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Sexual intercourse is a rare trigger of acute myocardial infarction (MI). In the 2 hours after intercourse, the risk for MI is increased twofold to fourfold. However, there is limited information on the risk for MI after intercourse in men receiving treatment for erectile dysfunction. This study aimed to evaluate whether the use of sildenafil citrate in men with erectile dysfunction is associated with the triggering of acute MI. A self-matched case-crossover approach was used to evaluate the incidence of MI in men enrolled in 80 clinical trials of sildenafil at sites worldwide from 1993 to 2000. The risk for MI was assessed during 2 hazard periods: within 24 and within 6 hours after the ingestion of sildenafil. Relative risk was estimated using the Mantel-Haenszel estimator for sparse person-time data. A total of 69 MIs were observed during >11,000 person-years of exposure to sildenafil. The mean time between the last dose of sildenafil and the onset of MI was 14 ± 2.9 days. The relative risk for MI was 0.80 (95% confidence interval [CI] 0.52 to 1.26) within 24 hours after taking sildenafil and 0.79 (95% CI 0.33 to 1.87) within 6 hours after taking sildenafil. In conclusion, these data indicate that sildenafil was not associated with short-term risk for MI and are consistent with the growing body of evidence that sildenafil use is not associated with an increased risk for cardiovascular events. [Copyright &y& Elsevier]

Depressed heart rate variability (HRV) is a powerful independent predictor of a poor outcome in patients with chronic and stable congestive heart failure (CHF). However, the prognostic value of HRV analysis in patients hospitalized for decompensated CHF is not known. The aim of this study was to investigate whether HRV parameters obtained during admission for decompensated CHF could predict survival after hospital discharge. We studied 199 patients (131 men, aged 60 ± 14 years) with a previous diagnosis of New York Heart Association class III or IV CHF who were admitted to the hospital for decompensated CHF. Twenty-four–hour Holter recordings were obtained on admission, and measures of HRV were calculated in the time and frequency domain. During a mean follow-up of 312 ± 150 days, 40 patients (21.1%) died. Kaplan-Meier analysis indicated that patients with SD of the RR intervals over a 24-hour period (p = 0.027), SD of all 5-minute mean RR intervals (p = 0.043), total power (p = 0.022), and ultra–low-frequency power (p = 0.008) in the lower tertile were at a higher risk of death. In a multivariate Cox regression model, the same indexes in the lower tertile were independent predictors of mortality: SD of the RR intervals over a 24-hour period (risk ratio [RR] 2.2, 95% confidence interval [CI] 1.05 to 4.3, p = 0.036), SD of all 5-minute mean RR intervals (RR 2.1, 95% CI 1.05 to 4.2, p = 0.04), total power (RR 2.2, 95% CI 1.08 to 4.2, p = 0.03), and ultra–low-frequency power (RR 2.6, 95% CI 1.3 to 5.3, p = 0.007). Therefore, the severity of autonomic perturbations during hospital admission for CHF decompensation, as reflected by measures of overall HRV, can predict survival after hospital discharge. Together with previous studies, our findings suggest that indexes of overall HRV provide useful prognostic information in the full spectrum of CHF severity. [Copyright &y& Elsevier]

Lesion eccentricity with irregularities on coronary angiography is associated with ruptured plaques and thrombus based on postmortem and clinical angiographic studies. However, the predictive value of such angiographic markers of plaque disruption and thrombus remains to be determined in vivo. The purpose of this study was to establish whether Ambrose’s angiographic coronary lesion types and other angiographic criteria predict the presence of disrupted plaques and thrombus using intracoronary angioscopy. Angioscopy was performed before angioplasty in 60 patients with various coronary syndromes and culprit lesions that were not totally occlusive. Lesions were classified angiographically according to Ambrose’s criteria as concentric, type I and II eccentric, and multiple irregularities, or as complex or noncomplex, and then compared with the corresponding angioscopic findings. Disruption and/or thrombus were seen in 17 of 19 type II eccentric lesions and 21 of 23 angiographically complex lesions and had the highest positive predictive value to detect complicated atherosclerotic plaques (type II eccentric lesions: positive predictive value 89%, 95% confidence intervals 67% to 99%; complex lesions: 91%, 95% confidence intervals 72% to 99%). We conclude that Ambrose’s type II eccentric stenoses and angiographically complex lesions are strongly associated with disrupted plaques and/or thrombus as assessed by angioscopy in patients and represent unstable plaque substrates. [Copyright &y& Elsevier]

Presents an assessment of coronary lesions underlying thrombus before percutaneous transluminal coronary angiography. Criteria needed in qualifying patients for angiography; Association of intracoronary thrombus with atherosclerotic plaques that appear yellow and disrupted by angioscopy; Interval between onset of clinical syndrome and angioscopy.

Comments on the article by Lorenz and others on the underuse of aspirin in both primary and secondary prevention of cardiovascular disease. Effectiveness of aspirin in decreasing the risk of acute myocardial infarction; Estimate of the prevalence of antecedent use of a treatment that prevents myocardial infarction; Comparison of results with previously reported prevalence of aspirin use among patients enrolled in the Myocardial Infarction Onset Study.

The Dietary Approaches to Stop Hypertension (DASH) diet reduces blood pressure, and consistency with the DASH diet has been associated with lower rates of heart failure (HF) in women. We examined the association between consistency with the DASH diet and rates of HF hospitalization or mortality in 38,987 participants in the Cohort of Swedish Men aged 45 to 79 years. The diet was measured using food-frequency questionnaires, and scores were created to assess the consistency with DASH by ranking the intake of the DASH diet components. Cox models were used to calculate the rate ratios of HF (807 incident cases) determined through the Swedish in-patient and cause-of-death registers from January 1, 1998 to December 31, 2006. In multivariate-adjusted analyses, men in the greatest quartile of the DASH component score had a 22% lower rate of HF events than those in the lowest quartile (95% confidence interval 5% to 35%, p for trend = 0.006). In conclusion, greater consistency with the DASH diet was associated with lower rates HF events in men aged 45 to 79 years. [Copyright &y& Elsevier]

Although inflammatory markers and anemia have both been associated with prognosis in patients with cardiovascular disease, their relation with atherosclerotic progression in patients with previous coronary artery bypass grafting (CABG) is unknown. A total of 1,273 patients enrolled in the Post CABG Trial who had undergone CABG 1 to 11 years before entry were studied. Subjects were randomly assigned to lovastatin in low or high doses and low-dose warfarin or placebo in a factorial design. Subjects underwent coronary angiography at baseline and after a mean follow-up of 4.3 years. White blood cells (WBCs), hemoglobin, and platelets were measured at baseline in all subjects. Graft progression was defined as a decrease ≥0.6 mm in lumen diameter at the site of greatest change at follow-up. During follow-up, 195 subjects sustained a clinical event and 857 grafts developed significant worsening. Risk of clinical events tended to be greater with higher WBC counts, with hazard ratios for ascending quartiles of 1.4 (95% confidence interval [CI] 0.9 to 2.2), 1.6 (95% CI 1.0 to 2.6), and 1.6 (95% CI 1.0 to 2.7). WBC count also tended to be associated with significant atherosclerotic progression, particularly in subjects assigned to placebo rather than warfarin (p interaction = 0.04). There was no association of hemoglobin or platelet count with risk of clinical events or graft progression, but few trial subjects were anemic. In conclusion, WBC count is associated with a graded increase in cardiovascular events in patients with coronary artery bypass grafts. [Copyright &y& Elsevier]

Studies have reported a possible link between cocaine use and risk for cardiovascular events. The aim of this study was to examine the association between self-reported cocaine use and physician-diagnosed myocardial infarction (MI) in the Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994. Odds ratios (ORs) were estimated using logistic regression models adjusted for age and additionally for gender, race, and other MI risk factors, which accounted for the complex sampling design. In the group aged 18 to 59 years, there was no statistically significant association between any exposure to cocaine and MI (age-adjusted OR 1.56, 95% confidence interval [CI] 0.44 to 5.50, p = 0.48; multivariate-adjusted OR 1.06, 95% CI 0.30 to 3.73, p = 0.92). Participants who reported using cocaine >10 times had a nonsignificant higher prevalence of MI (age-adjusted OR 3.13, 95% CI 0.80 to 12.25, p = 0.10; multivariate-adjusted OR 1.84, 95% CI 0.46 to 7.29, p = 0.40). However, participants aged 18 to 45 years who reported >10 occasions of cocaine use had a significantly elevated prevalence of MI in age-adjusted models (OR 4.60, 95% CI 1.12 to 18.88, p = 0.035). The association was attenuated in multivariate-adjusted models (OR 3.84, 95% CI 0.98 to 15.07, p = 0.054). The lifetime prevalence of cocaine use increased from 14% in NHANES III to 19% in NHANES 2005–2006. In conclusion, these data support a substantial association between cocaine use and MI; the temporal trend in cocaine use may increase the occurrence of MI, particularly in younger populations. [Copyright &y& Elsevier]

The association between short-term elevations in ambient particulate air pollution and increased cardiovascular morbidity and mortality is well documented. Ambient particles may also trigger acute decompensation in patients with congestive heart failure (CHF), but this hypothesis has not been evaluated in a systematic manner. This study evaluated the association between daily levels of respirable particulate matter of aerodynamic diameters ≤10 μm (PM10) and the rate of hospitalization from the emergency room for CHF in Medicare recipients (age ≥65 years) in 7 United States cities from 1986 and 1999. The time-stratified case-crossover design was used to separately estimate the effect of a 10 μg/m3 increase in PM10 in each city. A combined random-effects estimate was then obtained from the city-specific effect estimates. There were 292,918 admissions with primary diagnoses of CHF during the observation period. Overall, a 10 μg/m3 increase in PM10 was associated with a 0.72% (95% confidence interval 0.35% to 1.10%) increase in the rate of admission for CHF on the same day. The effect of PM10 appeared to be less in patients with secondary diagnoses of hypertension. There was no consistent effect modification by age, gender, race, or any other secondary diagnosis evaluated. In conclusion, these results support the hypothesis that elevated levels of particulate air pollution, below the current limits set by the United States Environmental Protection Agency, are associated with an increase in the rate of hospital admission for exacerbation of CHF. [Copyright &y& Elsevier]

This study demonstrates that plaque disruption and thrombus are absent in a considerable number of patients with unstable angina and that culprit lesion morphologies as assessed by angioscopy may differ among the various clinical subsets of patients. Although plaque disruption and thrombus undoubtedly play an important role in the pathogenesis of unstable angina, alternative mechanisms may be responsible for ischemia in some patients. [ABSTRACT FROM AUTHOR]

Long-term exposure to ambient air pollution has been associated with cardiovascular morbidity and mortality. Impaired vascular responses may, in part, explain these findings, but the association of such long-term exposure with measures of both conduit artery and microvascular function has not been widely reported. We evaluated the association between residential proximity to a major roadway (primary or secondary highway) and spatially resolved average fine particulate matter (PM2.5) and baseline brachial artery diameter and mean flow velocity, flow-mediated dilation%, and hyperemic flow velocity, in the Framingham Offspring and Third Generation Cohorts. We examined 5,112 participants (2,731 [53%] women, mean age 49 ± 14 years). Spatially resolved average PM2.5 was associated with lower flow-mediated dilation% and hyperemic flow velocity. An interquartile range difference in PM2.5 (1.99 μg/m³) was associated with L0.16% (95% confidence interval [CI] L0.27%, L0.05%) lower flow-mediated dilation% and L0.72 (95% CI L1.38, L0.06) cm/s lower hyperemic flow velocity%. Residential proximity to a major roadway was negatively associated with flow-mediated dilation%. Compared with living ≥400 m away, living <50 m from a major roadway was associated with 0.32% lower flowmediated dilation (95% CI L0.58%, L0.06%), but results for hyperemic flow velocity had wide confidence intervals L0.68 cm/s (95% CI L2.29, 0.93). In conclusion, residential proximity to a major roadway and higher levels of spatially resolved estimates of PM2.5 at participant residences are associated with impaired conduit artery and microvascular function in this large community-based cohort of middle-aged and elderly adults. [ABSTRACT FROM AUTHOR]

The aim of the present study was to explore the association between outbursts of anger and acute myocardial infarction (AMI) risk. Outbursts of anger are associated with an abrupt increase in cardiovascular events; however, it remains unknown whether greater levels of anger intensity are associated with greater levels of AMI risk or whether potentially modifiable factors can mitigate the short-term risk of AMI. We conducted a case-crossover analysis of 3,886 participants from the multicenter Determinants of Myocardial Infarction Onset Study, who were interviewed during the index hospitalization for AMI from 1989 to 1996. We compared the observed number and intensity of anger outbursts in the 2 hours preceding AMI symptom onset with its expected frequency according to each patient's control information, defined as the number of anger outbursts in the previous year. Of the 3,886 participants in the Determinants of Myocardial Infarction Onset Study, 1,484 (38%) reported outbursts of anger in the previous year. The incidence rate of AMI onset was elevated 2.43-fold (95% confidence interval 2.01 to 2.90) within 2 hours of an outburst of anger. The association was consistently stronger with increasing anger intensities (p trend <0.001). In conclusion, the risk of experiencing AMI was more than twofold greater after outbursts of anger compared with at other times, and greater intensities of anger were associated with greater relative risks. Compared with nonusers, regular β-blocker users had a lower susceptibility to heart attacks triggered by anger, suggesting that some drugs might lower the risk from each anger episode. [ABSTRACT FROM AUTHOR]

Although moderate alcohol drinkers have lower rates of incident coronary artery disease than abstainers, much less is known about the health effects of different patterns of alcohol use in women with established coronary artery disease. In the Determinants of Myocardial Infarction Onset Study, 1,253 women hospitalized for acute myocardial infarction (MI) at 64 centers nationwide from 1989 to 1996 were followed for mortality through December 31, 2007. Of the women, 761 (61%) reported abstention in the year before their MIs, 280 (22%) reported consumption of <1 serving/week, 75 (6%) reported consumption of 1 to 3 servings/week, and 137 (11%) reported consumption of ≥3 servings/week. Using Cox proportional-hazards models, the associations between total weekly volume of consumption, drinking days per week, drinks per drinking day, and beverage type with 10-year mortality were investigated, adjusting for clinical and socioeconomic potential confounders. Compared with abstention, adjusted hazard ratios were 0.66 (95% confidence interval 0.50 to 0.86) for <1 serving/week, 0.65 (95% confidence interval 0.38 to 1.11) for 1 to 3 servings/week, and 0.65 (95% confidence interval 0.38 to 1.11) for ≥3 servings/week (p for trend = 0.008). No differences were found by beverage type, and generally inverse associations of drinking frequency and quantity with mortality were found. In conclusion, in women who survive MI, moderate drinking is associated with a decreased risk for mortality, with no clear differences on the basis of pattern or beverage type. These results suggest that women who survive MI need not abstain from alcohol, but any derived benefit would appear to occur well below currently recommended limits in alcohol consumption. [ABSTRACT FROM AUTHOR]

Particulate pollution has been linked to risk for cardiac death; possible mechanisms include pollution-related increases in cardiac electrical instability. T-wave alternans (TWA) is a marker of cardiac electrical instability measured as differences in the magnitude between adjacent T waves. In a repeated-measures study of 48 patients aged 43 to 75 years, associations of ambient and home indoor particulate pollution, including black carbon (BC) and reports of traffic exposure, with changes in 0.5-hourly maximum TWA (TWA-MAX), measured by 24-hour Holter electrocardiographic monitoring, were investigated. Each patient was observed up to 4 times within 1 year after percutaneous intervention for myocardial infarction, acute coronary syndromes without infarction, or stable coronary artery disease, for a total of 5,830 0.5-hour observations. Diary data for each 0.5-hour period defined whether a patient was home or not home, or in traffic. Increases in TWA-MAX were independently associated with the previous 2-hour mean ambient BC (2.1%, 95% confidence interval 0.9% to 3.3%) and with being in traffic in the previous 2 hours (6.1%, 95% confidence interval 3.4% to 8.8%). When subjects were home, indoor home BC effects were largest and most precise; when subjects were away from home, ambient central site BC effects were strongest. Increases in pollution increased the odds of TWA-MAX ≥75th percentile (odds ratio 1.4, 95% confidence interval 1.2 to 1.6 for a 1 μg/m3 increase in 6-hour mean BC). In conclusion, after hospitalization for coronary artery disease, being in traffic and short-term ambient or indoor BC exposure increased TWA, a marker of cardiac electrical instability. [Copyright &y& Elsevier]

Impaired heart rate response to exercise is associated with adverse clinical outcomes in healthy adults and those with established coronary artery disease. It is unclear whether this association persists in subjects who have undergone coronary artery bypass grafting (CABG). In this study, 920 subjects enrolled in the Post CABG trial who had undergone CABG with patent saphenous vein grafts at baseline and known to have discontinued β blockers before exercise were studied. A maximal symptom-limited exercise treadmill test was performed on study entry. Chronotropic variables were measured at peak exercise. Participants were followed for a composite end point of death, myocardial infarction, stroke, or revascularization. Quantitative coronary angiography was performed at follow-up and compared with baseline angiography, with prespecified angiographic end points of the substantial progression of graft disease and complete occlusion. In multivariate analysis, a low chronotropic index was strongly associated with an increased risk for the composite clinical end point (p for trend = 0.04) and angiographic complete occlusion (p for trend = 0.007) but only weakly associated with angiographic substantial progression (p for trend = 0.07). In conclusion, impaired chronotropic response to exercise identifies subjects at risk for clinical outcomes and graft occlusion, even after revascularization with CABG. [Copyright &y& Elsevier]

The study seeks to describe the use of dietary supplements promoted for cardiovascular health and the relation between supplement use and coronary artery disease (CAD) and the presence of major CAD risk factors. The aim is also to explore whether use of medications for the treatment of cardiovascular disease or diabetes mellitus (DM) is associated with supplement use. We performed a cross-sectional analysis of the 1999 to 2002 National Health and Nutrition Examination Survey (NHANES) of 6,671 adults (representing 119.3 million US adults) aged ≥40 years. We categorized adults into 4 nonoverlapping groups as (1) having reported CAD or stroke (CAD/stroke), (2) DM without CAD/stroke, (3) hypertension (HTN) or hypercholesterolemia (HC) without CAD/stroke or DM (HTN/HC), or (4) none of these conditions (no reported CAD/CAD risk) and performed weighted (NHANES) multiple logistic regression to determine the odds of using supplements (reference group, no reported CAD/CAD risk). After controlling for sociodemographics, health, and lifestyle factors, we found that persons with CAD/Stroke used more supplements (any), vitamin E, folic acid, and niacin, and less fish oil. Those with DM used less coenzyme Q10, and adults with HTN/HC used more supplements (any), herbs (any), and ginseng. Adults with CAD/stroke who used medications for the treatment of cardiovascular disease or DM were more likely to use folic acid compared with those who did not use medications for these conditions. In adults with CAD/stroke, DM, or HTN/HC, those who did not use medications for these conditions were more likely to use herbs and other select supplements. In conclusion, use of dietary supplements is common in those with CAD or CAD risks. [Copyright &y& Elsevier]

Because most men with erectile dysfunction have underlying vascular disease, it is important to update the cardiovascular safety profile of medications used in the treatment of erectile dysfunction. This retrospective analysis evaluated serious cardiovascular treatment-emergent adverse events (CVTEAEs) reported in 36 clinical trials of tadalafil, a phosphodiesterase-5 inhibitor used for the treatment of erectile dysfunction. A serious CVTEAE was defined as myocardial infarction, cardiovascular death, or cerebrovascular death. In the 36 trials, 12,487 men (mean age 55 years) with erectile dysfunction received tadalafil, with 5,771 patient-years (PYs) of exposure, and 2,047 men (mean age 56 years) received placebo, with 460 PYs of exposure. Tadalafil 2 to 50 mg was taken as needed, 3 times/week, or once a day. Co-morbidities at baseline included hypertension (31%), diabetes (21%), hyperlipidemia (17%), and coronary artery disease (5%). Across all trials, the incidence rate of serious CVTEAEs was 0.40/100 PYs in tadalafil-treated patients and 0.43/100 PYs in placebo-treated patients. In patients taking tadalafil as needed, 3 times/week, or once a day, the incidence rates of serious CVTEAEs ranged from 0.17 to 0.54/100 PYs across placebo-controlled and open-label trials. In conclusion, the incidence rates of serious CVTEAEs were comparable among men with erectile dysfunction taking tadalafil as needed, 3 times/week, or once a day, and these rates were also comparable with those in placebo-treated patients. In this clinical trial population of men with erectile dysfunction, tadalafil was not associated with an increased risk for serious cardiovascular adverse events. [Copyright &y& Elsevier]

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended. [Copyright &y& Elsevier]

A greater life expectancy has led to an increasing proportion of elderly patients. Increasing age is an important risk factor for cardiovascular disease, but the mechanism of risk is not well understood. Because thrombosis plays a key role in plaque development and the onset of acute coronary syndromes, the age-related increase in cardiovascular risk may be a result of a prothrombotic imbalance. The study aim was to examine the relation between age and thrombotic potential in the Framingham Offspring Cohort. Hemostatic factors previously associated with cardiovascular risk were measured in 3,230 patients (55% women) without evidence of cardiovascular disease who were participating in cycle 5 of the Framingham Offspring Study. The subjects were divided by age into decades. Advancing age was associated with a significant increase in fibrinogen and von Willebrand factor levels and measures of impaired fibrinolytic potential (plasminogen activator inhibitor and tissue plasminogen activator antigens). For men, the mean fibrinogen levels were 21% higher in those ≥70 years versus those aged <40 years (326 vs 268 mg/dl, p <0.001 for linear trend). The mean fibrinogen levels were 15% higher in older than in younger women (330 vs 286 mg/dl, p <0.001). The significant relations persisted after multivariate adjustment. In conclusion, advancing age is associated with elevated levels of hemostatic factors indicative of a prothrombotic state. Because these factors are also associated with endothelial dysfunction, these findings are consistent with an injurious effect of age on the endothelium. Measures to reduce thrombotic potential may be of particular value in the elderly, because they counter the prothrombotic state that develops with aging. [Copyright &y& Elsevier]

We assessed educational attainment and complications during hospitalization in 3,882 patients with acute myocardial infarction for the Determinants of Myocardial Infarction Onset Study. Educational attainment had a graded, inverse association with prevalence of congestive heart failure (CHF) during hospitalization, with the lowest prevalence among patients who attended college (odds ratio 0.75; 95% confidence interval, 0.57 to 0.99; p for trend 0.02), with similar findings among men, women, whites, and blacks. [Copyright &y& Elsevier]

To evaluate the impact of elimination of the morning peak of cardiovascular events, we performed a meta-analysis of studies of circadian variation of myocardial infarction and sudden cardiac death. The impact would be significant because approximately 1 of every 11 acute myocardial infarctions and 1 of every 15 sudden cardiac deaths are attributable to the morning excess incidence. [ABSTRACT FROM AUTHOR]