospective study among hospitalized adults with laboratory-confirmed COVID-19 and hospitalized adults without evidence of COVID-19 matched for age, sex, race or ethnicity, acute illness severity, and month of hospitalization between February 2020 and August 2020 from two integrated health-care delivery systems with 36 hospitals. Outcomes included VTE (DVT or pulmonary embolism ascertained using diagnosis codes combined with validated natural language processing algorithms applied to electronic health records) and death resulting from any cause at 30 days. Fine and Gray hazards regression was performed to evaluate the association of COVID-19 with VTE after accounting for competing risk of death and residual differences between groups, as well as to identify predictors of VTE in patients with COVID-19.Results: We identified 6,319 adults with COVID-19 and 6,319 matched adults without COVID-19, with mean ± SD age of 60.0 ± 17.2 years, 46% women, 53.1% Hispanic, 14.6% Asian/Pacific Islander, and 10.3% Black. During 30-day follow-up, 313 validated cases of VTE (160 COVID-19, 153 control participants) and 1,172 deaths (817 in patients with COVID-19, 355 in control participants) occurred. Adults with COVID-19 showed a more than threefold adjusted risk of VTE (adjusted hazard ratio, 3.48; 95% CI, 2.03-5.98) compared with matched control participants. Predictors of VTE in patients with COVID-19 included age ≥ 55 years, Black race, prior VTE, diagnosed sepsis, prior moderate or severe liver disease, BMI ≥ 40 kg/m2, and platelet count > 217 k/μL.Interpretation: Among ethnically diverse hospitalized adults, COVID-19 infection increased the risk of VTE, and selected patient characteristics were associated with higher thromboembolic risk in the setting of COVID-19. [ABSTRACT FROM AUTHOR]

Clinically recognized atrial fibrillation (AF) is associated with higher risk of complications, including ischemic stroke, cognitive decline, heart failure, myocardial infarction, and death. It is increasingly recognized that AF frequently is undetected until complications such as stroke or heart failure occur. Hence, the public and clinicians have an intense interest in detecting AF earlier. However, the most appropriate strategies to detect undiagnosed AF (sometimes referred to as subclinical AF) and the prognostic and therapeutic implications of AF detected by screening are uncertain. Our report summarizes the National Heart, Lung, and Blood Institute's virtual workshop focused on identifying key research priorities related to AF screening. Global experts reviewed major knowledge gaps and identified critical research priorities in the following areas: (1) role of opportunistic screening; (2) AF as a risk factor, risk marker, or both; (3) relationship between AF burden detected with long-term monitoring and outcomes/treatments; (4) designs of potential randomized trials of systematic AF screening with clinically relevant outcomes; and (5) role of AF screening after ischemic stroke. Our report aims to inform and catalyze AF screening research that will advance innovative, resource-efficient, and clinically relevant studies in diverse populations to improve the diagnosis, management, and prognosis of patients with undiagnosed AF. [ABSTRACT FROM AUTHOR]

Studies using administrative data commonly rely on diagnosis codes to identify venous thromboembolism (VTE) events. Our objective was to assess the validity of using International Classification of Disease, 9th Revision (ICD-9) codes in identifying recurrent VTE. Among 5497 adults with confirmed incident VTE from four healthcare delivery systems in the Cardiovascular Research Network (CVRN), we identified all subsequent inpatient, emergency department (ED), and ambulatory clinical encounters associated with an ICD-9 code for VTE (combined with relevant radiology procedure codes for inpatient/ED VTE codes in the secondary discharge position or outpatient codes) during the follow-up period. Medical records were reviewed using standardized diagnostic criteria to assess for the presence of new, recurrent VTE. The positive predictive value (PPV) of codes was calculated as the number of valid events divided by total encounters. We identified 2397 encounters that were considered potential recurrent VTE by ICD-9 codes. However, only 31.1% (95%CI: 29.3–33.0%) of encounters were verified by reviewers as true recurrent VTE. Hospital or ED encounters with VTE codes in the primary position were more likely to represent valid recurrent VTE (PPV 61.3%, 95%CI: 56.7–66.3%) than codes in secondary positions (PPV 35.4%, 95%CI: 31.9–39.3%), or outpatient codes (PPV 20.3%, 95%CI: 18.3–22.5%). PPV was low for all VTE types (29.9% for pulmonary embolism, 38.3% for lower and 37.7% for upper extremity deep venous thrombosis, and 14.1% for other VTE). ICD-9 codes do not accurately identify new VTE events in patients with a prior history of VTE. • The validity of ICD-9 codes to identify recurrent venous thromboembolism is unknown. • Their positive predictive value to identify recurrent venous thromboembolism is 31%. • The validity varies according to type of venous thromboembolism and code position. • Combining codes with a new anticoagulation prescription improves their validity. • ICD-9 codes alone to identify recurrent venous thromboembolism should not be used. [ABSTRACT FROM AUTHOR]

Background: Dabigatran (150 mg twice daily) has been associated with lower rates of stroke than warfarin in trials of atrial fibrillation, but large-scale evaluations in clinical practice are limited.Objective: To compare incidence of stroke, bleeding, and myocardial infarction in patients receiving dabigatran versus warfarin in practice.Design: Retrospective cohort.Setting: National U.S. Food and Drug Administration Sentinel network.Patients: Adults with atrial fibrillation initiating dabigatran or warfarin therapy between November 2010 and May 2014.Measurements: Ischemic stroke, intracranial hemorrhage, extracranial bleeding, and myocardial infarction identified from hospital claims among propensity score-matched patients starting treatment with dabigatran or warfarin.Results: Among 25 289 patients starting dabigatran therapy and 25 289 propensity score-matched patients starting warfarin therapy, those receiving dabigatran did not have significantly different rates of ischemic stroke (0.80 vs. 0.94 events per 100 person-years; hazard ratio [HR], 0.92 [95% CI, 0.65 to 1.28]) or extracranial hemorrhage (2.12 vs. 2.63 events per 100 person-years; HR, 0.89 [CI, 0.72 to 1.09]) but were less likely to have intracranial bleeding (0.39 vs. 0.77 events per 100 person-years; HR, 0.51 [CI, 0.33 to 0.79]) and more likely to have myocardial infarction (0.77 vs. 0.43 events per 100 person-years; HR, 1.88 [CI, 1.22 to 2.90]). However, the strength and significance of the association between dabigatran use and myocardial infarction varied in sensitivity analyses and by exposure definition (HR range, 1.13 [CI, 0.78 to 1.64] to 1.43 [CI, 0.99 to 2.08]). Older patients and those with kidney disease had higher gastrointestinal bleeding rates with dabigatran.Limitation: Inability to examine outcomes by dabigatran dose (unacceptable covariate balance between matched patients) or quality of warfarin anticoagulation (few patients receiving warfarin had available international normalized ratio values).Conclusion: In matched adults with atrial fibrillation treated in practice, the incidences of stroke and bleeding with dabigatran versus warfarin were consistent with those seen in trials. The possible relationship between dabigatran and myocardial infarction warrants further investigation.Primary Funding Source: U.S. Food and Drug Administration. [ABSTRACT FROM AUTHOR]

Background: Monitoring trends in cardiovascular events can provide key insights into the effectiveness of prevention efforts. Leveraging data from electronic health records provides a unique opportunity to examine contemporary, community-based trends in acute myocardial infarction hospitalizations.Methods: We examined trends in hospitalized acute myocardial infarction incidence among adults aged ≥25 years in 13 US health plans in the Cardiovascular Research Network. The first hospitalization per member for acute myocardial infarction overall and for ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction was identified by International Classification of Diseases, Ninth Revision, Clinical Modification primary discharge codes in each calendar year from 2000 through 2008. Age- and sex-adjusted incidence was calculated per 100,000 person-years using direct adjustment with 2000 US census data.Results: Between 2000 and 2008, we identified 125,435 acute myocardial infarction hospitalizations. Age- and sex-adjusted incidence rates (per 100,000 person-years) of acute myocardial infarction decreased an average 3.8%/y from 230.5 in 2000 to 168.6 in 2008. Incidence of ST-segment elevation myocardial infarction decreased 8.7%/y from 104.3 in 2000 to 51.7 in 2008, whereas incidence of non-ST-segment elevation myocardial infarction increased from 126.1 to 129.4 between 2000 and 2004 and then decreased thereafter to 116.8 in 2008. Age- and sex-specific incidence rates generally reflected similar patterns, with relatively larger decreases in ST-segment elevation myocardial infarction rates in women compared with men. As compared with 2000, the age-adjusted incidence of ST-segment elevation myocardial infarction in 2008 was 48% lower among men and 61% lower among women.Conclusions and Relevance: Among a large, diverse, multicenter community-based insured population, there were significant decreases in incidence of hospitalized acute myocardial infarction and the more serious ST-segment elevation myocardial infarctions between 2000 and 2008. Decreases in ST-segment elevation myocardial infarctions were most pronounced among women. While ecologic in nature, these secular decreases likely reflect, at least in part, results of improvement in primary prevention efforts. [ABSTRACT FROM AUTHOR]

Objectives To explore barriers to anticoagulation in older adults with atrial fibrillation ( AF) at high risk of stroke and to identify opportunities for interventions that might increase use of oral anticoagulants ( OACs). Design Retrospective cohort study. Setting Two large community-based AF cohorts. Participants Individuals with ischemic stroke surviving hospitalization (N = 1,405, mean age 79). Measurements Using structured chart review, reasons for nonuse of OAC were identified, and 1-year poststroke survival was assessed. Logistic regression was used to identify correlates of OAC nonuse. Results Median CHA2 DS2- VASc score was 5, yet 44% of participants were not prescribed an OAC at discharge. The most-frequent (nonmutually exclusive) physician reasons for not prescribing OAC included fall risk (26.7%), poor prognosis (19.3%), bleeding history (17.1%), participant or family refusal (14.9%), older age (11.0%), and dementia (9.4%). Older age (odds ratio ( OR) = 8.96, 95% confidence interval ( CI) = 5.01-16.04 for aged ≥85 vs <65) and disability ( OR = 12.58, 95% CI = 5.82-27.21 for severe vs no deficit) were the most-important independent predictors of nonuse of OACs. By 1 year, 42.5% of those not receiving an OAC at discharge had died, versus 19.1% of those receiving an OAC ( P < .001), far higher than recurrent stroke rates. Conclusion Despite very high stroke risk, more than 40% of participants were not discharged with an OAC. Dominant reasons included fall risk, poor prognosis, older age, and dementia. These individuals' high 1-year mortality rate confirmed their high level of comorbidity. To improve anticoagulation decisions and outcomes in this population, future research should focus on strategies to mitigate fall risk, improve assessment of risks and benefits of anticoagulation in individuals with AF, and determine whether newer anticoagulants are safer in complex elderly and frail individuals. [ABSTRACT FROM AUTHOR]

Objectives To provide greater understanding of the 'real world' effect of anticoagulation on stroke risk over several years. Design Cohort study. Setting Anticoagulation and Risk Factors in Atrial Fibrillation Study community-based cohort. Participants Adults with nonvalvular atrial fibrillation ( AF) between 1996 and 2003 (13,559). Measurements All events were clinician adjudicated. Extended Cox regression with longitudinal warfarin exposure was used to estimate cause-specific hazard ratios ( HRs) for thromboembolism and the competing risk event (all cause death). The Fine and Gray subdistribution regression approach was used to estimate this association while accounting for competing death events. As a secondary analysis, follow-up was limited to 1, 3, and 5 years. Results The rate of death was much higher in the group not taking warfarin (8.1 deaths/100 person-years ( PY)) than in the group taking warfarin (5.5 deaths/100 PY). The cause-specific HR indicated a large reduction in thromboembolism with warfarin use (adjusted HR = 0.57, 95% confidence interval ( CI) = 0.50-0.65), although this association was substantially attenuated after accounting for competing death events (adjusted HR = 0.87, 95% CI = 0.77-0.99). In analyses limited to 1 year of follow-up, with fewer competing death events, the results for models that did and did not account for competing risks were similar. Conclusion Analyses accounting for competing death events may provide a more-realistic estimate of the longer-term stroke prevention benefits of anticoagulants than traditional noncompeting risk analyses for individuals with AF, particularly those who are not currently treated with anticoagulants. [ABSTRACT FROM AUTHOR]

Background The presence of multimorbidity is known to be related to adverse clinical outcomes. However, its association with mortality in patients undergoing cardiac valve replacement is not known. Methods Multimorbidity (as a continuous variable) was characterized in adults receiving cardiac valve replacement surgery between 2008 and 2012 within Kaiser Permanente Northern California based on information from health plan electronic health records. Our primary outcome was 3-year all-cause mortality after surgery. We used Cox proportional hazards regression to evaluate the independent association of each additional comorbidity with mortality. Results Among 3686 eligible patients, mean age was 67.9 ± 13.5 years and median comorbidity burden was 3 (IQR: 2). The presence of most individual comorbidities except hypertension and hyperlipidemia did not occur in isolation. The unadjusted annual incidence (per 100 person-years) of death increased with higher comorbidity burden: ≤ 1: 4.61 (95% CI: 3.29–6.45), 2–3: 13.7 (95% CI: 11.9–15.8), 4–5: 23.6 (95% CI: 20.6–26.9), and ≥ 6: 43.4(95% CI: 34.6–54.4). Advancing age, diabetes mellitus, cerebrovascular accident, heart failure, lung disease, urgent status and use of aldosterone-receptor antagonists were independently associated with an increased risk of mortality. In multivariable analyses, each additional comorbidity was significantly associated with an increased risk of long-term (adjusted hazard ratio (HR) 1.30, 95% CI: 1.22–1.39) but not short-term mortality (HR 0.92, 95% CI: 0.80–1.07). Conclusions Our study demonstrated that multimorbidity in patients undergoing cardiac valve replacement is significantly associated with long-term but not short-term mortality. [ABSTRACT FROM AUTHOR]

Background: Diagnosed diabetes mellitus (DM) is a consistently documented risk factor for ischemic stroke in patients with atrial fibrillation (AF).Objectives: The purpose of this study was to assess the association between duration of diabetes and elevated hemoglobin A1c (HbA1c) with risk of stroke among diabetic patients with AF.Methods: We assessed this association in the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) California community-based cohort of AF patients (study years 1996 to 2003) where all events were clinician adjudicated. We used Cox proportional hazards regression to estimate the rate of ischemic stroke in diabetic patients according to time-varying measures of estimated duration of diabetes (≥3 years compared with <3 years) and HbA1c values (≥9.0% and 7.0% to 8.9% compared with <7.0%), focusing on periods where patients were not anticoagulated.Results: There were 2,101 diabetic patients included in the duration analysis: 40% with duration <3 years and 60% with duration ≥3 years at baseline. Among 1,933 diabetic patients included in the HbA1c analysis, 46% had HbA1c <7.0%, 36% between 7.0% and 8.9%, and 19% ≥9.0% at baseline. Duration of diabetes ≥3 years was associated with an increased rate of ischemic stroke compared with duration <3 years (adjusted hazard ratio [HR]: 1.74, 95% confidence interval [CI]: 1.10 to 2.76). The increased stroke rate was observed in older (age ≥75 years) and younger (age <75 years) individuals. Neither poor glycemic control (HbA1c ≥9.0%, adjusted HR: 1.04, 95% CI: 0.57 to 1.92) nor moderately increased HbA1c (7.0% to 8.9%, adjusted HR: 1.21, 95% CI: 0.77 to 1.91) were significantly associated with an increased rate of ischemic stroke compared with patients who had HbA1c <7.0%.Conclusions: Duration of diabetes is a more important predictor of ischemic stroke than glycemic control in patients who have diabetes and AF. [ABSTRACT FROM AUTHOR]

To date, there have been few studies evaluating outcomes of patients with atrial fibrillation (AF) who have experienced gastrointestinal (GI) hemorrhages. We examined short- and long-term mortality of major GI hemorrhage in patients with AF on and off warfarin in recent clinical care. We evaluated this association in the large Anticoagulation and Risk Factors in Atrial fibrillation (ATRIA) and ATRIA-Cardiovascular Research Network (CVRN) California community-based cohorts of patients with AF (study years 1996 to 2003 and 2006 to 2009, respectively), where all events were clinician adjudicated. We used proportional hazards regression with propensity score adjustment to estimate the short- (30 days) and long-term (>30 days for 1 year) mortality rate ratio for patients using warfarin compared with those who were not using warfarin at the time of GI hemorrhage. In the 414 ATRIA participants with major GI hemorrhage, 54% were taking warfarin at the time of the hemorrhage; in the 361 ATRIA-CVRN participants with major GI hemorrhage, 58% were taking warfarin. Warfarin use at the time of GI hemorrhage was not associated with 30-day mortality in the ATRIA cohort but was associated with significantly reduced 30-day mortality in the ATRIA-CVRN cohort (adjusted mortality rate ratio [95% confidence interval], ATRIA 0.97 [0.54 to 1.74]; ATRIA-CVRN 0.38 [0.17 to 0.83]). There was a modest suggestion of lower mortality on warfarin after 30 days in both cohorts. In conclusion, our study demonstrates that GI hemorrhages on warfarin are certainly no worse and may be less life threatening than those occurring off warfarin. These findings are in stark contrast to the deleterious effect of warfarin on mortality from intracranial hemorrhage and add another factor favoring anticoagulation in clinical decision making for patients with AF. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to examine the effectiveness of clopidogrel in real-world, medically managed patients with unstable angina (UA) or non–ST-segment elevation myocardial infarction (NSTEMI). Background: Although clinical trials have demonstrated the efficacy of clopidogrel to reduce cardiovascular (CV) morbidity and mortality in medically managed patients with UA or NSTEMI, the effectiveness of clopidogrel in actual clinical practice is less certain. Methods: A retrospective cohort study was conducted of Kaiser Permanente Northern California members without known coronary artery disease or prior clopidogrel use who presented with UA or NSTEMI between 2003 and 2008 and were medically managed (i.e., no percutaneous coronary intervention or coronary artery bypass grafting during the index hospitalization or within 7 days post-discharge). Over 2 years of follow-up, we measured the association between clopidogrel use and all-cause mortality, hospital stay for MI, and a composite endpoint of death or MI using propensity-matched multivariable Cox analyses. Results: We identified 16,365 patients with incident UA (35%) or NSTEMI (65%); 36% of these patients were prescribed clopidogrel within 7 days of discharge. In 8,562 propensity score–matched patients, clopidogrel users had lower rates of all-cause mortality (8.3% vs. 13.0%; p < 0.01; adjusted hazard ratio [HR]: 0.63; 95% confidence interval [CI]: 0.54 to 0.72) and the composite of death or MI (13.5% vs. 17.4%; p < 0.01; HR: 0.74, CI: 0.66 to 0.84), but not MI alone (6.7% vs. 7.2%; p = 0.30; HR: 0.93, CI: 0.78 to 1.11), compared with nonusers of clopidogrel. The association between clopidogrel use and the composite of death or MI was significant only among patients presenting with NSTEMI (HR: 0.67; CI: 0.59 to 0.76; pint < 0.01), not among those presenting with UA (HR: 1.25; CI: 0.94 to 1.67). Conclusions: In a large, community-based cohort of patients who were medically managed after UA/NSTEMI, clopidogrel use was associated with a lower risk of death and MI, particularly among patients with NSTEMI. [Copyright &y& Elsevier]

The Anticoagulation Length of Therapy and Risk of New Adverse Events In Venous Thromboembolism (ALTERNATIVE) study was designed to compare the benefits and harms of different treatment options for extended treatment of venous thromboembolism (VTE). In this paper, we describe the study cohort, survey data collection, and preliminary results. We identified 39,605 adult patients (age ≥ 18 years) from two large integrated health care delivery systems who were diagnosed with incident VTE and received initial anticoagulation therapy of 3 months or longer. A subset of the cohort (12,737) was invited to participate in a survey. Surveys were completed in English, Spanish or Mandarin via a mailed questionnaire, an online secure web link, or telephone. The survey domains included demographics, personal medical history, anticoagulant treatment history, anticoagulant treatment satisfaction, health-related quality of life and health literacy. A total of 5,017 patients participated in the survey for an overall response rate of 39.4%. The mean (SD) age of the survey respondents was 63.0 (14.5) years and self-reported race was 76.0% White/European, 11.1% Black/African American, and 3.8% Asian/Pacific Islander and 14.0% reported Hispanic ethnicity. Sixty percent of respondents completed the web survey, while 29.0% completed the mail-in paper survey, and 11.0% completed the survey via telephone. The ALTERNATIVE Study will address knowledge gaps by comparing several treatment alternatives for the extended management of VTE so that this information could be used by patients and clinicians to make more informed, patient-centered treatment choices. [ABSTRACT FROM AUTHOR]

The article presents a report by the American Heart Association (AHA) on heart disease and stroke statistics for 2013. It includes update on data coverage for poor cardiovascular health behaviors, prevalence and control of cardiovascular health factors, and overall rates of death by cardiovascular disease (CVD). Further, update on critical data and quality of care metrics for CVD and cardiovascular procedure use and cost are provided.

Furthermore, a stepwise association is present between the number of ideal cardiovascular health metrics and risk of all-cause mortality, CVD mortality, and ischemic HD mortality after 14.5 years of follow-up in the United States.[12] The adjusted hazard ratios (HRs) for individuals with 6 or 7 ideal health metrics compared with individuals with 0 ideal health metrics were 0.49 (95% CI, 0.33-0.74) for all-cause mortality, 0.24 (95% CI, 0.13-0.47) for CVD mortality, and 0.30 (95% CI, 0.13-0.68) for ischemic HD mortality.[12] Ford et al[13] demonstrated similar relationships. Multiple trials of most dietary supplements, including folate, vitamin C, and vitamin E, have generally shown no significant benefits for CVD risk, and even potential for harm.[118] For example, a multicenter randomized trial in patients with diabetic nephropathy found that B vitamin supplementation (folic acid 2.5 mg/d, vitamin B6 25 mg/d, and vitamin B12 1 mg/d) decreased glomerular filtration rate (GFR) and increased risk of MI and stroke compared with placebo.[125] Fish oil supplements at doses of 1 to 2 g/d have shown CVD benefits in 2 large randomized, open-label trials and 1 large randomized, placebo-controlled trial (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico [GISSI]-Prevenzione, Japan Eicosapentaenoic Acid Lipid Intervention Study, and GISSI-HF),[NaN] but other smaller trials of fish oil have not shown significant effects on CVD risk.[129] A meta-analysis of placebo-controlled trials (ie, excluding the 2 large open-label trials) showed a modest benefit for CVD mortality but no statistically significant effects on other CVD end points.[130]. [Extracted from the article]

AHA Scientific Statements; cardiovascular diseases; epidemiology; risk factors; statistics; stroke This year's edition also implements a new chapter organization to reflect the spectrum of cardiovascular health behaviors and health factors and risks, as well as subsequent complicating conditions, disease states, and outcomes. The total direct and indirect cost of CVD and stroke in the United States for 2009 is estimated to be $312.6 billion. AHA Scientific Statements, cardiovascular diseases, epidemiology, risk factors, statistics, stroke. [Extracted from the article]

Objectives To examine whether the total burden of comorbidity and pattern of co-occurring conditions varies in individuals with heart failure ( HF) with preserved left ventricular ejection fraction ( LVEF) ( HF-P) or HF with reduced LVEF ( HF-R). Design Cross-sectional cohort study. Setting Four participating health plans within the National Heart, Lung, and Blood Institute-sponsored Cardiovascular Research Network. Participants All members aged 65 and older with HF based on hospital discharge and ambulatory visit diagnoses. Measurements Participants with a LVEF of 50% or greater were classified as having HF-P. Presence of cardiac and noncardiac comorbidities was obtained from health plan administrative databases. Results Of 23,435 individuals identified with HF and LVEF information, 53% (12,407) had confirmed HF-P (mean age 79.6; 60% female). More than three-quarters of the sample had three or more co-occurring conditions in addition to HF, and half had five or more cooccurring conditions. Participants with HF-P had a slightly higher burden of comorbidity than those with HF-R (mean 4.5 vs 4.4, P = .002). Patterns of how specific conditions co-occurred did not vary in participants with preserved or reduced systolic function. Conclusion There is a high degree of comorbidity and multiple morbidity in individuals with HF. The burden and pattern of comorbidity varies only slightly in individuals with preserved or reduced LVEF. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to examine whether kidney dysfunction is associated with the type of clinical presentation of coronary heart disease (CHD). Background: Reduced kidney function increases the risk for developing CHD, but it is not known whether it also influences the acuity of clinical presentation, which has important prognostic implications. Methods: A case-control study was conducted of subjects whose first clinical presentation of CHD was either acute myocardial infarction or stable exertional angina between October 2001 and December 2003. Estimated glomerular filtration rate (eGFR) before the incident event was calculated using calibrated serum creatinine and the abbreviated MDRD (Modification of Diet in Renal Disease) equation. Patient characteristics and use of medications were ascertained from self-report and health plan databases. Multivariable logistic regression was used to examine the association of reduced eGFR and CHD presentation. Results: A total of 803 adults with incident acute myocardial infarctions and 419 adults with incident stable exertional angina who had baseline eGFRs ≤130 ml/min/1.73 m2 were studied. Mean eGFR was lower in subjects with acute myocardial infarctions compared with those with stable angina. Compared with eGFR of 90 to 130 ml/min/1.73 m2, a strong, graded, independent association was found between reduced eGFR and presenting with acute myocardial infarction, with adjusted odds ratios of 1.36 (95% confidence interval: 0.99 to 1.86) for eGFR 60 to 89 ml/min/1.73 m2, 1.55 (95% confidence interval: 0.92 to 2.62) for eGFR 45 to 59 ml/min/1.73 m2, and 3.82 (95% confidence interval: 1.55 to 9.46) for eGFR <45 ml/min/1.73 m2 (p < 0.001 for trend). Conclusions: An eGFR <45 ml/min/1.73 m2 is a strong, independent predictor of presenting with acute myocardial infarction versus stable angina as the initial manifestation of CHD. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to develop a risk stratification score to predict warfarin-associated hemorrhage. Background: Optimal decision making regarding warfarin use for atrial fibrillation requires estimation of hemorrhage risk. Methods: We followed up 9,186 patients with atrial fibrillation contributing 32,888 person-years of follow-up on warfarin, obtaining data from clinical databases and validating hemorrhage events using medical record review. We used Cox regression models to develop a hemorrhage risk stratification score, selecting candidate variables using bootstrapping approaches. The final model was internally validated by split-sample testing and compared with 6 published hemorrhage risk schemes. Results: We observed 461 first major hemorrhages during follow-up (1.4% annually). Five independent variables were included in the final model and weighted by regression coefficients: anemia (3 points), severe renal disease (e.g., glomerular filtration rate <30 ml/min or dialysis-dependent, 3 points), age ≥75 years (2 points), prior bleeding (1 point), and hypertension (1 point). Major hemorrhage rates ranged from 0.4% (0 points) to 17.3% per year (10 points). Collapsed into a 3-category risk score, major hemorrhage rates were 0.8% for low risk (0 to 3 points), 2.6% for intermediate risk (4 points), and 5.8% for high risk (5 to 10 points). The c-index for the continuous risk score was 0.74 and 0.69 for the 3-category score, higher than in the other risk schemes. There was net reclassification improvement versus all 6 comparators (from 27% to 56%). Conclusions: A simple 5-variable risk score was effective in quantifying the risk of warfarin-associated hemorrhage in a large community-based cohort of patients with atrial fibrillation. [Copyright &y& Elsevier]

The article presents a review of different studies to analyze the secular trends of the epidemiology of myocardial infarction (MI) in communities. The study obtained the data by focusing on the population-based studies that conducted surveys and questionnaires in several communities. The results showed that existing studies were limited in sample sizes and diversity in the study populations and have failed to characterize the long-term effects of outpatient medication of MI.

To determine whether acute renal failure (ARF) increases the long-term risk of progressive chronic kidney disease (CKD), we studied the outcome of patients whose initial kidney function was normal or near normal but who had an episode of dialysis-requiring ARF and did not develop end-stage renal disease within 30 days following hospital discharge. The study encompassed 556,090 adult members of Kaiser Permanente of Northern California hospitalized over an 8 year period, who had pre-admission estimated glomerular filtration rates (eGFR) equivalent to or greater than 45 ml/min/1.73 m2 and who survived hospitalization. After controlling for potential confounders such as baseline level of eGFR and diabetes status, dialysis-requiring ARF was independently associated with a 28-fold increase in the risk of developing stage 4 or 5 CKD and more than a twofold increased risk of death. Our study shows that in a large, community-based cohort of patients with pre-existing normal or near normal kidney function, an episode of dialysis-requiring ARF was a strong independent risk factor for a long-term risk of progressive CKD and mortality. [ABSTRACT FROM AUTHOR]

The article provides information on a study on the comparative effectiveness of various β-blockers. It cites the statistics of chronic heart failure victims in the U.S. which affect more than 5 million Americans. The researchers compared mortality linked with different β-blockers after being hospitalized due to heart failure between 2001 and 2003. The patient characteristics were identified via administrative, state mortality, and Social Security Administration databases. Results showed that about 7976 out of 11,326 adults surviving a hospitalization for heart failure received β-blockers. It suggests that randomized trials within real-world settings be conducted to reassure the clinical effectiveness of β-blockers for heart failure.

Objectives. We sought to determine whether chronic conditions and functional limitations are equally predictive of mortality among older adults. Methods. Participants in the 1998 wave of the Health and Retirement Study (N = 19430) were divided into groups by decades of age, and their vital status in 2004 was determined. We used multivariate Cox regression to determine the ability of chronic conditions and functional limitations to predict mortality. Results. As age increased, the ability of chronic conditions to predict mortality declined rapidly, whereas the ability of functional limitations to predict mortality declined more slowly. In younger participants (aged 50-59 years), chronic conditions were stronger predictors of death than were functional limitations (Harrell C statistic 0.78 vs. 0.73; P = .001). In older participants (aged 90-99 years), functional limitations were stronger predictors of death than were chronic conditions (Harrell C statistic 0.67 vs. 0.61; P = .004). Conclusions. The importance of chronic conditions as a predictor of death declined rapidly with increasing age. Therefore, risk-adjustment models that only consider comorbidities when comparing mortality rates across providers may be inadequate for adults older than 80 years. [ABSTRACT FROM AUTHOR]

Objectives: We assessed 5 risk stratification schemes for their ability to predict atrial fibrillation (AF)–related thromboembolism in a large community-based cohort. Background: Risk schemes can help target anticoagulant therapy for patients at highest risk for AF–related thromboembolism. We tested the predictive ability of 5 risk schemes: the Atrial Fibrillation Investigators, Stroke Prevention in Atrial Fibrillation, CHADS2 (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, and prior Stroke or transient ischemic attack) index, Framingham score, and the 7th American College of Chest Physicians Guidelines. Methods: We followed a cohort of 13,559 adults with AF for a median of 6.0 years. Among non-warfarin users, we identified incident thromboembolism (ischemic stroke or peripheral embolism) and risk factors from clinical databases. Each scheme was divided into low, intermediate, and high predicted risk categories and applied to the cohort. Annualized thromboembolism rates and c-statistics (to assess discrimination) were calculated for each risk scheme. Results: We identified 685 validated thromboembolic events that occurred during 32,721 person-years off warfarin therapy. The risk schemes had only fair discriminating ability, with c-statistics ranging from 0.56 to 0.62. The proportion of patients assigned to individual risk categories varied widely across the schemes. The proportion categorized as low risk ranged from 11.7% to 37.1% across schemes, and the proportion considered high risk ranged from 16.4% to 80.4%. Conclusions: Current risk schemes have comparable, but only limited, overall ability to predict thromboembolism in persons with AF. Recommendations for antithrombotic therapy may vary widely depending on which scheme is applied for individual patients. Better risk stratification is crucially needed to improve selection of AF patients for anticoagulant therapy. [Copyright &y& Elsevier]

Placebo-controlled randomized trials have demonstrated the efficacy of selected β blockers on outcomes in chronic heart failure (HF), but the relative effectiveness of different β blockers in usual clinical care is poorly understood. We compared 12-month risk of rehospitalization for HF associated with receipt of different β blockers in 7,883 adults hospitalized for HF within 2 large health plans between January 1, 2001 and December 31, 2002. Beta-blocker use was ascertained from electronic pharmacy databases and readmissions within 12 months were identified from hospital discharge databases. Extended Cox regression was used to examine the association between receipt of different β blockers and risk of readmission for HF after adjustment for potential confounders. During follow-up, there were 3,234 person-years of exposure to β blockers (39.3% atenolol, 42.0% metoprolol tartrate, 12.3% carvedilol, and 6.4% other). Crude 12-month rates of readmissions for HF were high overall (42.6 per 100 person-years). After adjustment for potential confounders, cumulative exposure to each β blocker, and propensity to receive carvedilol compared with atenolol, adjusted risks of readmission were not significantly different for metoprolol tartrate (adjusted hazard ratio 0.95, 95% confidence interval 0.85 to 1.05) or for carvedilol (adjusted hazard ratio 0.92, 95% confidence interval 0.74 to 1.14). In conclusion, in a contemporary cohort of high-risk patients hospitalized with HF, we found that adjusted risks of rehospitalization for HF within 12 months were not significantly different in patients receiving atenolol, shorter-acting metoprolol tartrate, or carvedilol. [Copyright &y& Elsevier]

Objectives: Little is known about the outcomes of patients who have hemorrhagic complications while receiving warfarin therapy. We examined the rates of death and disability resulting from warfarin-associated intracranial and extracranial hemorrhages in a large cohort of patients with atrial fibrillation.Methods: We assembled a cohort of 13,559 adults with nonvalvular atrial fibrillation and identified patients hospitalized for warfarin-associated intracranial and major extracranial hemorrhage. Data on functional disability at discharge and 30-day mortality were obtained from a review of medical charts and state death certificates. The relative odds of 30-day mortality by hemorrhage type were calculated using multivariable logistic regression.Results: We identified 72 intracranial and 98 major extracranial hemorrhages occurring in more than 15,300 person-years of warfarin exposure. At hospital discharge, 76% of patients with intracranial hemorrhage had severe disability or died, compared with only 3% of those with major extracranial hemorrhage. Of the 40 deaths from warfarin-associated hemorrhage that occurred within 30 days, 35 (88%) were from intracranial hemorrhage. Compared with extracranial hemorrhages, intracranial events were strongly associated with 30-day mortality (odds ratio 20.8 [95% confidence interval, 6.0-72]) even after adjusting for age, sex, anticoagulation intensity on admission, and other coexisting illnesses.Conclusions: Among anticoagulated patients with atrial fibrillation, intracranial hemorrhages caused approximately 90% of the deaths from warfarin-associated hemorrhage and the majority of disability among survivors. When considering anticoagulation, patients and clinicians need to weigh the risk of intracranial hemorrhage far more than the risk of all major hemorrhages. [ABSTRACT FROM AUTHOR]

Objectives: We sought to examine the association between the metabolic syndrome (MetS) (defined both by the 2001 National Cholesterol Educational Program Adult Treatment Panel III [ATP-III] definition and the American Heart Association/National Heart, Lung and Blood Institute [AHA/NHLBI] revision incorporating the lower threshold for impaired fasting glucose [IFG]) and early-onset coronary artery disease (CAD). Background: The impact of MetS on premature CAD has not been studied extensively. Lowering the threshold to define the IFG component (from 110 to 100 mg/dl) and the value of the syndrome as a whole versus its individual components are subjects of intense debate. Methods: We performed a case-control study with 393 early-onset CAD subjects (acute myocardial infarction, angina with ≥50% stenosis, or coronary revascularization) in men under age 46 years or women under age 56 years and 393 control subjects individually matched for gender, age, and race/ethnicity. Results: By conditional logistic regression, presence of ATP-III MetS without diabetes (adjusted odds ratio [adj-OR] 4.9; 95% confidence interval [CI] 3.4 to 8.0) and with diabetes (adj-OR 8.0, 95% CI 4.39 to 14.6) was a strong independent determinant of early-onset CAD. Using the AHA/NHLBI revision, these ORs became slightly stronger. However, neither definition of MetS remained significantly associated with early-onset CAD in multivariate models adjusting for individual components. Conclusions: The presence of MetS imparts a high risk of early-onset clinical CAD, but the prognostic information associated with the syndrome is not greater than the sum of its parts. [Copyright &y& Elsevier]

This article presents a study on hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins) therapy and its prevention of death and hospitalization in those who suffer from chronic heart failure. The study concluded that statins are effective for primary and secondary prevention of atherosclerotic events in the general population. Alterations of lipoprotein levels, the reduction of levels of inflammatory factors, improved endothelial function and the stabilization of coronary plaque may be particularly beneficial to patients with heart failure.

OBJECTIVES: To assess whether older age is independently associated with hemorrhage risk in patients with atrial fibrillation, whether or not they are taking warfarin therapy. DESIGN: Cohort study. SETTING: Integrated healthcare delivery system. PARTICIPANTS: Thirteen thousand five hundred fifty-nine adults with nonvalvular atrial fibrillation. MEASUREMENTS: Patient data were collected from automated clinical and administrative databases using previously validated search algorithms. Medical charts were reviewed from patients hospitalized were for major hemorrhage (intracranial, fatal, requiring ≥2 units of transfused blood, or involving a critical anatomic site). Age was categorized into four categories (<60, 60–69, 70–79, and ≥80), and multivariable Poisson regression was used to assess whether major hemorrhage rates increased with age, stratified by warfarin use and adjusted for other clinical risk factors for hemorrhage. RESULTS: A total of 170 major hemorrhages were identified during 15,300 person-years of warfarin therapy and 162 major hemorrhages during 15,530 person-years off warfarin therapy. Hemorrhage rates rose with older age, with an average increase in hemorrhage rate of 1.2 (95% confidence interval (CI) 1.0–1.4) per older age category in patients taking warfarin and 1.5 (95% CI=1.3–1.8) in those not taking warfarin. Intracranial hemorrhage rates were significantly higher in those aged 80 and older (adjusted rate ratio=1.8, 95% CI=1.1–3.1 for those taking warfarin, adjusted rate ratio=4.7, 95% CI=2.4–9.2 for those not taking warfarin) than in those younger than 80. CONCLUSION: Older age increases the risk of major hemorrhage, particularly intracranial hemorrhage, in patients with atrial fibrillation, whether or not they are taking warfarin. Hemorrhage rates were generally comparable with those reported in previous randomized trials, indicating that carefully monitored warfarin therapy can be used with reasonable safety in older patients. [ABSTRACT FROM AUTHOR]

Background: Coronary atherosclerosis develops slowly over decades but is frequently characterized clinically by sudden unstable episodes. Patients who present with unstable coronary disease, such as acute myocardial infarction, may systematically differ from patients who present with relatively stable coronary disease, such as exertional angina. Objective: To examine whether medication use or patient characteristics influence the mode of initial clinical presentation of coronary disease. Design: Case-control study. Setting: Large integrated health care delivery system in northern California. Patients: Adults whose first clinical presentation of coronary disease was either acute myocardial infarction (n = 916) or stable exertional angina (n = 468). Measurements: Use of cardiac medications before the event from pharmacy databases and demographic, lifestyle, and clinical characteristics from self-report and clinical and administrative databases. Results: Compared with patients with incident stable exertional angina, patients with incident acute myocardial infarction were more likely to be men, smokers, physically inactive, and hypertensive but were less likely to have a parental history of coronary disease. Patients presenting with myocardial infarction were much less likely to have received statins (19.3% vs. 40.4%; P < 0.001) and β-blockers (19.0% vs. 47.7%; P < 0.001) than patients presenting with exertional angina. After adjustment for potential confounders, recent use of statins (adjusted odds ratio, 0.45 [95% CI, 0.32 to 0.62]) and β-blockers (adjusted odds ratio, 0.26 [CI, 0.19 to 0.35]) was associated with lower likelihoods of presenting with an acute myocardial infarction than with stable angina. Limitations: This observational study did not have information on all possible confounding factors, including use of aspirin therapy. Conclusion: Statin and β-blocker use was associated with lower odds of presenting with an acute myocardial infarction than with stable angina. Additional studies are needed to confirm that these therapies protect against unstable, higher-risk clinical presentations of coronary disease. [ABSTRACT FROM AUTHOR]

Background: Left ventricular hypertrophy (LVH) frequently complicates chronic renal insufficiency. Anemia is also common in these patients and may contribute to LVH.Methods: We conducted an open-label interventional trial to evaluate the effect of recombinant erythropoietin (rhEPO) on left ventricular mass index (LVMI) in anemic patients with renal insufficiency. Adults with creatinine clearance 10 to 30 mL/min (nondiabetics) or 20 to 40 mL/min (diabetics) were recruited, and rhEPO was given to those with anemia (hemoglobin level <10 g/dL). Baseline and 6-month LVMI and LVH (LVMI >130 g/m(2) in men and >100 g/m(2) in women), hemoglobin levels, creatinine clearance, blood pressure, medications, and medical history were obtained. Forty anemic and 61 nonanemic control subjects were enrolled.Results: Overall, the prevalence of LVH was 68.3% (95% CI 58.3-77.2), and entry hemoglobin level was the only significant predictor of baseline LVH (adjusted OR 0.69 per g/dL increase in hemoglobin, 95% CI 0.50-0.94). After 6 months, LVMI decreased in anemic patients receiving rhEPO (142 +/- 56 vs. 157 +/- 56 g/m(2)) (P= 0.007), with an increase in hemoglobin (11.3 +/- 1.9 vs. 9.1 +/- 0.7 g/dL) (P= 0.001). There were no changes in LVMI or hemoglobin level among controls. After adjusting for confounders and change in hemoglobin, receipt of rhEPO was associated with a significant reduction in LVMI (P= 0.01).Conclusion: Treatment with rhEPO was not independently associated with significant changes in blood pressure or renal function. LVH is a common finding in chronic renal insufficiency and is associated with lower hemoglobin levels. Treatment with rhEPO may decrease LVH in patients with severe renal insufficiency and anemia. [ABSTRACT FROM AUTHOR]

Objective: Vascular calcification holds promise as a useful cardiovascular risk maker. Our objective was to examine the association between breast vascular calcification and risk of cardiovascular disease (CVD) outcomes. Methods: A cohort study was performed among 12,761 women, 40-79 years of age at baseline (1968-1973), who attended multiphasic health checkups that included mammography. The outcome measures included coronary heart disease (CHD), ischemic stroke, transient ischemic attack (TIA), hemorrhagic stroke, and heart failure, ascertained using discharge diagnosis codes and death records through December 31, 2000 (median follow-up, 24.8 years). Results: Breast vascular calcification was present in 424 (3%) women, It was independently and positively associated with age, high parity, and diabetes and inversely associated with education level and current cigarette smoking. After adjustment for age, education level, race, cigarette smoking, alcohol use, body mass index (BMI), serum total cholesterol, hypertension, diabetes, parental history of myocardial infarction (MI), parity, and hormone replacement therapy (HRT), breast vascular calcification was associated with a 1.32-fold increased risk of CHD (95% confidence interval [CI] 1.08-4.60), a 1.41-fold increased risk of ischemic stroke (95% CI 1.11-1.78), and a 1,52=fold increased risk of heart failure (95% CI 1.18-1.98). Conclusions: Breast vascular calcification detected as part of a screening mammogram was an independent risk factor for multiple cardiovascular outcomes among women, The value of mammography in cardiovascular risk stratification deserves further investigation. [ABSTRACT FROM AUTHOR]

Context: Warfarin has been shown to be highly efficacious for preventing thromboembolism in atrial fibrillation in randomized trials, but its effectiveness and safety in clinical practice is less clear. Objective: To evaluate the effect of warfarin on risk of thromboembolism, hemorrhage, and death in atrial fibrillation within a usual care setting. Design: Cohort study assembled between July 1, 1996, and December 31, 1997, and followed up through August 31, 1999. Setting: Large integrated health care system in Northern California. Patients: Of 13 559 adults with nonvalvular atrial fibrillation, 11 526 were studied, 43% of whom were women, mean age 71 years, with no known contraindications to anticoagulation at baseline. Main Outcomes: Ischemic stroke, peripheral embolism, hemorrhage, and death according to warfarin use and comorbidity status, as determined by automated databases, review of medical records, and state mortality files. Results: Among 11 526 patients, 397 incident thromboembolic events (372 ischemic strokes, 25 peripheral embolism) occurred during 25 341 person-years of follow-up, and warfarin therapy was associated with a 51% (95% confidence interval [CI], 39%-60%) lower risk of thromboembolism compared with no warfarin therapy (either no antithrombotic therapy or aspirin) after adjusting for potential confounders and likelihood of receiving warfarin. Warfarin was effective in reducing thromboembolic risk in the presence or absence of risk factors for stroke. A nested case-control analysis estimated a 64% reduction in odds of thromboembolism with warfarin compared with no antithrombotic therapy. Warfarin was also associated with a reduced risk of all-cause mortality (adjusted hazard ratio, 0.69; 95% CI, 0.61-0.77). Intracranial hemorrhage was uncommon, but the rate was moderately higher among those taking vs those not taking warfarin (0.46 vs 0.23 per 100 person-years, respectively; P = .003, adjusted hazard ratio, 1.97; 95% CI, 1.24-3.13). However, warfarin therapy was not associated with an increased adjusted risk of nonintracranial major hemorrhage. The effects of warfarin were similar when patients with contraindications at baseline were analyzed separately or combined with those without contraindications (total cohort of 13 559). Conclusions: Warfarin is very effective for preventing ischemic stroke in patients with atrial fibrillation in clinical practice while the absolute increase in the risk of intracranial hemorrhage is small. Results of randomized trials of anticoagulation translate well into clinical care for patients with atrial fibrillation. [ABSTRACT FROM AUTHOR]

Reports implications for rhythm management and stroke prevention in adults in the United States. Anticoagulation and risk factors in atrial fibrillation (ATRIA) study; Risk factors for stroke as well as reduction in quality of life, functional status, and cardiac performance; Atrial fibrillation to increase; Need for stroke prevention.

Purpose: To assess the effects of physician specialty on the knowledge, management, and outcomes of patients with coronary disease or heart failure.Materials and Methods: We performed a systematic search of MEDLINE from 1980 to 1997, as well as bibliographic references to articles about the effects of physician specialty on the knowledge, treatment, and outcomes of patients with coronary disease or heart failure in the United States.Results: Twenty-four articles met our criteria for inclusion (including eight that involved knowledge or self-reported practices, 14 that described actual practice patterns, and six that measured clinical outcomes). Cardiologists were more knowledgeable than generalist physicians about the optimal evaluation and management of coronary disease but not about the use of angiotensin-converting enzyme (ACE) inhibitors for heart failure. Patients with unstable angina or myocardial infarction were more likely to receive proven medical therapies, and possibly had improved outcomes, if they were treated by cardiologists. The use of lipid-lowering drugs after myocardial infarction was also more common among patients of cardiologists. ACE inhibitor use for heart failure was probably greater, and short-term readmission rates were lower, with cardiology care.Conclusions: Patients with coronary disease or heart failure in the United States who are treated by cardiologists appear more likely to receive evidence-based care and probably have better outcomes. Investigation of collaborative models of care and innovative efforts to improve the use of proven therapies by physicians are needed. [ABSTRACT FROM AUTHOR]

In patients with left bundle branch block (LBBB) and acute chest pain, the association between the clinical presentation and the diagnosis of myocardial infarction has not been investigated. We sought to identify features in the clinical history of patients with LBBB and acute cardiopulmonary symptoms that predict myocardial infarction among candidates for reperfusion therapy. We retrospectively studied a consecutive cohort of 75 patients (94 presentations) who presented to a university emergency department from 1994 to 1997 with LBBB on initial electrocardiogram (ECG) and acute chest pain of ≥20 min duration or acute pulmonary edema. Among the 94 presentations meeting criteria for the cohort, 26 (28%) had confirmed myocardial infarction. Coronary heart disease risk factors, past cardiac history, prior LBBB on the ECG, and presenting symptoms did not predict whether patients were having myocardial infarction. The clinical history was not effective at distinguishing LBBB patients with myocardial infarction among patients who appeared to be candidates for acute reperfusion therapy.Copyright © 2000 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Warfarin dramatically reduces the risk for ischemic stroke in nonvalvular atrial fibrillation, but its use among ambulatory patients with atrial fibrillation has not been widely studied.Objective: To assess the rates and predictors of warfarin use in ambulatory patients with nonvalvular atrial fibrillation.Design: Cross-sectional study.Setting: Large health maintenance organization.Patients: 13428 patients with a confirmed ambulatory diagnosis of nonvalvular atrial fibrillation and known warfarin status between 1 July 1996 and 31 December 1997.Measurements: Data from automated pharmacy, laboratory, and clinical-administrative databases were used to determine the prevalence and determinants of warfarin use in the 3 months before or after the identified diagnosis of atrial fibrillation.Results: Of 11082 patients with nonvalvular atrial fibrillation and no known contraindications, 55% received warfarin. Warfarin use was substantially lower in patients who were younger than 55 years of age (44.3%) and those who were 85 years of age or older (35.4%). Only 59.3% of patients with one or more risk factors for stroke and no contraindications were receiving warfarin. Among a subset of "ideal" candidates to receive warfarin (persons 65 to 74 years of age who had no contraindications and had previous stroke, hypertension, or both), 62.1% had evidence of warfarin use. Among our entire cohort, the strongest predictors of receiving warfarin were previous stroke (adjusted odds ratio, 2.55 [95% CI, 2.23 to 2.92]), heart failure (odds ratio, 1.63 [CI, 1.51 to 1.77]), previous intracranial hemorrhage (odds ratio, 0.33 [CI, 0.21 to 0.52]), age 85 years or older (odds ratio, 0.35 [CI, 0.31 to 0.40]), and previous gastrointestinal hemorrhage (odds ratio, 0.47 [CI, 0.40 to 0.57]).Conclusions: In a large, contemporary cohort of ambulatory patients with atrial fibrillation who received care within a health maintenance organization, warfarin use was considerably higher than in other reported studies. Although the reasons why physicians did not prescribe warfarin could not be elucidated, many apparently eligible patients with atrial fibrillation and at least one additional risk factor for stroke, especially hypertension, did not receive anticoagulation. Interventions are needed to increase the use of warfarin for stroke prevention among appropriate candidates. [ABSTRACT FROM AUTHOR]

Background: Left bundle-branch block (BBB) is considered an important predictor of poor outcome in patients with acute myocardial infarction, but the consequences of right BBB are not well understood.Objectives: To 1) estimate the prevalence of left and right BBB in patients with myocardial infarction; 2) compare the clinical characteristics of and treatments received by patients with left, right, or no BBB; and 3) determine the independent association of left BBB and right BBB with in-hospital death.Design: Retrospective cohort study.Setting: Multicenter registry of 1571 U.S. hospitals.Patients: 297,832 patients with acute myocardial infarction who had left, right, or no BBB on initial electrocardiography.Measurements: Presence and type of BBB, clinical characteristics of patients, therapies given, and in-hospital death.Results: Patients with left BBB (n = 19,967; 6.7%) or right BBB (n = 18,354; 6.2%) were older and had more comorbid illness and congestive heart failure than patients with no BBB. Among patients for whom thrombolytic therapy was clearly indicated, fewer patients with left or right BBB (16.6% and 32.0%, respectively) than patients with no BBB (66.5%) received this therapy (P < 0.001). Fewer patients with left or right BBB (60.6% and 67.3%, respectively) than patients with no BBB (75.6%) received aspirin within the first 24 hours (P < 0.001), and fewer patients with left or right BBB (23.9% and 31.8%, respectively) than patients with no BBB (40.4%) received beta-blockers within the first 24 hours (P < 0.001). Unadjusted in-hospital mortality rates were almost twice as high for patients with left or right BBB (22.6% and 23.0%, respectively) as for patients with no BBB (13.1%) (P < 0.001). Compared with no BBB and no ST-segment elevation, left BBB was associated with a 34% increase (odds ratio, 1.34 [95% CI, 1.28 to 1.39]) and right BBB was associated with a 64% increase (odds ratio, 1.64 [CI, 1.57 to 1.71]) in the risk for in-hospital death, after adjustment for potential confounders.Conclusions: In patients with acute myocardial infarction, prevalences of right and left BBB are similar. Patients with BBB have more comorbid conditions, are less likely to receive therapy, and have an increased risk for in-hospital death compared with patients with no BBB. Compared with left BBB, right BBB seems to be a stronger independent predictor of in-hospital death. [ABSTRACT FROM AUTHOR]

Evaluates whether cardiologists provide more recommended therapies to elderly patients with acute myocardial infarction (MI) to determine if the variations in processes of care account for differences in patient outcome. Non-related differences in the use of recommended therapies by specialists and patient outcome; Underutilization of recommended MI therapies regardless of medical specialization.

This letter comments on the letter by Timo Strandberg [ABSTRACT FROM AUTHOR]

Background We compared the efficacy of the antiviral agent, remdesivir, versus standard-of-care treatment in adults with severe coronavirus disease 2019 (COVID-19) using data from a phase 3 remdesivir trial and a retrospective cohort of patients with severe COVID-19 treated with standard of care. Methods GS-US-540–5773 is an ongoing phase 3, randomized, open-label trial comparing two courses of remdesivir (remdesivir-cohort). GS-US-540–5807 is an ongoing real-world, retrospective cohort study of clinical outcomes in patients receiving standard-of-care treatment (non-remdesivir-cohort). Inclusion criteria were similar between studies: patients had confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, were hospitalized, had oxygen saturation ≤94% on room air or required supplemental oxygen, and had pulmonary infiltrates. Stabilized inverse probability of treatment weighted multivariable logistic regression was used to estimate the treatment effect of remdesivir versus standard of care. The primary endpoint was the proportion of patients with recovery on day 14, dichotomized from a 7-point clinical status ordinal scale. A key secondary endpoint was mortality. Results After the inverse probability of treatment weighting procedure, 312 and 818 patients were counted in the remdesivir- and non-remdesivir-cohorts, respectively. At day 14, 74.4% of patients in the remdesivir-cohort had recovered versus 59.0% in the non-remdesivir-cohort (adjusted odds ratio [aOR] 2.03: 95% confidence interval [CI]: 1.34–3.08, P <.001). At day 14, 7.6% of patients in the remdesivir-cohort had died versus 12.5% in the non-remdesivir-cohort (aOR 0.38, 95% CI:.22–.68, P =.001). Conclusions In this comparative analysis, by day 14, remdesivir was associated with significantly greater recovery and 62% reduced odds of death versus standard-of-care treatment in patients with severe COVID-19. Clinical Trials Registration NCT04292899 and EUPAS34303. [ABSTRACT FROM AUTHOR]

A review of the article "Current trial-associated outcomes with warfarin in prevention of stroke in patients with nonvalvular atrial fibrillation, a meta analysis," which appeared in the March 26, 2012 issue is presented.

The article reflects upon studies on treatments to reduce the risk of stroke in patients with atrial fibrillation. The author discusses the increasing incidence of atrial fibrillation, oral vitamin K therapy for stroke prevention, and the problems in identifying people at high risk for stroke. He explores the Active A clinical trials and the significance of the results and defends the use of vitamin K for preventive stroke therapy. Ways to improve stroke prevention are also presented.

This article comments on a study in this issue which examined if idraparinux was non-inferior to oral vitamin K antagonists in the prevention of thromboembolism in patients with atrial fibrillation. The trial was forced to stop early due to excessive bleeding in those getting the idraparinux which the author says is a step sideways for research into a new class of anticoagulants. The author examines why an alternative for vitamin K antagonists is being sought. This trial was the third recent unsuccessful attempt to replace the use of warfarin for atrial fibrillation.