Search

OBJECTIVE: To determine the temporal trends in prevalence of confirmed diabetes mellitus (DM), time from the date DM criteria were met to myocardial infarction (MI), and impact of DM on survival. SUBJECTS AND METHODS: A retrospective cohort design was used to identify residents of Olmsted County, Minnesota, with incident MI from 1979 to 1998. The MI cases were characterized according to prevalent DM. Cases with and without DM were followed up for vital status until January 1, 2003. RESULTS: Of 2171 MI cases, 364 (17%) met criteria for prevalent DM. In the age- and sex-adjusted logistic regression models, the odds of prevalent DM Increased 3% with each Increasing year between 1979 and 1998 (95% confidence Interval [CI], 1%-5%; P=.007). Survival for MI cases with DM was unchanged between 1979-1983 and 1994-1998 (P=.74). For all MI cases, age-, sex-, and DM-adjusted risk of death decreased 3% from 1979 to 1998 (95% CI, 1%-5%) per year for 28-day survival (P=.02) and 2% (95% CI, 1%-3%) per year for 5-year survival (P=.02). There was a significant adverse effect of DM on 5-year survival after MI (age-, sex-, and calendar year-adjusted hazard ratio, 1.70; 95% CI, 1.38-2.09; P<.001). The adverse effect of DM persisted after adjusting for other cardiovascular disease risk factors, MI severity, and reperfusion therapy (hazard ratio, 1.66; 95% CI, 1.34-2.05; P<.001) and was unchanged over time (interaction between DM and calendar year, P=-.63). CONCLUSION: These data indicate that the prevalence of DM among patients with MI is increasing and that its adverse impact on survival after MI remains unchanged. [ABSTRACT FROM AUTHOR]

Objective: To characterize the prognostic implications of exercise echocardiography in patients who have reduced exercise capacity at the time of testing. Patients and Methods: We examined the outcomes of 941 patients at the Mayo Clinic in Rochester, Minn, between January 1, 1990, and December 31, 1995, who had reduced exercise capacity on exercise echocardiography (women, <5 metabolic equivalents; men, <7 metabolic equivalents) and evaluated the potential association between clinical, electrocardiographic, and echocardiographic variables and outcomes for patients with normal vs abnormal exercise echocardiograms. We used variables of independent prognostic value to estimate cardiac risk. Results: For patients with normal exercise echocardiograms (n=282), the rate of cardiac death or nonfatal myocardial infarction was 09% per person-year of follow-up, and previous coronary revascularization was the only predictor of the time to cardiac event. For patients with abnormal exercise echocardiograms (n=659), the cardiac event rate was 4.4%. Independent predictors of outcome were exercise left ventricular (LV) ejection fraction (risk ratio, 1.44 per 10% decrement; 95% confidence interval, 1.2-1.7; P<.001) and an increase or no change in LV end-systolic size in response to exercise (risk ratio, 2.22; 95% confidence interval, 1.2-4.1; P=.01). Conclusion: Exercise echocardiographic findings have important prognostic implications for patients who have reduced exercise capacity on testing. Echocardiographic descriptors of LV systolic function and dysfunction obtained immediately after exercise can be used to stratify cardiac risk of patients who do not achieve a level of exercise ordinarily considered to be of "diagnostic" value. [ABSTRACT FROM AUTHOR]

Objective: To examine possible adverse effects of sulfonylureas on survival among patients with diabetes mellitus (DM) who experience a myocardial infarction (MI).Patients and Methods: Residents of Olmsted County, Minnesota, with an MI that met standardized criteria from January 1, 1985, through December 31, 2002, were followed up for mortality.Results: Among 2189 patients with MI (mean+/-SD age, 68+/-14 years; 1237 men [57%]), 409 (19%) had DM. The 23 patients treated with first-generation sulfonylureas, biguanides, or thiazolidinediones were excluded from analyses. Among the remaining 386 patients with DM, 120 (31%) were taking second-generation sulfonylureas, 180 (47%) were taking insulin, and 86 (22%) were receiving nonpharmacological treatment. Patients with DM treated with second-generation sulfonylureas were more likely to be men and have higher creatinine clearance than those treated with insulin. After adjusting for age, sex, Killip class, duration of DM, creatinine clearance, and reperfusion therapy or revascularization, patients treated with second-generation sulfonylureas had a lower risk of death than did diabetic patients receiving insulin (hazard ratio, 0.41; 95% confidence interval, 0.21-0.80; P=.009).Conclusion: These population-based data do not support the concern about an adverse effect of second-generation sulfonylureas on survival after MI and underscore the importance of population-based studies of surveillance of drug safety. [ABSTRACT FROM AUTHOR]

Objective: To assess participation bias in the assembly of a specimen repository for genetic studies and to examine the association of participation with outcome within the Olmsted County myocardial infarction (MI) cohort.Participants and Methods: From January 1, 1979, to May 31, 2006, 3081 persons had MI in Olmsted County, MN. Face-to-face contact was used to recruit patients who were hospitalized for an acute event. Persons who had had an MI before establishment of this repository were contacted by mail. At initial contact, we sought consent to use blood samples for genetic studies. Persons who refused were contacted by mail and were asked to consent to the use of stored tissue samples. For deceased subjects, stored tissue was collected when available.Results: Of the 3081 persons in the Olmsted County MI cohort, 1994 participated in the study; 1007 (50.5%) blood and 987 (49.5%) tissue specimens were provided. Participants were more likely to be younger men with hypertension, comorbidities, and non-ST-segment elevation MI (all, P<.05). Participants who provided blood specimens were more likely to have non-ST-segment elevation MI and lower Killip class than those who provided tissue. After adjustment for age, sex, hypertension, ST-segment elevation, Killip class, and comorbidities, participation was not associated with outcome. Participants who provided blood specimens were less likely to have heart failure (hazard ratio, 0.49; 95% confidence interval, 0.40-0.59; P<.01) or to die (hazard ratio, 0.16; 95% confidence interval, 0.12-0.21; P<.01) than those who provided tissue.Conclusion: A variety of sources can be used to assemble community specimen repositories. Baseline characteristics differed between participants and nonparticipants and, among participants, by specimen source. Participants who provided blood specimens had better outcomes than those who provided tissue specimens. No survival advantage was observed for participants after combining blood and tissue specimens. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To compare the characteristics and survival of participants and nonparticipants in a community-based study of myocardial infarction (MI). PARTICIPANTS AND METHODS: Residents of Olmsted County, MN, who presented with elevated cardiac troponin T levels from September 1, 2002, through December 31, 2005, were prospectively enrolled and classified with standardized criteria for MI. With specific Institutional Review Board approval, the medical records of patients with MI who did not provide consent but who had given general research authorization were reviewed, as was done for their consenting peers. RESULTS: During the study period, 2277 individuals with elevated cardiac troponin T levels were approached, of whom 1863 (82 percent) consented to participate. Among the 414 nonparticipants, 375 (91 percent) had general research authorization. Of the 558 with general research authorization who met the criteria for incident (ie, first-ever) MI, 67 (12 percent) refused to participate. These participants tended to be older (mean plus or minus SD age, 71 plus or minus 14 vs 67 plus or minus 15 years; P equals .04), were more likely to be of races other than white (9 percent vs 2 percent; P equals .01), and had more comorbidities, including peripheral vascular disease (P equals .02), chronic pulmonary disease (P equals .06), heart failure (P equals .07), and impaired creatinine clearance (P equals .02). No significant differences were detected in cardiovascular risk factors or MI characteristics. During a median follow-up of 517 days, nonparticipants experienced increased mortality rates compared with participants (hazard ratio, 1.97; 95 percent confidence interval, 1.21 to 3.20), which was largely attributable to their older age and excess comorbidities (adjusted hazard ratio, 1.43; 95 percent confidence interval, 0.86 to 2.35). CONCLUSION: In this community-based study of MI, nonparticipants experienced worse survival rates than participants largely because of differences in demographic and clinical characteristics. These differences should be kept in mind when interpreting study results, particularly if participation is low. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the use of tests that measure ejection fraction (EF) and the use of coronary angiography among patients with an initial diagnosis of heart failure (HF). PATIENTS AND METHODS: All potential cases of incident HF in Olmsted County, Minnesota, between 1979 and 1999 were identifled. In a random sample of cases validated with the Framingham criteria, we examined the frequency of tests that measure EF (echocardiography, radionuclide ventriculography, and left ventricular angiography) and coronary angiography within 90 days after diagnosis. RESULTS: A total of 655 patients with incident HF were included in the analysis. The use of tests that measure EF and coronary angiography increased early in the study period but stabilized thereafter. In the most recent years (1995-1999), EF was measured in 65% of the patients and coronary angiography performed in 12%. After adjustment for year of diagnosis, body mass index, hypertension, diabetes mellitus, smoking, hyperlipidemia, comorbidity, prior myocardial infarction, and prior angina, men were more likely than women to have EF measured (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.01-2.16) and coronary angiography (OR, 2.61; 95% CI, 1.43-4.76). Increasing age was associated with less use of tests (OR, 0.83; 95% CI, 0.76-0.91; for EF measurement; OR, 0.72; 95% CI, 0.63-0.82; for coronary angiography for every 5-year increase in age). CONCLUSION: Among patients with HF, tests that measure EF are used substantially less than recommended, and coronary angiograms are used infrequently. Use was particularly low in women and elderly patients. Given the potential benefits of such tests, including more appropriate therapy and more objective monitoring of ventricular function, outcomes in persons with HF may be improved with more consistent use. [ABSTRACT FROM AUTHOR]

Objective: To determine how well patient-reported cardiovascular disease (CVD) and CVD risk factor information agrees with medical record information.Methods: Information from Patient/Family History (PFH) questionnaires completed between 1996 and 1999 by residents of Olmsted County, Minnesota, aged 20 years and older was compared with information available through the Mayo Clinic medical diagnostic index. Positive and negative agreement values were calculated by comparing agreement between the 2 data sources. Also, with the Mayo Medical Index serving as the criterion standard, sensitivity, specificity, and positive and negative predictive values of questionnaire information were calculated overall and by subgroups of sex, age, and years of education.Results: Questionnaire responses were retrieved for 26,162 patients. Positive agreement values ranged from 31% for report of a medical problem or surgery related to arteries to the head, arms, or legs or the aorta to 78% for high blood pressure. Negative agreement values ranged from 90% for high cholesterol to 98% for medical problem or surgery related to arteries to the head, arms, or legs or the aorta. Sensitivity of questionnaire information ranged from 37% to 73%, whereas positive predictive values ranged from 27% to 86%. Positive agreement, sensitivity, and positive predictive values tended to increase with increasing age of the patient. Specificity and negative predictive values were 87% or greater, and negative agreement, specificity, and negative predictive values decreased with increasing age.Conclusion: Positive patient reports of CVD conditions and risk factors are relatively inaccurate. However, negative self-reports of these conditions are unlikely to be noted in the medical record. Further development of the PFH questionnaire is necessary to ensure accurate patient reporting of CVD data. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine secular trends in the use of evidence-based therapies in a geographically defined cohort of patients with myocardial infarction (MI) and to test the hypotheses that baseline use is increasing and that disparities in use are diminishing, PATIENTS AND METHODS: All consecutively hospitalized patients who were dismissed from Olmsted County, Minnesota, hospitals between 1979 and 1998 with a diagnosis of MI were identified using standardized criteria (biomarkers, cardiac pain, and electrocardiography). The entire community medical record, available via the Rochester Epidemiology Project, was reviewed to ascertain baseline characteristics including comorbidity, presence of ST-segment elevation on electrocardiography, and treatment. Logistic regression models were used to examine the association of treatment with age and sex, independent of other baseline characteristics. RESULTS: Between 1979 and 1998, 2317 incident MIs (patient mean +/- SD age, 67+/-14 years; 43% women; 57% aged > or = 65 years) occurred in Olmsted County. The use of all evidence-based therapies increased over time, primarily reflecting the introduction of these medications at the time of Index MI. Between 1989 and 1998, age was not independently associated with use of aspirin or ACE inhibitors. Disparities in use persisted for reperfusion therapy and beta-blockers. Reperfusion therapy or revascularization was used less frequently in older persons, particularly in elderly women (P<.001). Use of beta-blockers decreased 16% among persons aged 65 years or older, independent of measurable differences in baseline characteristics and MI severity (hazard ratio, 0.84; 95% confidence interval, 0.74-0.93). CONCLUSIONS: The use of all evidence-based therapies for MI increased markedly over time; however, residual gaps in use were noted. Reperfusion therapy or revascularization is used less frequently in women and elderly persons, and beta-blockers are used less frequently in elderly persons. These differences are not explained by measurable differences in baseline characteristics. Women and elderly persons represent an increasing proportion of patients with MIs in the community; therefore, these findings define therapeutic opportunities. [ABSTRACT FROM AUTHOR]

National or statewide estimates of excess deaths have limited value to understanding the impact of the COVID-19 pandemic regionally. We assessed excess deaths in a 9-county geographically defined population that had low rates of COVID-19 and widescale availability of testing early in the pandemic, well-annotated clinical data, and coverage by 2 medical examiner's offices. We compared mortality rates (MRs) per 100,000 person-years in 2020 and 2021 with those in the 2019 reference period and MR ratios (MRRs). In 2020 and 2021, 177 and 219 deaths, respectively, were attributed to COVID-19 (MR = 52 and 66 per 100,000 person-years, respectively). COVID-19 MRs were highest in males, older persons, those living in rural areas, and those with 7 or more chronic conditions. Compared with 2019, we observed a 10% excess death rate in 2020 (MRR = 1.10 [95% CI, 1.04 to 1.15]), with excess deaths in females, older adults, and those with 7 or more chronic conditions. In contrast, we did not observe excess deaths overall in 2021 compared with 2019 (MRR = 1.04 [95% CI, 0.99 to 1.10]). However, those aged 18 to 39 years (MRR = 1.36 [95% CI, 1.03 to 1.80) and those with 0 or 1 chronic condition (MRR = 1.28 [95% CI, 1.05 to 1.56]) or 7 or more chronic conditions (MRR = 1.09 [95% CI, 1.03 to 1.15]) had increased mortality compared with 2019. This work highlights the value of leveraging regional populations that experienced a similar pandemic wave timeline, mitigation strategies, testing availability, and data quality., (Copyright © 2023 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Artificial intelligence (AI) is a nontechnical, popular term that refers to machine learning of various types but most often to deep neural networks. Cardiology is at the forefront of AI in medicine. For this review, we searched PubMed and MEDLINE databases with no date restriction using search terms related to AI and cardiology. Articles were selected for inclusion on the basis of relevance. We highlight the major achievements in recent years in nearly all areas of cardiology and underscore the mounting evidence suggesting how AI will take center stage in the field. Artificial intelligence requires a close collaboration among computer scientists, clinical investigators, clinicians, and other users in order to identify the most relevant problems to be solved. Best practices in the generation and implementation of AI include the selection of ideal data sources, taking into account common challenges during the interpretation, validation, and generalizability of findings, and addressing safety and ethical concerns before final implementation. The future of AI in cardiology and in medicine in general is bright as the collaboration between investigators and clinicians continues to excel., (Copyright © 2020 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To identify differences between participants and nonparticipants in a survey of physical and psychosocial aspects of health among a population-based sample of patients with heart failure (HF)., Patients and Methods: Residents from 11 Minnesota counties with a first-ever code for HF (International Classification of Diseases, Ninth Revision 428 and Tenth Revision I50) between January 1, 2013, and December 31, 2016, were identified. Participants completed a questionnaire by mail or telephone. Characteristics and outcomes were extracted from medical records and compared between participants and nonparticipants. Response rate was calculated using guidelines of the American Association for Public Opinion Research. The association between nonparticipation and outcomes was examined using Cox proportional hazards regression for death and Andersen-Gill modeling for hospitalizations., Results: Among 7911 patients, 3438 responded to the survey (American Association for Public Opinion Research response rate calculated using formula 2 = 43%). Clinical and demographic differences between participants and nonparticipants were noted, particularly for education, marital status, and neuropsychiatric conditions. After a mean ± SD of 1.5±1.0 years after survey administration, 1575 deaths and 5857 hospitalizations occurred. Nonparticipation was associated with a 2-fold increased risk for death (hazard ratio, 2.29; 95% CI, 2.05-2.56) and 11% increased risk for hospitalization (hazard ratio, 1.11; 95% CI, 1.02-1.22) after adjusting for age, sex, time from HF diagnosis to index date, marital status, coronary disease, arrhythmia, hyperlipidemia, diabetes, cancer, chronic kidney disease, arthritis, osteoporosis, depression, and anxiety., Conclusion: In a large survey of patients with HF, participation was associated with notable differences in clinical and demographic characteristics and outcomes. Examining the impact of participation is critical to draw inference from studies of patient-reported measures., (Copyright © 2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the use of stress testing in a community population with de novo stable chest pain, a normal resting electrocardiogram (ECG), and the ability to exercise., Patients and Methods: We identified eligible patients by searching the electronic medical record of all outpatients seen at Mayo Clinic Rochester from January 1, 2010, through December 31, 2013. We determined the frequency of initial exercise stress testing, computed tomography coronary angiography, and invasive coronary angiography, as well as the use of subsequent second procedures (including percutaneous coronary intervention [PCI] and coronary artery bypass grafting) within 90 days. Patients were followed for 5 years for death, nonfatal myocardial infarction, and hospitalization for unstable angina., Results: The data search identified 1175 patients with chest pain and normal resting ECGs. Only 331 patients underwent cardiac testing. A slight majority (185; 55.9%) underwent an exercise ECG alone. The remainder underwent exercise echocardiography (112; 33.8%), exercise single-photon-emission computed tomography (32; 9.7%), or computed tomography coronary angiography (2; 0.9%). Few patients (30; 9.1%) required additional testing within 90 days. Of the 14 patients (4.2%) who underwent invasive coronary angiography, 12 (85.7%) had significant coronary artery disease, and were referred for percutaneous coronary intervention or coronary artery bypass grafting. At 5 years, the mortality rate was 1.2%, and the combined event rate was 3.8%., Conclusion: Most community patients with chest pain and a normal resting ECG do not require further cardiac evaluation. In patients who require testing, and are able to exercise, noninvasive stress testing is preferred. Invasive coronary angiography is applied selectively and associated with a high rate of significant coronary artery disease and referral to coronary revascularization. Long-term outcomes are excellent., (Copyright © 2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To study the association between time in therapeutic range (TTR) during warfarin therapy and risk of dementia in a population-based cohort of incident atrial fibrillation (AF)., Patients and Methods: We conducted an observational population-based study of 2800 nondemented patients with incident AF from January 1, 2000, through December 31, 2010. The association of incident dementia with warfarin therapy and TTR was examined using Cox proportional hazards regression models., Results: Mean patient age was 71.2 years; 53% were men (n=1495), and warfarin was prescribed to 50.5% (n=1414) within 90 days of AF diagnosis. Incident dementia diagnosis occurred in 357 patients (12.8%) over a mean ± SD follow-up of 5.0±3.7 years. After adjusting for confounders, warfarin therapy was associated with a reduced incidence of dementia (hazard ratio [HR], 0.80; 95% CI, 0.64-0.99). However, only those in the 2 highest quartiles of TTR were associated with lower risk of dementia. A 10% increase in TTR with a 10% reduction in time spent in the subtherapeutic (HR, 0.71; 95% CI, 0.64-0.79) and supratherapeutic (HR, 0.67; 95% CI, 0.57-0.79) ranges were associated with decreased risk of dementia., Conclusion: In the community, warfarin therapy for AF is associated with a 20% reduction in risk of dementia. Increasing TTR on warfarin is associated with reduced risk of dementia. The risk of dementia was reduced with a reduction in time spent in subtherapeutic and supratherapeutic international normalized ratio range. Effective anticoagulation may prevent cognitive impairment in patients with AF., (Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the impact of health literacy on hospitalizations and death in a population of patients with heart failure (HF)., Patients and Methods: Residents from the 11-county region in southeast Minnesota with a first-ever International Classification of Diseases, Ninth Revision code 428 or Tenth Revision code 150 (n=5121) from January 1, 2013, through December 31, 2015, were identified and prospectively surveyed to measure health literacy using established screening questions. A total of 2647 patients returned the survey (response rate, 52%); 2487 patients with complete health literacy data were retained for analysis. Health literacy, measured as a composite score on three 5-point scales, was categorized as adequate (≥8) or low (<8). Cox proportional hazards regression and Andersen-Gill models were used to examine the association of health literacy with mortality and hospitalization., Results: Of 2487 patients (mean age, 73.5 years; 53.6% male [n=1333]), 10.5% (n= 261) had low health literacy. After mean ± SD follow-up of 15.5±7.2 months, 250 deaths and 1584 hospitalizations occurred. Low health literacy was associated with increased mortality and hospitalizations. After adjusting for age, sex, comorbidity, education, and marital status, the hazard ratios for death and hospitalizations in patients with low health literacy were 1.91 (95% CI, 1.38-2.65; P<.001) and 1.30 (95% CI, 1.02-1.66; P=.03), respectively, compared with patients with adequate health literacy., Conclusion: Low health literacy is associated with increased risks of hospitalization and death in patients with HF. The clinical evaluation of health literacy could help design interventions individualized for patients with low health literacy., (Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the effect of skilled nursing facility (SNF) use on hospitalizations in patients with heart failure (HF) and to examine predictors of hospitalization in patients with HF admitted to a SNF., Patients and Methods: Olmsted County, Minnesota, residents with first-ever HF from January 1, 2000, through December 31, 2010, were identified, and clinical data were linked to SNF utilization data from the Centers for Medicare and Medicaid Services. Andersen-Gill models were used to determine the association between SNF use and hospitalizations and to determine predictors of hospitalization., Results: Of 1498 patients with incident HF (mean ± SD age, 75±14 years; 45% male), 605 (40.4%) were admitted to a SNF after HF diagnosis (median follow-up, 3.6 years; range, 0-13.0 years). Of those with a SNF admission, 225 (37%) had 2 or more admissions. After adjustment for age, sex, ejection fraction, and comorbidities, SNF use was associated with a 50% increased risk of hospitalization compared with no SNF use (adjusted hazard ratio, 1.52; 95% CI, 1.31-1.76). In SNF users, arrhythmia, asthma, chronic kidney disease, and the number of activities of daily living requiring assistance were independently associated with an increased risk of hospitalization., Conclusion: Approximately 40% of patients with HF were admitted to a SNF at some point after diagnosis. Compared with SNF nonusers, SNF users were more likely to be hospitalized. Characteristics associated with hospitalization in SNF users were mostly noncardiovascular, including reduced ability to perform activities of daily living. These findings underscore the effect of physical functioning on hospitalizations in patients with HF in SNFs and the importance of strategies to improve physical functioning., (Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To study the temporal distribution and causes of hospitalizations after heart failure (HF) diagnosis., Patients and Methods: Hospitalizations were studied in 1972 Olmsted County, Minnesota, residents with incident HF from January 1, 2000, to December 31, 2011. All hospitalizations were examined for the 2 years following incident HF, and each was categorized as due to HF, other cardiovascular causes, or noncardiovascular causes. Negative binomial regression examined associations between time periods (0-30, 31-182, 183-365, and 366-730 days after diagnosis) and hospitalizations., Results: During the 2 years after diagnosis, 3495 hospitalizations were observed among 1336 of the 1972 patients with HF. The age- and sex-adjusted rates of hospitalizations were highest in the first 30 days after diagnosis (3.33 per person-year vs 1.33, 1.07, and 1.00 per person-year for 31-182 days, 183-365 days, and 366-730 days, respectively). The rates of hospitalizations were similar across sex, presentation of HF (inpatient or outpatient), and type of HF (preserved or reduced ejection fraction). Patients diagnosed as inpatients who had long hospital stays (>5 days) experienced more than a 30% increased risk of rehospitalization within 30 days of dismissal. Importantly, most hospitalizations (2222 of 3495 [63.6%]) were due to noncardiovascular causes, and a minority (440 of 3495 [12.6%]) were due to HF. The rates of noncardiovascular hospitalizations were higher than those for HF or other cardiovascular hospitalizations across all follow-up for all time periods after HF., Conclusion: Patients with HF experience high rates of hospitalizations, particularly within the first 30 days, and mostly for noncardiovascular causes. To reduce hospitalizations in patients with HF, an integrated approach focusing on comorbidities is required., (Copyright © 2016 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To determine how often unnecessary resting echocardiograms that are "not recommended" by clinical practice guidelines are performed in patients with stable chest pain and normal resting electrocardiograms (ECGs)., Patients and Methods: We performed a retrospective search of electronic medical records of all outpatients seen at Mayo Clinic Rochester from January 1, 2010, through December 31, 2013, to identify residents of Olmsted County, Minnesota, with stable chest pain and known or suspected coronary artery disease who underwent resting echocardiography and had normal resting ECGs and no other indication for echocardiography., Results: Of the 8280 outpatients from Olmsted County who were evaluated at Mayo Clinic Rochester with chest pain, 590 (7.1%) had resting echocardiograms. Ninety-two of these 590 patients (15.6%) had normal resting ECGs. Thirty-three of these 92 patients (35.9%) had other indications for echocardiography. The remaining 59 patients (10.0% of all echocardiograms and 0.7% of all patients) had normal resting ECGs and no other indication for echocardiography. Fifty-seven of these 59 patients (96.6%) had normal echocardiograms. Thirteen of these 59 echocardiograms (22.0%) were "preordered" before the provider (physicians, nurses, physician assistants) visit., Conclusion: The overall rate of echocardiography in Olmsted County outpatients with chest pain seen at Mayo Clinic Rochester is low. Only 1 in 10 of these echocardiograms was performed in violation of the class III recommendation in the American College of Cardiology Foundation/American Heart Association guidelines for the management of stable angina. These unnecessary echocardiograms were almost always normal. The rate of unnecessary echocardiograms could be decreased by eliminating preordering., (Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objectives: To measure the incidence of acute coronary syndrome (ACS), defined as first-ever myocardial infarction (MI) or unstable angina (UA); evaluate recent temporal trends; and determine whether survival after ACS has changed over time and differs by type., Patients and Methods: This was a population surveillance study conducted in Olmsted County, Minnesota (population: 144,248). All persons hospitalized with incident ACS between January 1, 2005, and December 31, 2010, were identified using International Classification of Diseases, Ninth Revision codes, natural language processing of the medical records, and biomarkers. Myocardial infarction was validated by epidemiologic criteria and UA by the Braunwald classification. Patients were followed through June 30, 2013, for death., Results: Of 1244 incident ACS cases, 35% (n=438) were UA and 65% (n=806) were MI. The standardized rates (per 100,000) of ACS were 284 (95% CI, 248-319) in 2005 and 184 (95% CI, 157-210) in 2010 (2010 vs 2005: rate ratio, 0.62; 95% CI, 0.53-0.73), indicating a 38% decline (similar for MI and UA). The 30-day case fatality rates did not differ by year of diagnosis but were worse for MI (8.9%; 95% CI, 6.9%-10.9%) compared with UA (1.9%; 95% CI, 0.6%-3.1%). Among 30-day survivors, the risk of death did not differ by ACS type or diagnosis year., Conclusion: In the community, UA constitutes 35% of ACS. The incidence of ACS has declined in recent years, and trends were similar for UA and MI, reaffirming a substantial decline in all acute manifestations of coronary disease. Survival after ACS did not change over time, but 30-day survival was worse for MI compared with UA., (Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the long-term prognostic effect of resting heart rate (HR) at index myocardial infarction (MI) and during the first year after MI among 1-year survivors., Patients and Methods: The community-based cohort consisted of 1571 patients hospitalized with an incident MI from January 1, 1983, through December 31, 2007, in Olmsted County, Minnesota, who were in sinus rhythm at index MI and had HR measurements on electrocardiography at index and during the first year after MI. Outcomes were all-cause and cardiovascular deaths., Results: During a median follow-up of 7.0 years, 627 deaths and 311 cardiovascular deaths occurred. Using patients with HRs of 60/min or less as the referent, this study found that long-term all-cause mortality risk increased progressively with increasing HR at index (hazard ratio, 1.62; 95% CI, 1.25-2.09) and even more with increasing HR during the first year after MI (hazard ratio, 2.16; 95% CI, 1.64-2.84) for patients with HRs greater than 90/min, adjusting for clinical characteristics and β-blocker use. Similar results were observed for cardiovascular mortality (adjusted hazard ratio, 1.66; 95% CI, 1.14-2.42; and adjusted hazard ratio, 1.93; 95% CI, 1.27-2.94; for HR at index and within 1 year after MI, respectively)., Conclusion: These data from a large MI community cohort indicate that HR is a strong predictor of long-term all-cause and cardiovascular mortality not only at initial presentation of MI but also during the first year of follow-up., (Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the prevalence of multimorbidity involving 20 selected chronic conditions in a geographically defined US population, emphasizing age, sex, and racial/ethnic differences., Patients and Methods: Using the Rochester Epidemiology Project records linkage system, we identified all residents of Olmsted County, Minnesota, on April 1, 2010, and electronically extracted the International Classification of Diseases, Ninth Revision codes associated with all health care visits made between April 1, 2005, and March 31, 2010 (5-year capture frame). Using these codes, we defined the 20 common chronic conditions recommended by the US Department of Health and Human Services. We counted only persons who received at least 2 codes for a given condition separated by more than 30 days, and we calculated the age-, sex-, and race/ethnicity-specific prevalence of multimorbidity., Results: Of the 138,858 study participants, 52.4% were women (n=72,732) and 38.9% had 1 or more conditions (n=54,012), 22.6% had 2 or more conditions (n=31,444), and 4.9% had 5 or more conditions (n=6853). The prevalence of multimorbidity (≥2 conditions) increased steeply with older age and reached 77.3% at 65 years and older. However, the absolute number of people affected by multimorbidity was higher in those younger than 65 years. Although the prevalence of multimorbidity was similar in men and women overall, the most common dyads and triads of conditions varied by sex. Compared with white persons, the prevalence of multimorbidity was slightly higher in black persons and slightly lower in Asian persons., Conclusion: Multimorbidity is common in the general population; it increases steeply with older age, has different patterns in men and women, and varies by race/ethnicity., (Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether technically innovative cardiac surgical platforms (ie, robotics) deployed in conjunction with surgical process improvement (systems innovation) influence total hospital costs to address the concern that expanding adoption might increase health care expenses., Patients and Methods: We studied 185 propensity-matched patient pairs (370 patients) undergoing isolated conventional open vs robotic mitral valve repair with identical repair techniques and care teams between July 1, 2007, and January 31, 2011. Two time periods were considered, before the implementation of system innovations (pre-July 2009) and after implementation. Generalized linear mixed models were used to estimate the effect of the type of surgery on cost while adjusting for a time effect., Results: Baseline characteristics of the study patients were similar, and all patients underwent successful mitral valve repair with no early deaths. Median length of stay (LOS) for patients undergoing open repair was unchanged at 5.3 days (P=.636) before and after systems innovation implementation, and was lower for robotic patients at 3.5 and 3.4 days, respectively (P=.003), throughout the study. The overall median costs associated with open and robotic repair were $31,838 and $32,144, respectively (P=.32). During the preimplementation period, the total cost was higher for robotic ($34,920) than for open ($32,650) repair (P<.001), but during the postimplementation period, the median cost of robotic repair ($30,606) became similar to that of open repair ($31,310) (P=.876). The largest decrease in robotic cost was associated with more rapid ventilator weaning and shortened median intensive care unit LOS, from 22.7 hours before July 2009 to 9.3 hours after implementation of systems innovations (P<.001)., Conclusion: Following the introduction of systems innovation, the total hospital cost associated with robotic mitral valve repair has become similar to that for a conventional open approach, while facilitating quicker patient recovery and diminished utilization of in-hospital resources. These data suggest that innovations in techniques (robotics) along with care systems (process improvement) can be cost-neutral, thereby improving the affordability of new technologies capable of improving early patient outcomes., (Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the age and sex patterns of drug prescribing in Olmsted County, Minnesota., Patients and Methods: Population-based drug prescription records for the Olmsted County population in 2009 were obtained using the Rochester Epidemiology Project medical records linkage system (n=142,377). Drug prescriptions were classified using RxNorm codes and were grouped using the National Drug File-Reference Terminology., Results: Overall, 68.1% of the population (n=96,953) received a prescription from at least 1 drug group, 51.6% (n=73,501) received prescriptions from 2 or more groups, and 21.2% (n=30,218) received prescriptions from 5 or more groups. The most commonly prescribed drug groups in the entire population were penicillins and β-lactam antimicrobials (17%; n=23,734), antidepressants (13%; n=18,028), opioid analgesics (12%; n=16,954), antilipemic agents (11%; n=16,082), and vaccines/toxoids (11%; n=15,918). However, prescribing patterns differed by age and sex. Vaccines/toxoids, penicillins and β-lactam antimicrobials, and antiasthmatic drugs were most commonly prescribed in persons younger than 19 years. Antidepressants and opioid analgesics were most commonly prescribed in young and middle-aged adults. Cardiovascular drugs were most commonly prescribed in older adults. Women received more prescriptions than men for several drug groups, in particular for antidepressants. For several drug groups, use increased with advancing age., Conclusion: This study provides valuable baseline information for future studies of drug utilization and drug-related outcomes in this population., (Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the prevalence of nonacute conditions among patients seeking health care in a defined US population, emphasizing age, sex, and ethnic differences., Patients and Methods: The Rochester Epidemiology Project (REP) medical records linkage system was used to identify all residents of Olmsted County, Minnesota, on April 1, 2009, who had consented to review of their medical records for research (142,377 patients). We then electronically extracted all International Classification of Diseases, Ninth Revision codes noted in the records of these patients by any health care institution between January 1, 2005, and December 31, 2009. We grouped International Classification of Diseases, Ninth Revision codes into clinical classification codes and then into 47 broader disease groups associated with health-related quality of life. Age- and sex-specific prevalence was estimated by dividing the number of individuals within each group by the corresponding age- and sex-specific population. Patients within a group who had multiple codes were counted only once., Results: We included a total of 142,377 patients, 75,512 (53%) of whom were female. Skin disorders (42.7%), osteoarthritis and joint disorders (33.6%), back problems (23.9%), disorders of lipid metabolism (22.4%), and upper respiratory tract disease (22.1%, excluding asthma) were the most prevalent disease groups in this population. Ten of the 15 most prevalent disease groups were more common in women in almost all age groups, whereas disorders of lipid metabolism, hypertension, and diabetes were more common in men. Additionally, the prevalence of 7 of the 10 most common groups increased with advancing age. Prevalence also varied across ethnic groups (whites, blacks, and Asians)., Conclusion: Our findings suggest areas for focused research that may lead to better health care delivery and improved population health., (Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the role of cardiac troponin T (cTnT) in predicting death, recurrent ischemic events, and heart failure among community-dwelling persons with first myocardial infarction (MI)., Patients and Methods: Consecutive Olmsted County, Minnesota, residents with an incident MI between November 6, 2002, and December 31, 2007, were studied (N=1177; mean age, 68 years). Maximal cTnT value was measured at a median of 1 day after MI (median, 0.52 ng/mL; interquartile range, 0.16-1.75 ng/mL) and evaluated as a prognostic factor using measures of absolute risk., Results: During a mean follow-up of 16 months, 276 deaths (23%) occurred, 341 patients (29%) experienced a recurrent ischemic event, and 326 patients (28%) experienced heart failure. A dose-response relationship was demonstrated early after MI between cTnT and the adjusted cumulative incidence of all outcomes. The multivariate-adjusted absolute risk differences (events per 100 patients) between the upper and lower cTnT tertiles at 30 days were 5.8 (95% confidence interval [CI], 1.4-10.2) for death, 5.2 (95% CI, 0.2-10.3) for recurrent ischemic event, and 6.9 (95% CI, 1.4-12.4) for heart failure. These differences were either maintained or increased at 2 years., Conclusion: In the community, cTnT level predicts death and nonfatal cardiac events independently of other prognostic factors. The increased risk associated with elevated cTnT level appears shortly after MI and persists for at least 2 years., (Copyright © 2012 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the risk of hospitalization and death in relation to preexisting depression and anxiety among patients with cardiovascular disease (CVD)., Patients and Methods: The cohort consisted of 799 Olmsted County, MN, residents diagnosed with CVD (myocardial infarction or heart failure) from January 1, 1979, to December 31, 2009, who completed a Minnesota Multiphasic Personality Inventory (MMPI) prior to their event. The MMPI was used to identify depression and anxiety, and participants were followed up for hospitalizations and death during an average of 6.2 years., Results: Depression and anxiety were identified in 282 (35%) and 210 (26%) participants, respectively. After adjustment, depression and anxiety were independently associated with a 28% (95% confidence interval [CI], 8%-51%) and 26% (95% CI, 3%-53%) increased risk of being hospitalized, respectively. Depression also conferred an increased risk of all-cause mortality of similar magnitude, whereas the hazard ratio for anxiety was not statistically significant. The combined occurrence of depression and anxiety led to a 35% (95% CI, 8%-71%) increase in the risk of hospitalizations., Conclusion: Among patients with CVD, both preexisting depression and anxiety, occurring on average 17 years before the CVD event, independently predict hospitalizations. In addition, the 2 conditions may act synergistically on increasing health care utilization in patients with CVD.

Objective: To investigate the association between 347 single-nucleotide polymorphisms within candidate genes of the tumor necrosis factor, interleukin 1 and interleukin 6 families with neutrophil count., Patients and Methods: Four hundred cases with heart failure after myocardial infarction (MI) were matched by age, sex, and date of incident MI to 694 controls (MI without post-MI heart failure). Both genotypes and neutrophil count at admission for incident MI were available in 314 cases and 515 controls., Results: We found significant associations between the TNFSF8 poly morphisms rs927374 (P=5.1 x 10(-5)) and rs2295800 (P=1.3 x 10(-4)) and neutrophil count; these single-nucleotide polymorphisms are in high linkage disequilibrium (r(2)=0.97). Associations persisted after controlling for clinical characteristics and were unchanged after adjusting for case-control status. For rs927374, the neutrophil count of GG homozygotes (7.6±5.1) was 16% lower than that of CC homozygotes (9.0±5.2)., Conclusion: The TNFSF8 polymorphisms rs927374 and rs2295800 were associated with neutrophil count. This finding suggests that post-MI inflammatory response is genetically modulated.

Objective: To determine medication use and adherence among community-dwelling patients with heart failure (HF)., Patients and Methods: Residents of Olmsted County, Minnesota, with HF were recruited from October 10, 2007, through February 25, 2009. Pharmacy records were obtained for the 6 months after enrollment. Medication adherence was measured by the proportion of days covered (PDC). A PDC of less than 80% was classified as poor adherence. Factors associated with medication adherence were investigated., Results: Among the 209 study patients with HF, 123 (59%) were male, and the mean ± SD age was 73.7 ± 13.5 years. The median (interquartile range) number of unique medications filled during the 6-month study period was 11 (8-17). Patients with a documented medication allergy were excluded from eligibility for medication use within that medication class. Most patients received conventional HF therapy: 70% (147/209) were treated with β-blockers and 75% (149/200) with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Most patients (62%; 127/205) also took statins. After exclusion of patients with missing dosage information, the proportion of those with poor adherence was 19% (27/140), 19% (28/144), and 13% (16/121) for β-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, and statins, respectively. Self-reported data indicated that those with poor adherence experienced more cost-related medication issues. For example, those who adhered poorly to statin therapy more frequently reported stopping a prescription because of cost than those with good adherence (46% vs 6%; P < .001), skipping doses to save money (23% vs 3%; P = .03), and not filling a new prescription because of cost (46% vs 6%; P < .001)., Conclusion: Community-dwelling patients with HF take a large number of medications. Medication adherence was suboptimal in many patients, often because of cost.

Objective: To assess the association between erectile dysfunction (ED) and the long-term risk of coronary artery disease (CAD) and the role of age as a modifier of this association., Participants and Methods: From January 1, 1996, to December 31, 2005, we biennially screened a random sample of 1402 community-dwelling men with regular sexual partners and without known CAD for the presence of ED. Incidence densities of CAD were calculated after age stratification and adjusted for potential confounders by time-dependent Cox proportional hazards models., Results: The prevalence of ED was 2% for men aged 40 to 49 years, 6% for men aged 50 to 59 years, 17% for men aged 60 to 69 years, and 39% for men aged 70 years or older. The CAD incidence densities per 1000 person-years for men without ED in each age group were 0.94 (40-49 years), 5.09 (50-59 years), 10.72 (60-69 years), and 23.30 (> or =70 years). For men with ED, the incidence densities of CAD for each age group were 48.52 (40-49 years), 27.15 (50-59 years), 23.97 (60-69 years), and 29.63 (> or =70 years)., Conclusion: ED and CAD may be differing manifestations of a common underlying vascular pathology. When ED occurs in a younger man, it is associated with a marked increase in the risk of future cardiac events, whereas in older men, ED appears to be of little prognostic importance. Young men with ED may be ideal candidates for cardiovascular risk factor screening and medical intervention.

Frailty is characterized by vulnerability to acute stressors and is a consequence of decline in overall function and physiologic reserves. An estimated 7% of the US population older than 65 years and 30% of octogenarians are frail. The domains to define frailty include mobility, strength, balance, motor processing, cognition, nutrition, endurance, and physical activity. Pathophysiologic pathways leading to frailty involve a multisystem cascade that includes neuroendocrine dysfunction with lower insulin-like growth factor and dehydroepiandrosterone sulfate and an altered inflammatory milieu with increased levels of C-reactive protein, interleukins, tumor necrosis factor alpha, and abnormal coagulation. Frailty predicts death and heralds the transition to disability in general populations. As the population with coronary artery disease shifts toward older patients, physicians must consider the role of frailty in their patients. This review will enable clinicians to recognize frailty and consider its relevance in their daily practice. We also elaborate on reasons to consider frailty in older adults with cardiovascular disease and focus on its early identification, on referral to specialists, and on care after serious cardiac events.

Objective: To evaluate the association of neighborhood-level income and individual-level education with post-myocardial infarction (MI) mortality in community patients., Participants and Methods: From November 1, 2002, through May 31, 2006, 705 (mean+/-SD age, 69+/-15 years; 44% women) residents of Olmsted County, MN, who experienced an MI meeting standardized criteria were prospectively enrolled and followed up. The neighborhood's median household income was estimated by census tract data; education was self-reported. Demographic and clinical variables were obtained from the medical records., Results: Living in a less affluent neighborhood and having a low educational level were both associated with older age and more comorbidity. During follow-up (median, 13 months), 155 patients died. Neighborhood income (hazard ratio [HR], 2.10; 95% confidence interval [CI], 1.42-3.12; for lowest [median, $34,205] vs highest [median, $60,652] tertile) and individual education (HR, 2.21; 95% CI, 1.47-3.32; for <12 vs >12 years) were independently associated with mortality risk. Adjustment for demographics and various post-MI prognostic indicators attenuated these estimates, yet excess risk persisted for low neighborhood income (HR, 1.62; 95% CI, 1.08-2.45). Modeled as a continuous variable, each $10,000 increase in annual income was associated with a 10% reduction in mortality risk (adjusted HR, 0.90; 95% CI, 0.82-0.99)., Conclusion: In this geographically defined cohort of patients with MI, low individual education and poor neighborhood income were associated with a worse clinical presentation. Poor neighborhood income was a powerful predictor of mortality even after controlling for a variety of potential confounding factors. These data confirm the socioeconomic disparities in health after MI.

Objective: To examine sex differences in evaluation and outcome after stress testing for coronary artery disease (CAD) in a geographically defined cohort., Subjects and Methods: Subjects were residents of Olmsted County, Minnesota, who underwent an initial stress test between January 1, 1987, and December 31, 1990. End points included referral for coronary angiography, death, and cardiac events, defined as cardiac death, nonfatal myocardial infarction, or congestive heart failure., Results: A total of 2276 men and 1270 women under went stress tests. Women were older and had more risk factors and comorbidities (P < .05). Among persons without documented CAD (86% of the cohort), the median probability of CAD was 11% (interquartile range, 5%-25%) for men and 8% (interquartile range, 2%-31%) for women (P < .001). Within 6 months after stress testing, 9% of men and 7% of women underwent coronary angiography. Among persons without documented CAD, there was no sex difference in referral for angiography when the stress test result was negative. When the test result was positive, men were more likely to be referred for angiography (adjusted odds ratio [OR] for male sex, 2.02; 95% confidence interval [CI], 1.21-3.38; P = .008). After adjusting for the predicted probability of CAD, this association was no longer detected (adjusted OR for male sex, 0.67; 95% CI, 0.26-1.73; P = .41). Among persons with documented CAD, no sex difference was noted. After a mean +/- SD follow-up of 7.6 +/- 2.7 years and among persons without documented CAD, male sex was associated with a higher adjusted risk of death (relative risk for male sex, 1.40; 95% CI, 1.05-1.86; P = .02) and cardiac events (relative risk for male sex, 1.67; 95% CI, 1.24-2.26; P < .001). Among persons with documented CAD, no sex difference in outcome was noted., Conclusion: These population-based data indicate that, when the diagnosis of CAD was not established, there was a greater use of angiography among men with positive stress test results, which could be attributed to the increased probability of CAD in men. In the absence of documented CAD, men fared worse than women, with an increase in the risk of death and cardiac events. Among persons with documented CAD, no sex difference in use of angiography and outcome was noted.

Objective: To evaluate the validity of death certificate diagnosis of out-of-hospital (OOH) coronary heart disease (CHD) and sudden cardiac death (SCD) in Olmsted County, Minnesota, between 1981 and 1994., Methods: In this review of the medical records, autopsy reports, and coroner's files, OOH deaths with heart disease as the underlying cause of death on the death certificate were classified into CHD (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] codes 410-414) and non-CHD (other ICD-9-CM heart disease codes) deaths. A 10% random sample (n = 174) of these death certificates was reviewed by physicians, and published validation criteria were applied to classify these deaths into validated CHD or non-CHD categories. Sudden cardiac death was defined as validated CHD that occurred at an OOH location with less than 24 hours between symptom onset and death., Results: The death certificate definition of OOH CHD death (ICD-9-CM codes 410-414) had high sensitivity and positive predictive value of 91% and 96%, respectively. The specificity and the negative predictive value were slightly lower at 86% and 72%, respectively. The sensitivity of death certificate diagnosis of CHD for validated SCD was 89%, and the positive predictive value was 77%. Using a more restrictive definition of SCD, that is, less than 1 hour between the onset of symptoms and death, the positive predictive value of CHD codes for SCD was lower at 52%., Conclusions: In Olmsted County, the positive predictive values of death certificate diagnosis for OOH CHD and SCD are high. Relying on death certificate diagnoses results in about 5% underestimation of the true CHD rates, whereas their use as a surrogate for SCD yields a 16% overestimation of the true SCD rates.

Background: Although age-adjusted heart disease mortality has declined since the 1960s, this decline may not have applied equally to all subgroups., Objective: To examine recent trends in heart disease mortality, specifically in women and in the elderly., Methods: Age- and sex-specific heart disease mortality (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] codes 390-398, 402, 404-429) in Olmsted County, Minnesota, between 1979 and 1994 were studied., Results: The total number of heart disease deaths was 3095; 1578 (51%) occurred in women and 1984 (64%) in persons aged 75 years or older. Most heart disease deaths (77%) were coronary disease deaths (ICD-9-CM codes 410-414). Age-adjusted heart disease mortality rates declined from 123 per 100,000 (95% confidence interval [CI], 102-144/100,000) in 1979 to 81 per 100,000 (95% CI, 67-95/100,000) in 1994. Poisson regression analyses indicated that the trends differed according to sex and age. For women, the relative risk (RR) of heart disease death in 1994 compared with 1979 was 0.69 vs 0.53 for men (P = .06). This equates to a decline in heart disease mortality of 2.5% per year in women or 32% over the period and 4.2% per year in men or 47% over the period. The decline was less pronounced as age increased (P < .001). For 60-year-old women, the RR for 1994 compared with 1979 was 0.59, whereas for 80-year-old women, the RR for 1994 compared with 1979 was 0.76. For men, the RR for 1994 compared with 1979 was 0.60 for 80-year-old men vs 0.46 for 60-year-old men., Conclusions: Between 1979 and 1994, in Olmsted County, the decline in heart disease mortality was of lesser magnitude in women and in the elderly, emphasizing the importance of age- and sex-specific trends to characterize time patterns in heart disease deaths to target preventive measures.

Objective: To examine the use of Doppler echocardiography in preoperative assessment of aortic stenosis and to determine its effect on subsequent use of hemodynamic cardiac catheterization., Material and Methods: We retrospectively reviewed a consecutive series of 574 adult patients who underwent aortic valve replacement for aortic stenosis between 1990 and 1992 at our institution. The use of Doppler echocardiography and cardiac catheterization and the predictive factors for use of hemodynamic catheterization were analyzed., Results: After Doppler echocardiography in 423 patients, invasive hemodynamic assessment of the severity of aortic stenosis was performed in only 42% (179 patients). The use of cardiac catheterization declined over time (54% in 1990, 40% in 1991, and 35% in 1992) (P = 0.003), whereas no significant change in the baseline clinical characteristics of the population or in severity of stenosis as determined by Doppler echocardiography occurred during that time. Multivariate analysis identified the following variables as independent predictors of use of cardiac catheterization after Doppler echocardiography: clinically not severe aortic stenosis, mean gradient of less than 50 mm Hg determined by Doppler echocardiography, Doppler-determined aortic valve area of more than 0.8 cm2 or not calculated, attending cardiologist not specialized in echocardiography, and earlier year of assessment., Conclusion: After Doppler echocardiography, less than 50% of our patients undergoing aortic valve replacement for aortic stenosis have cardiac catheterization preoperatively. The use of cardiac catheterization after Doppler echocardiography--thus, duplication of hemodynamic assessment--declined significantly over time during the study period. Decline in the use of catheterization is related to the degree of diagnostic certainty provided by Doppler echocardiography and to the level of familiarity of the attending cardiologist with the technique.

An unusual echocardiographic appearance of a cardiac echinococcal lesion confirmed intraoperatively is described in a patient with nonspecific cardiac complaints. Although previous reports have emphasized the echolucent, often multiseptated nature of echinococcal lesions, such characteristics were absent in this case. Thus, in the appropriate clinical setting, echinococcal infection should be included in the differential diagnosis of solid mass lesions of the heart because the surgical approach may need to be altered.

Objective: To describe the rationale, methods, and clinical applications for dobutamine stress echocardiography., Design: We review our experience with the first 1,000 Mayo Clinic patients who underwent this procedure and discuss studies from the literature that have assessed the accuracy of dobutamine stress echocardiography in determining the presence and extent of coronary artery disease., Material and Methods: The Mayo protocol for dobutamine stress echocardiography is presented, and the indications for use of this test and comparisons of sensitivity and specificity with other tests are summarized., Results: Although exercise stress testing is the usual noninvasive method for the detection and assessment of coronary artery disease, a substantial number of patients are unable to perform adequate exercise because of physical limitations. In these patients, dobutamine stress echocardiography has emerged as a feasible, safe, and accurate method for the evaluation of coronary artery disease. The test has been proved to be valuable in the noninvasive diagnosis of coronary artery disease and to have an accuracy comparable to that of tomographic perfusion imaging. Other indications for dobutamine stress echocardiography include risk stratification before noncardiac surgical procedures, risk stratification after myocardial infarction, and identification of viable myocardium in patients with left ventricular dysfunction., Conclusion: Dobutamine stress echocardiography is an accurate, safe, cost-effective, and portable procedure for the noninvasive diagnosis of coronary artery disease and for the preoperative assessment of patients with such disease, especially those who are unable to perform adequate exercise tests.

Objective: To describe the techniques and applications of exercise echocardiography., Design: We review pertinent experimental and clinical studies from the literature and present our experience with the first 2,000 patients who underwent exercise echocardiography in our laboratory., Material and Methods: The indications for and contraindications to exercise echocardiography and the advantages, limitations, and accuracy of this procedure in comparison with other techniques for detecting coronary artery disease are discussed., Results: Exercise echocardiography is increasingly used for the noninvasive evaluation of coronary artery disease because, in addition to its diagnostic capabilities, it offers attractive features such as portability, versatility, rapid availability of results, and relatively low cost. For accurate interpretation of the results, the workload achieved and the time between completion of exercise and image acquisition must be considered. The major limitation of exercise echocardiography is the high degree of operator dependence. For accurate interpretation of regional wall motion abnormalities and recognition of ischemic changes, specific training and extensive experience are necessary., Conclusion: Although exercise echocardiography has only relatively recently become a widely used technique, it has proved to have considerable accuracy in the diagnosis of coronary artery disease (mean sensitivity, 84%; mean specificity, 87%). In high-volume laboratories, feasibility studies have shown success rates between 90 and 99%; thus far, reproducibility has been satisfactory. Other applications of exercise echocardiography being studied are follow-up monitoring after revascularization, determination of prognosis, and assessment of valvular heart disease.