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Objectives The purpose of this study was to determine the association of complete heart block (CHB) with outcomes and to examine temporal trends in the incidence and outcomes of CHB complicating ST-segment elevation myocardial infarction (STEMI). Background There are limited data available on the incidence and outcomes of CHB in STEMI patients who undergo contemporary management. Methods We used the 2003 to 2012 National Inpatient Sample databases to identify all patients age ≥18 years hospitalized with STEMI. Patients with a concomitant diagnosis of CHB were then identified. Multivariable logistic regression was used to analyze the association of CHB with outcomes and to examine the temporal trends in incidence and outcomes of CHB complicating STEMI. Results Of 2,273,853 patients with STEMI, 49,882 (2.2%) had CHB. The incidence of CHB increased from 2.1% in 2003 to 2.3% in 2012 (adjusted odds ratio [OR] per year: 1.02; 95% confidence interval [CI]: 1.02 to 1.03). STEMI patients with CHB had higher in-hospital mortality than those without CHB (20.4% vs. 8.7%; adjusted OR: 2.47; 95% CI: 2.41 to 2.53). The higher mortality associated with CHB was independent of the location of STEMI; however, the magnitude of this association was greatest in patients with anterior STEMI. In patients with CHB complicating STEMI, although permanent pacemaker implantation rates declined (adjusted OR per year: 0.96; 95% CI: 0.95 to 0.97), in-hospital mortality remained unchanged during the study period (adjusted OR per year: 1.00; 95% CI: 0.99 to 1.01). Conclusions The incidence of CHB complicating STEMI has increased slightly over the last decade, although the absolute incidence remains quite low. CHB remains associated with higher in-hospital mortality in STEMI patients even in the current era of prompt reperfusion therapy. In patients with CHB complicating STEMI, there was no change in risk-adjusted in-hospital mortality during the study period.

Peripheral arterial disease is an important predictor of cardiovascular morbidity and mortality. Patients with peripheral arterial disease are at a higher risk of myocardial infarction and stroke. The well-known coronary artery disease risk factors such as diabetes, hypertension, smoking and dyslipidemia are also risk factors for peripheral arterial disease. Hyperglycemia is an important mediator in the pathogenesis of this disease in diabetics, more so in women. The morbidity and poor outcomes associated with peripheral arterial disease in women are emerging. Women are more likely to present at an older age are often asymptomatic and have poorer outcomes with revascularization. Women experience specific sex-related challenges in the various diagnostic methods which could lead to a delay in diagnosis. This is a group which needs close attention and aggressive risk factor modification.

There is a paucity of data regarding the complications and in-hospital mortality after catheter ablation for ventricular tachycardia (VT) in patients with ischemic heart disease.The purpose of this study was to determine the temporal trends in utilization, in-hospital mortality, and complications of catheter ablation of postinfarction VT in the United States.We used the 2002-2011 Nationwide Inpatient Sample (NIS) database to identify all patients ≥18 years of age with a primary diagnosis of VT (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] code 427.1) and who also had a secondary diagnosis of prior history of myocardial infarction (ICD-9-CM 412). Patients with supraventricular arrhythmias were excluded. Patients who underwent catheter ablation were identified using ICD-9-CM procedure code 37.34. Temporal trends in catheter ablation, in-hospital complications, and in-hospital mortality were analyzed.Of 81,539 patients with postinfarct VT, 4653 (5.7%) underwent catheter ablation. Utilization of catheter ablation increased significantly from 2.8% in 2002 to 10.8% in 2011 (Ptrend.001). The overall rate of any in-hospital complication was 11.2% (523/4653), with vascular complications in 6.9%, cardiac in 4.3%, and neurologic in 0.5%. In-hospital mortality was 1.6% (75/4653). From 2002 to 2011, there was no significant change in the overall complication rates (8.4% to 10.2%, Ptrend = .101; adjusted odds ratio [per year] 1.02, 95% confidence interval 0.98-1.06) or in-hospital mortality (1.3% to 1.8%, Ptrend = .266; adjusted odds ratio [per year] 1.03, 95% confidence interval 0.92-1.15).The utilization rate of catheter ablation as therapy for postinfarct VT has steadily increased over the past decade. However, procedural complication rates and in-hospital mortality have not changed significantly during this period.

Background The role of angiotensin-converting enzyme (ACE) inhibitors in patients with heart failure and preserved ejection fraction remains unclear. Methods Of the 10,570 patients aged ≥65 years with heart failure and preserved ejection fraction (≥40%) in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (2003-2004) linked to Medicare (through December 2008), 7304 were not receiving angiotensin receptor blockers and had no contraindications to ACE inhibitors. After excluding 3115 patients with pre-admission ACE inhibitor use, the remaining 4189 were eligible for new discharge prescriptions for ACE inhibitors, and 1706 received them. Propensity scores for the receipt of ACE inhibitors, calculated for each of the 4189 patients, were used to assemble a cohort of 1337 pairs of patients, balanced on 114 baseline characteristics. Results Matched patients had a mean age of 81 years and mean ejection fraction of 55%, 64% were women, and 9% were African American. Initiation of ACE inhibitor therapy was associated with a lower risk of the primary composite end point of all-cause mortality or heart failure hospitalization during 2.4 years of median follow-up (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84-0.99; P = .028), but not with individual end points of all-cause mortality (HR, 0.96; 95% CI, 0.88-1.05; P = .373) or heart failure hospitalization (HR, 0.93; 95% CI, 0.83-1.05; P = .257). Conclusion In hospitalized older patients with heart failure and preserved ejection fraction not receiving angiotensin receptor blockers, discharge initiation of ACE inhibitor therapy was associated with a modest improvement in the composite end point of total mortality or heart failure hospitalization but had no association with individual end point components.

Background Prior studies have found that smokers undergoing thrombolytic therapy for ST ‐segment elevation myocardial infarction have lower in‐hospital mortality than nonsmokers, a phenomenon called the “smoker's paradox.” Evidence, however, has been conflicting regarding whether this paradoxical association persists in the era of primary percutaneous coronary intervention. Methods and Results We used the 2003–2012 National Inpatient Sample databases to identify all patients aged ≥18 years who underwent primary percutaneous coronary intervention for ST ‐segment elevation myocardial infarction. Multivariable logistic regression was used to compare in‐hospital mortality between smokers (current and former) and nonsmokers. Of the 985 174 patients with ST ‐segment elevation myocardial infarction undergoing primary percutaneous coronary intervention, 438 954 (44.6%) were smokers. Smokers were younger, were more often men, and were less likely to have traditional vascular risk factors than nonsmokers. Smokers had lower observed in‐hospital mortality compared with nonsmokers (2.0% versus 5.9%; unadjusted odds ratio 0.32, 95% CI 0.31–0.33, P CI 0.58–0.62, P P P OR 0.78, 95% CI 0.76–0.81, P Conclusions In this nationwide cohort of patients undergoing primary percutaneous coronary intervention for ST ‐segment elevation myocardial infarction, we observed significantly lower risk‐adjusted in‐hospital mortality in smokers, suggesting that the smoker's paradox also applies to ST ‐segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

In the Beta-Blocker Evaluation of Survival Trial (BEST), systolic blood pressure (SBP) ≤ 120 mm Hg was an independent predictor of poor prognosis in ambulatory patients with chronic systolic heart failure (HF). Because SBP is an important predictor of response to β-blocker therapy, the BEST protocol prespecified a post hoc analysis to determine whether the effect of bucindolol varied by baseline SBP.In the BEST, 2706 patients with chronic systolic (left ventricular ejection fraction35%) HF and New York Heart Association class III (92%) or IV (8%) symptoms and receiving standard background therapy were randomized to receive either bucindolol (n = 1354) or placebo (n = 1354). Of these, 1751 had SBP ≤ 120 mm Hg, and 955 had SBP120 mm Hg at baseline.Among patients with SBP120 mm Hg, all-cause mortality occurred in 28% and 22% of patients receiving placebo and bucindolol, respectively (hazard ratio when bucindolol was compared with placebo, 0.77; 95% confidence interval [CI], 0.59-0.99; P = 0.039). In contrast, among those with SBP ≤ 120 mm Hg, 36% and 35% of patients in the placebo and bucindolol groups died, respectively (hazard ratio, 0.95; 95% CI, 0.81-1.12; P = 0.541). Hazard ratios (95% CIs; P values) for HF hospitalization associated with bucindolol use were 0.70 (0.56-0.89; P = 0.003) and 0.82 (0.71-0.95; P = 0.008) for patients with SBP120 and ≤ 120 mm Hg, respectively.Bucindolol, a nonselective β-blocker with weak α(2)-blocking properties, significantly reduced HF hospitalization in systolic HF patients regardless of baseline SBP. However, bucindolol reduced mortality only in those with SBP120 mm Hg.

Reduced right ventricular ejection fraction (RVEF) is associated with poor outcomes in patients with chronic systolic heart failure (HF). Although most HF patients are older adults, little is known about the relationship between low RVEF and outcomes in older adults with systolic HF.Of the 2008 Beta-Blocker Evaluation of Survival Trial (BEST) participants with systolic HF (left ventricular ejection fraction ≤ 35%) 822 were ≥ 65 years and had data on baseline RVEF estimated by gated-equilibrium radionuclide ventriculography. Using RVEF ≥ 40% (n = 308) as reference, we examined association of RVEF 30-39% (n = 214), 20-29% (n = 206) and20% (n = 94) with outcomes using Cox regression models.All-cause mortality occurred in 36%, 40%, 39% and 56% of patients with RVEF ≥ 40%, 30-39%, 20-29% and20% respectively. Compared with RVEF ≥ 40%, unadjusted hazard ratios (HR) and 95% confidence intervals (CI) for all-cause mortality associated with RVEF 30-39%, 20-29% and20% were 1.19 (0.90-1.57; P = 0.220), 1.13 (0.84-1.51; P = 0.423) and 1.97 (1.43-2.73; P0.001) respectively. Respective multivariable-adjusted HR's (95% CI's) for all-cause mortality were 1.19 (0.88-1.60; P = 0.261), 1.00 (0.73-1.39; P = 0.982) and 1.70 (1.14-2.53; P = 0.009). Adjusted HR's (95% CI's) associated with RVEF20% (versus ≥ 40%) for cardiovascular mortality and HF mortality were 1.79 (1.17-2.76; P = 0.008) and 1.97 (1.02-3.83; P = 0.045) respectively. RVEF had no independent association with sudden cardiac death, all-cause or HF hospitalization.Abnormally low RVEF is a significant independent predictor of mortality, but not of HF hospitalization, in older adults with systolic HF.

Older age is an independent predictor of all-cause mortality in patients with mild to moderate heart failure (HF). Whether older age is also an independent predictor of mortality in patients with more advanced HF is unknown.Of the 2707 Beta-Blocker Evaluation of Survival Trial (BEST) participants with ambulatory chronic HF (New York Heart Association class III/IV and left ventricular ejection fraction35%), 1091 were elderly (≥ 65 years). Propensity scores for older age, estimated for each of the 2707 patients, were used to assemble a cohort of 603 pairs of younger and older patients, balanced on 66 baseline characteristics.All-cause mortality occurred in 33% and 36% of younger and older matched patients respectively during 4 years of follow-up (hazard ratio {HR} associated with age ≥ 65 years, 1.05; 95% confidence interval {CI}, 0.87-1.27; P=0.614). HF hospitalization occurred in 38% and 40% of younger and older matched patients respectively (HR, 1.01; 95% CI, 0.84-1.21; P=0.951). Among 603 pairs of unmatched and unbalanced patients, all-cause mortality occurred in 28% and 36% of younger and older patients respectively (HR, 1.34; 95% CI, 1.10-1.64; P=0.004) and HF hospitalization occurred in 34% and 40% of younger and older unmatched patients respectively (HR, 1.24; 95% CI, 1.03-1.50; P=0.024).Significant bivariate associations suggest that older age is a useful marker of poor outcomes in patients with advanced chronic systolic HF. However, lack of significant independent associations suggests that older age per se has no intrinsic effect on outcomes in these patients.

Diabetes mellitus (DM) is a risk factor for incident heart failure (HF) in older adults. However, the extent to which this association is independent of other risk factors remains unclear. Of 5,464 community-dwelling adults ≥65 years old in the Cardiovascular Health Study without baseline HF, 862 had DM (fasting plasma glucose levels ≥126 mg/dl or treatment with insulin or oral hypoglycemic agents). Propensity scores for DM were estimated for each of the 5,464 participants and were used to assemble a cohort of 717 pairs of participants with and without DM who were balanced in 65 baseline characteristics. Incident HF occurred in 31% and 26% of matched participants with and without DM, respectively, during >13 years of follow-up (hazard ratio 1.45 for DM vs no DM, 95% confidence interval [CI] 1.14 to 1.86, p = 0.003). Of the 5,464 participants before matching unadjusted and multivariable-adjusted hazard ratios for incident HF associated with DM were 2.22 (95% CI 1.94 to 2.55, p

Aging is often associated with increased systolic blood pressure and decreased diastolic blood pressure. Isolated systolic hypertension or an elevated systolic blood pressure without an elevated diastolic blood pressure is a known risk factor for incident heart failure in older adults. In the current study, we examined whether isolated diastolic hypotension, defined as a diastolic blood pressure 12 years of median follow-up, centrally adjudicated incident heart failure developed in 25% and 20% of matched participants with and without isolated diastolic hypotension, respectively (hazard ratio associated with isolated diastolic hypotension: 1.33 [95% CI: 1.10–1.61]; P =0.004). Among the 5376 prematch individuals, multivariable-adjusted hazard ratio for incident heart failure associated with isolated diastolic hypotension was 1.29 (95% CI: 1.09–1.53; P =0.003). As in isolated systolic hypertension, among community-dwelling older adults without prevalent heart failure, isolated diastolic hypotension is also a significant independent risk factor for incident heart failure.

Warfarin is often used in patients with systolic heart failure (HF) to prevent adverse outcomes. However, its long-term effect remains controversial. The objective of this study was to determine the association of warfarin use and outcomes in patients with advanced chronic systolic HF without atrial fibrillation (AF), previous thromboembolic events, or prosthetic valves. Of the 2,708 BEST patients, 1,642 were free of AF without a history of thromboembolic events and without prosthetic valves at baseline. Of these, 471 patients (29%) were receiving warfarin. Propensity scores for warfarin use were estimated for each patient and were used to assemble a matched cohort of 354 pairs of patients with and without warfarin use who were balanced on 62 baseline characteristics. Kaplan-Meier and Cox regression analyses were used to estimate the association between warfarin use and outcomes during 4.5 years of follow-up. Matched participants had a mean age ± SD of 57 ± 13 years with 24% women and 24% African-Americans. All-cause mortality occurred in 30% of matched patients in the 2 groups receiving and not receiving warfarin (hazard ratio 0.86, 95% confidence interval 0.62 to 1.19, p = 0.361). Warfarin use was not associated with cardiovascular mortality (hazard ratio 0.97, 95% confidence interval 0.68 to 1.38, p = 0.855), or HF hospitalization (hazard ratio 1.09, 95% confidence interval 0.82 to 1.44, p = 0.568). In conclusion, in patients with chronic advanced systolic HF without AF or other recommended indications for anticoagulation, prevalence of warfarin use was high. However, despite a therapeutic international normalized ratio in those receiving warfarin, its use had no significant intrinsic association with mortality and hospitalization.

Presence of concentric left ventricular (LV) geometry has important pathophysiologic and prognostic implications. However, little is known about its natural history in older adults. Of the 5,795 community-dwelling adults ≥65 years of age in the Cardiovascular Health Study, 1,871 without baseline heart failure had data on baseline and 7-year echocardiograms. Of these 343 (18%) had baseline concentric LV geometry (concentric remodeling 83%, concentric LV hypertrophy [LVH] 17%) and are the focus of the present study. LV geometry at year 7 was categorized into 4 groups based on LVH (LV mass indexed for height51 g/m²·⁷) and relative wall thickness (RWT): eccentric hypertrophy (RWT ≤0.42 with LVH), concentric hypertrophy (RWT0.42 with LVH), concentric remodeling (RWT0.42 without LVH), and normal (RWT ≤0.42 without LVH). At year 7, LV geometry normalized in 57%, remained unchanged in 35%, and transitioned to eccentric hypertrophy in 7% of participants. Incident eccentric hypertrophy occurred in 4% and 25% of those with baseline concentric remodeling and concentric hypertrophy, respectively, and was associated with increased LV end-diastolic volume and decreased LV ejection fraction at year 7. Previous myocardial infarction and baseline above-median LV mass (39 g/m²·⁷) and RWT (0.46) had significant unadjusted associations with incident eccentric LVH; however, only LV mass39 g/m²·⁷ (odds ratio 17.52, 95% confidence interval 3.91 to 78.47, p0.001) and previous myocardial infarction (odds ratio 4.73, 95% confidence interval 1.16 to 19.32, p = 0.031) had significant independent associations. In conclusion, in community-dwelling older adults with concentric LV geometry, transition to eccentric hypertrophy was uncommon but structurally maladaptive.

The association between hyperuricemia and incident heart failure (HF) is relatively unknown.Of the 5461 community-dwelling older adults,or=65 years, in the Cardiovascular Health Study without HF at baseline, 1505 had hyperuricemia (baseline serum uric acidor=6 mg/dL for women andor=7 mg/dL for men). Using propensity scores for hyperuricemia, estimated for each participant using 64 baseline covariates, we were able to match 1181 pairs of participants with and without hyperuricemia.Incident HF occurred in 21% and 18% of participants respectively with and without hyperuricemia during 8.1 years of mean follow-up (hazard ratio {HR} for hyperuricemia versus no hyperuricemia, 1.30; 95% confidence interval {CI}, 1.05-1.60; P=0.015). The association between hyperuricemia and incident HF was significant only in subgroups with normal kidney function (HR, 1.23; 95% CI, 1.02-1.49; P=0.031), without hypertension (HR, 1.31; 95% CI, 1.03-1.66; P=0.030), not receiving thiazide diuretics (HR, 1.20; 95% CI, 1.01-1.42; P=0.044), and without hyperinsulinemia (HR, 1.35; 95% CI, 1.06-1.72; P=0.013). Used as a continuous variable, each 1 mg/dL increase in serum uric acid was associated with a 12% increase in incident HF (HR, 1.12; 95% CI, 1.03-1.22; P=0.006). Hyperuricemia had no association with acute myocardial infarction or all-cause mortality.Hyperuricemia is associated with incident HF in community-dwelling older adults. Cumulative data from our subgroup analyses suggest that this association is only significant when hyperuricemia is a marker of increased xanthine oxidase activity but not when hyperuricemia is caused by impaired renal elimination of uric acid.

To determine the association between obesity and outcomes in post-acute myocardial infarction (AMI) patients with systolic heart failure (HF).Of the 6632 Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) participants, 6611 had data on baseline body mass index (BMI) and 6561 had BMIor = 18.5 kg/m(2). Of these, 1573 were obese (BMIor = 30 kg/m(2)) and 4988 were non-obese (BMI 18.5-29.9 kg/m(2)). Propensity scores for obesity, estimated for each patient, were used to assemble a cohort of 1519 pairs of obese and non-obese patients who were balanced on 65 baseline characteristics. All-cause mortality occurred in 13.7 and 13.8% of matched obese and non-obese patients, respectively, during 16 months of median follow-up [matched hazard ratio (HR) for obesity 0.98; 95% confidence interval (CI) 0.79-1.21; P = 0.831]. Before matching, the obese group was younger (mean age, 62 vs. 64 years; P0.0001) and had more women (37 vs. 26%; P0.0001). The paradoxical pre-match association between obesity and reduced mortality (unadjusted HR 0.82; 95% CI 0.70-0.95; P = 0.008) disappeared when adjusted for age alone (age-adjusted HR 0.91; 95% CI 0.78-1.06; P = 0.206) but not for gender alone (gender-adjusted HR 0.79; 95% CI 0.68-0.92; P = 0.003). Obesity had no association with mortality in 1573 pairs of age-matched obese and non-obese patients (age-adjusted HR 0.94; 95% CI 0.77-1.13; P = 0.484).In post-AMI patients with systolic HF, obesity provides no independent intrinsic survival benefit. The paradoxical unadjusted survival associated with obesity is largely explained by the younger age of obese patients.

Background— Studies of the effect of right ventricular ejection fraction (RVEF) on outcomes in heart failure (HF) are limited by small sample size and short follow-up. Methods and Results— We examined the effect of baseline RVEF on outcomes in 2008 Beta-Blocker Evaluation of Survival Trial (BEST) participants with HF and left ventricular ejection fraction ≤35% during 24 months of mean follow-up. RVEF, estimated by gated-equilibrium radionuclide ventriculography, was used to categorize patients into 4 RVEF groups: ≥40% (n=733), 30% to 39% (n=531), 20% to 29% (n=473), and P =0.087), 1.45 (1.17 to 1.78; P =0.001), and 1.98 (1.59 to 2.47; P P =0.518), 1.12 (0.89 to 1.40; P =0.328), and 1.32 (1.02 to 1.71; P =0.034), respectively. Adjusted hazard ratios (95% confidence intervals) for other outcomes associated with RVEF P =0.041); HF mortality, 1.61 (1.03 to 2.52; P =0.037); sudden cardiac death, 1.29 (0.87 to 1.91; P =0.212); all-cause hospitalization, 1.21 (1.00 to 1.47; P =0.056); and HF hospitalization, 1.39 (1.10 to 1.77; P =0.007). Conclusions— Baseline RVEF

In the Digitalis Investigation Group trial, digoxin-associated decrease in the combined end point of heart failure (HF) hospitalization or HF mortality was significant in systolic but not in diastolic HF. To assess whether this apparent disparity could be explained by differences in baseline characteristics and sample size, we used propensity score matching to assemble a cohort of 916 pairs of patients with systolic and diastolic HF who were balanced in all measured baseline covariates. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) of the effect of digoxin on outcomes separately in systolic and diastolic HF, at 2 years (protocol prespecified), and at the end of 3.2 years of median follow-up. HF hospitalization or HF mortality occurred in 28% and 32% of patients with systolic HF (HR digoxin vs placebo 0.85, 95% CI 0.67 to 1.08, p = 0.188) and 20% and 25% in those with diastolic HF (HR 0.79, 95% CI 0.60 to 1.03, p = 0.085) receiving digoxin and placebo, respectively. At 2 years, HRs for this combined end point were similar for systolic HF (0.72, 95% CI 0.55 to 0.95, p = 0.022) and diastolic HF (0.69, 95% CI 0.50 to 0.95, p = 0.025). Digoxin also decreased 2-year HF hospitalization in systolic HF (HR 0.73, 95% CI 0.54 to 0.97, p = 0.033) and diastolic HF (HR 0.64, 95% CI 0.45 to 0.90, p = 0.010). In conclusion, as in patients with systolic HF, digoxin was equally effective in those with diastolic HF, who constitute half of all patients with HF, yet have few evidence-based therapeutic options.

Background The association of chronic renal insufficiency with outcomes after percutaneous coronary intervention ( PCI ) in the current era of drug‐eluting stents and modern antithrombotic therapy has not been well characterized. Methods and Results We queried the 2007–2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years who underwent PCI . Multivariable logistic regression was used to compare in‐hospital outcomes among patients with chronic kidney disease ( CKD ), patients with end‐stage renal disease ( ESRD ), and those without CKD or ESRD . Of 3 187 404 patients who underwent PCI , 89% had no CKD / ESRD ; 8.6% had CKD ; and 2.4% had ESRD . Compared to patients with no CKD / ESRD , patients with CKD and patients with ESRD had higher in‐hospital mortality (1.4% versus 2.7% versus 4.4%, respectively; adjusted odds ratio for CKD 1.15, 95% CI 1.12 to 1.19, P ESRD 2.29, 95% CI 2.19 to 2.40, P CKD 1.21, 95% CI 1.18 to 1.23, P ESRD 1.27, 95% CI 1.23 to 1.32, P P P PCI for acute coronary syndrome or stable ischemic heart disease. Conclusions In patients undergoing PCI , chronic renal insufficiency is associated with higher in‐hospital mortality, higher postprocedure hemorrhage, longer average length of stay, and higher average hospital charges.

Background: Atrial fibrillation is a relatively common comorbid condition in patients with coronary artery disease. However, there are limited data on the association of atrial fibrillation (AF) with outcomes in ST-elevation myocardial infarction (STEMI). Methods: We queried the 2003-2011 Nationwide Inpatient Sample databases using the ICD-9 diagnosis codes, to identify all patients > 18 years admitted with a primary diagnosis of STEMI. We studied the association of AF with in-hospital outcomes in these patients both by regression analysis and propensity match to adjust for demographics, hospital characteristics and co-morbidities. Results: Of the total 452,772 (64.5% men) STEMI hospitalizations, AF was documented in 58,273 (12.9%) cases. Patients with AF were older (mean age 75±12 vs 64±14 years; p Conclusions: In patients hospitalized with STEMI, AF was independently associated with modestly higher in-hospital mortality, higher hospital charges, and longer length of stay.

Older females presenting with ST-Elevation Myocardial Infarction (STEMI) are less likely to receive revascularization and have higher in-hospital mortality compared to their male counterparts. Data on gender differences and temporal trends in revascularization and outcomes of STEMI in younger adults

Background Acute myocardial infarction is a recognized complication in patients with hypertrophic cardiomyopathy. However, limited data are available on outcomes of patients with hypertrophic cardiomyopathy and acute myocardial infarction. Methods We analyzed the 2003-2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years with a principal diagnosis of acute myocardial infarction. Patients with a concomitant diagnosis of hypertrophic cardiomyopathy were then identified and analyzed as a separate cohort. Multivariate logistic regression was used to compare outcomes in patients with acute myocardial infarction with and without hypertrophic cardiomyopathy. Results Of 5,901,827 patients with acute myocardial infarction, 5688 (0.1%) had a diagnosis of hypertrophic cardiomyopathy. Patients with hypertrophic cardiomyopathy were older, more likely to be female, and less likely to have traditional cardiovascular risk factors. Compared with patients without hypertrophic cardiomyopathy, patients with hypertrophic cardiomyopathy were less likely to present with ST-elevation myocardial infarction and more likely to present with non-ST-elevation myocardial infarction. Patients with hypertrophic cardiomyopathy with ST-elevation myocardial infarction or non-ST-elevation myocardial infarction were less likely to receive revascularization. In the overall population with acute myocardial infarction, there was no difference in risk-adjusted in-hospital mortality between patients with and without hypertrophic cardiomyopathy (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.84-1.11; P = .59). In the population with ST-elevation myocardial infarction, patients with hypertrophic cardiomyopathy had lower risk-adjusted in-hospital mortality than those without hypertrophic cardiomyopathy (OR, 0.75; 95% CI, 0.63-0.91; P = .003), whereas in the population with non–ST-elevation myocardial infarction, there was no difference in risk-adjusted in-hospital mortality between patients with and without hypertrophic cardiomyopathy (OR, 0.97; 95% CI, 0.84-1.11; P = .63). Conclusions Patients with hypertrophic cardiomyopathy represent a small proportion of patients with acute myocardial infarction and are less likely to receive revascularization. Compared with patients without hypertrophic cardiomyopathy, patients with hypertrophic cardiomyopathy with ST-elevation myocardial infarction have lower risk-adjusted in-hospital mortality.

Acute myocardial infarction in patients with end-stage renal disease (ESRD) is associated with increased risk of morbidity and mortality. Limited data are available on the contemporary trends in management and outcomes of ST-elevation myocardial infarction (STEMI) in patients with ESRD. We analyzed the 2003 to 2011 Nationwide Inpatient Sample databases to examine the temporal trends in STEMI, use of mechanical revascularization for STEMI, and in-hospital outcomes in patients with ESRD aged ≥18 years in the United States. From 2003 to 2011, whereas the number of patients with ESRD admitted with the primary diagnosis of acute myocardial infarction increased from 13,322 to 20,552, there was a decrease in the number of STEMI hospitalizations from 3,169 to 2,558 (ptrend0.001). The overall incidence rate of cardiogenic shock in patients with ESRD and STEMI increased from 6.6% to 18.3% (ptrend0.001). The use of percutaneous coronary intervention for STEMI increased from 18.6% to 37.8% (ptrend0.001), whereas there was no significant change in the use of coronary artery bypass grafting (ptrend = 0.32). During the study period, in-hospital mortality increased from 22.3% to 25.3% (adjusted odds ratio [per year] 1.09; 95% confidence interval 1.08 to 1.11; ptrend0.001). The average hospital charges increased from $60,410 to $97,794 (ptrend0.001), whereas the average length of stay decreased from 8.2 to 6.5 days (ptrend0.001). In conclusion, although there have been favorable trends in the utilization of percutaneous coronary intervention and length of stay in patients with ESRD and STEMI, the incidence of cardiogenic shock has increased threefold, with an increase in risk-adjusted in-hospital mortality, likely because of the presence of greater co-morbidities.

The southeastern region of the United States is known as the "stroke belt" because of excess stroke mortality in this region compared to the rest of the country. However, whether a similar geographic variation in heart failure mortality exists is unknown. Using the Center for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research publicly available compressed mortality data files and 2000 United States population as the standard, we estimated age-adjusted heart failure and stroke mortality rates per 100,000 for patients of all ages, men and women, and all races during 1979 through 1998 in the United States and mapped rates at the state level. Age-adjusted heart failure mortality rate for the 6 contiguous southeastern states (Alabama, Arkansas, Mississippi, Oklahoma, Louisiana, and Georgia) was 31.0/100,000, which was 69% higher than the national rate of 18.3/100,000. This geographic disparity was similar in African-Americans (32.9/100,000 in the southeast vs 21.7/100,000 nationally) and whites (30.8/100,000 in the southeast vs 18.1/100,000 nationally). These findings suggest that, in addition to the stroke belt, the southeastern region of the United States may also be burdened by a "heart failure belt." To better understand the causes of excess stroke mortality in the stroke belt, the National Institutes of Health has funded the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study (n = 30,239, >1/2 from the southeastern region), which provides a unique opportunity to study the underlying causes of excess heart failure mortality in the heart failure belt.

Background There has been a paradigm shift in the definition of timing of early invasive strategy ( EIS ) for patients admitted with non‐ ST ‐elevation myocardial infarction ( NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in‐hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in‐hospital outcomes of NSTEMI in the United States. Methods and Results We analyzed the 2002–2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction ( AMI ) and NSTEMI . Logistic regression was used for overall, age‐, sex‐, and race/ethnicity‐stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI . Of these, 3 981 119 (61.1%) had NSTEMI . The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [ OR; per year], 1.055; 95% confidence interval [ CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age‐, sex‐, and race/ethnicity‐stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% ( P trend EIS at day 0 or 1 increased from 27.8% to 41.4% ( P trend OR [per year], 0.976; 95% CI, 0.974 to 0.978). Conclusions There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS . This has been accompanied by temporal decreases in in‐hospital mortality and length of stay.

Catheter ablation has been used to treat incessant ventricular tachycardia (VT) and also to prevent or reduce the frequency of episodes of VT in patients with ischemic cardiomyopathy. However, there are limited data regarding the complications and in-hospital mortality after catheter ablation for

Non ST-elevation myocardial infarction (NSTEMI) is a major cause of morbidity and mortality in the older patient population. We sought to analyze the trends in incidence, utilization of early invasive strategy (diagnostic coronary angiography with intent to perform revascularization within 24 hours

In-hospital cardiac arrest (IHCA) is common and is associated with poor prognosis. Data on the effect of smoking on outcomes after IHCA are limited. We analyzed the Nationwide Inpatient Sample databases from 2003 to 2011 for all patients aged≥18 years who underwent cardiopulmonary resuscitation (CPR) for IHCA to examine the differences in survival to hospital discharge and neurologic status between smokers and nonsmokers. Of the 838,464 patients with CPR for IHCA, 116,569 patients (13.9%) were smokers. Smokers were more likely to be younger, Caucasian, and male. They had a greater prevalence of dyslipidemia, coronary artery disease, hypertension, chronic pulmonary disease, obesity, and peripheral vascular disease. Atrial fibrillation, heart failure, and diabetes mellitus with complications were less prevalent in smokers. Smokers were more likely to have a primary diagnosis of acute myocardial infarction (14.8% vs 9.1%, p0.001) and ventricular tachycardia or ventricular fibrillation as the initial cardiac arrest rhythm (24.3% vs 20.5%, p0.001). Smokers had a higher rate of survival to hospital discharge compared with nonsmokers (28.2% vs 24.1%, adjusted odds ratio 1.06, 95% confidence interval 1.05 to 1.08, p0.001). Smokers were less likely to have a poor neurologic status after IHCA compared with nonsmokers (3.5% vs 3.9%, adjusted odds ratio 0.92, 95% confidence interval 0.89 to 0.95, p0.001). In conclusion, among patients aged ≥18 years who underwent CPR for IHCA, we observed a higher rate of survival in smokers than nonsmokers-consistent with the "smoker's paradox." Smokers were also less likely to have a poor neurologic status after IHCA.

Background Limited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST ‐elevation myocardial infarction ( STEMI ). Methods and Results We queried the 2003–2010 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with STEMI and cardiogenic shock. Overall and age‐, sex‐, and race/ethnicity‐specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra‐aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥40 years with STEMI , 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 ( P trend P trend P trend P trend OR , 0.71; 95% CI , 0.68 to 0.75), whereas the average total hospital cost increased from $35 892 to $45 625 ( P trend P trend =0.394). These temporal trends were similar in patients Conclusions The incidence of cardiogenic shock complicating STEMI has increased during the past 8 years together with increased use of early mechanical revascularization and intra‐aortic balloon pumps. There has been a concomitant decrease in risk‐adjusted inhospital mortality, but an increase in total hospital costs during this period.

Introduction: Left ventricular ejection fraction (LVEF) is a predictor of incident heart failure (HF). However, baseline LVEF is often unavailable in population studies of HF. Material and methods: Of the 5324 Cardiovascular Health Study (CHS) participants free of baseline HF, 143 (3%) had LVEF < 45% and 1091 (21%) developed HF during 13 years of follow-up. Using public-use copies of the CHS data, we compared two predictor models of incident HF, with and without adjustment for baseline LVEF. Results: Baseline impaired LVEF was a strong independent predictor of incident HF (adjusted hazard ratio, 2.78; P < 0.001) but had no impact on the direction, magnitude or significance of independent associations of the other predictors of incident HF such as age, sex, race, coronary artery disease, hypertension and diabetes. Conclusion: Baseline LVEF is an important predictor for incident HF but is not essential in population studies of risk factors for incident HF.

Previous studies have demonstrated improved outcomes with an early invasive strategy in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI). However, there are limited data for patients ≥80 years of age in these studies.We used the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥80 years of age (octogenarians) with UA/NSTEMI. Multivariable logistic regression was used to compare in-hospital outcomes in octogenarians with UA/NSTEMI undergoing early invasive (coronary angiography within 48 hours of admission, with or without revascularization) versus initial conservative treatment.Among 968,542 octogenarians with UA/NSTEMI, 806,902 (83.3%) were managed using an initial conservative approach and 161,640 (16.7%) using an early invasive strategy. Patients in the early invasive group were more likely to be younger, men, white, and had a higher prevalence of smoking, dyslipidemia, obesity, hypertension, known coronary artery disease, carotid artery disease, and peripheral vascular disease. In-hospital mortality was significantly lower in octogenarians in the early invasive group (adjusted odds ratio [OR] 0.76; 95% confidence interval [CI], 0.74-0.78). Early invasive strategy was associated with lower rates of acute ischemic stroke (adjusted OR 0.63; 95% CI, 0.60-0.66), intracranial hemorrhage (adjusted OR 0.60; 95% CI, 0.510.70), gastrointestinal bleeding (adjusted OR 0.63; 95% CI, 0.60-0.65), and shorter average length of stay (5.3 vs 5.8 days, P.001), but higher cardiogenic shock (adjusted OR 2.14; 95% CI, 2.06-2.23) and total hospital cost (23,584 vs 13,278 USD).Compared with an initial conservative approach, an early invasive strategy in octogenarians with UA/NSTEMI was associated with lower in-hospital mortality, acute ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and shorter length of stay, but higher cardiogenic shock and total hospital cost.

We analyzed the Nationwide Inpatient Sample database from 2002 to 2010 to examine the temporal trends in incidence of acute kidney injury (AKI), AKI requiring dialysis, and associated in-hospital mortality in patients ≥75 years of age hospitalized with acute myocardial infarction and undergoing early (within 24 hours) percutaneous coronary intervention. Of 2,225,707 patients ≥75 years of age with acute myocardial infarction, 233,508 (10.5%) underwent early percutaneous coronary intervention, of which 21,961 (9.4%) developed AKI and 1,257 (0.54%) developed AKI requiring dialysis. From 2002 to 2010, the incidence of AKI increased from 5.6% to 14.2% (p for trend0.001) and that for AKI requiring dialysis decreased (0.6% to 0.4%; p for trend 0.018). Compared with 2002, multivariable-adjusted odds ratios and 95% confidence intervals for AKI, AKI requiring dialysis, and in-hospital mortality in 2010 were 1.87 (1.71 to 2.05), 0.20 (0.15 to 0.27) and 0.74 (0.60 to 0.90), respectively. In conclusion, among hospitalized adults ≥75 years of age, from 2002 to 2010, there was an increase in AKI, but there was paradoxical decrease in AKI requiring dialysis and in-hospital mortality, potentially reflecting increased health-care provider awareness resulting in early recognition and implementation of renal-protective strategies and diagnosis-related group creep.

Elderly patients with ST-elevation myocardial infarction (STEMI) are often underrepresented in major percutaneous coronary intervention (PCI) trials. Use of PCI for STEMI, and associated outcomes in patients aged ≥65 years with STEMI needed further investigation.We used the 2001-2010 United States Nationwide Inpatient Sample (NIS) database to examine the temporal trends in STEMI, use of PCI for STEMI, and outcomes among patients aged 65-79 and ≥80 years.During 2001-2010, of 4,017,367 patients aged ≥65 years with acute myocardial infarction (AMI), 1,434,579 (35.7%) had STEMI. Over this period, among patients aged 65-79 and ≥80 years, STEMI decreased by 16.4% and 19%, whereas the use of PCI for STEMI increased by 33.5% and 22%, respectively (Ptrend0.001). There was a significant decrease in age-adjusted in-hospital mortality (per 1000) in patients aged ≥80 years (150 versus 116, Ptrend=0.02) but not in patients aged 65-79 years (63 versus 59, Ptrend=0.886). Stepwise logistic regression identified intra-aortic balloon pump use, acute renal failure, acute cerebrovascular disease, age ≥80 years, peripheral vascular disease, gastrointestinal bleeding, female gender, congestive heart failure, chronic lung disease, weekend admission and multivessel PCI as independent predictors of in-hospital mortality among all patients ≥65 years of age who underwent PCI for STEMI.In this large, multi-institutional cohort of elderly patients, a decreasing trend in STEMI, an increasing trend in PCI utilization for STEMI, and reduction in in-hospital mortality were observed from 2001 to 2010.

The presence of end-stage renal disease (ESRD) is an adverse prognostic factor in patients with ST-elevation myocardial infarction (STEMI). However, whether outcomes of STEMI differ among patients with ESRD requiring long-term dialysis versus those with a functional renal transplant has not been

Objectives: To review clinical outcomes of endovascular treatment of type B aortic dissection. Methods: All patients treated for type B aortic dissection between 2006-2011 were identified from a prospectively maintained registry. Health systems charts and medical correspondences were reviewed. Measured outcomes included resolution of the indication for intervention, additional procedures, and survival at 30 days and 1 year. Results: 55 patients were treated with TEVAR for type B dissection (mean age, 61 14 years), 39 (71%) for acute dissections and 16 (29%) for chronic dissections. Indications for treatment were pain (21), malperfusion (13), aneurysm (6), uncontrolled hypertension (6), expansion (5), and rupture (4). Success, defined by relief of indication and freedom from death or re-intervention at 30 days, was achieved in 87% of patients. Twenty-six additional procedures were performed in 22 patients prior to, or at the time of TEVAR. These included debranching procedures (8), renal stenting (7), Iliac stenting (5), iliac exposure or conduit creation (2), mesenteric stenting (2), thrombectomy (1), and tube thoracostomy (1). Left subclavian artery coverage was required in 23 patients. Spinal ischemia occurred in 4 patients, and lumbar drainage performed in 2 patients. Three patients required reintervention during the study period. Survival was 93% at thirty-days and 78% at one year. Conclusions: TEVAR is effective in the treatment of the complications of both acute and chronic type B aortic dissection. Additional procedures are frequently necessary, but early results indicate favorable outcomes, while reintervention is rare.

Left ventricular diastolic dysfunction (LVDD) has been reported to have strong correlation with exercise capacity. However, this relationship has not been studied extensively in community-dwelling older adults. Data on pulse and tissue Doppler echocardiographic estimates of resting early (E) and atrial (A) transmitral peak inflow and early (Em) mitral annular velocities, and six-minute walk test were obtained from 89 community-dwelling older adults (mean age, 74; range, 65-93 years; 54% women), without a history of heart failure. Overall, 47% had cardiovascular morbidity and 60% had normal diastolic function (E/A 0.75-1.5 and E:Em10). Among the 36 individuals with LVDD, 83%, 14% and 3% had grade I (E/A0.75, regardless of E/E(m)), II (E/A 0.75-1.5 and E/E(m) ≥10) and III (E/A1.5 and E/E(m) ≥10) LVDD, respectively. Those with LVDD were older (77 versus 73 years; p = 0.001) and had a trend for higher prevalence of cardiovascular morbidity (58% versus 40%; p = 0.083). LVDD negatively correlated with six-minute walk distance (1013 versus 1128 feet; R = -0.25; p = 0.017). This association remained significant despite adjustment for cardiovascular morbidity (R = -0.35; p = 0.048), but lost significance when adjusted for age (R = -0.32; p = 0.105), age and cardiovascular morbidity (R = -0.38; p = 0.161), and additional adjustment for sex, race, body mass index, and systolic blood pressure (R = -0.44; p = 0.365). In conclusion, most community-dwelling older adults without heart failure had normal left ventricular diastolic function or grade-I LVDD. Although LVDD was associated with decreased performance on a six-minute walk test, that association was no longer evident after adjustment for age, body mass index and cardiovascular morbidity.

Anticoagulation has been shown to decrease ischemic stroke in atrial fibrillation (AF). However, concerns remain regarding their safety and efficacy in those ≥70 years of age who constitute most patients with AF. Of the 4,060 patients (mean age 65 years, range 49 to 80) in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 2,248 (55% of 4,060) were 70 to 80 years of age, 1,901 of whom were receiving warfarin. Propensity score for warfarin use, estimated for each of the 2,248 patients, was used to match 227 of the 347 patients not on warfarin (in 1:1, 1:2, or 1:3 sets) to 616 patients on warfarin who were balanced in 45 baseline characteristics. All-cause mortality occurred in 18% and 33% of matched patients receiving and not receiving warfarin, respectively, during up to 6 years (mean 3.4) of follow-up (hazard ratio [HR] when warfarin use was compared to its nonuse 0.58, 95% confidence interval [CI] 0.43 to 0.77, p0.001). All-cause hospitalization occurred in 64% and 67% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.93, 95% CI 0.77 to 1.12, p = 0.423). Ischemic stroke occurred in 4% and 8% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.57, 95% CI 0.31 to 1.04, p = 0.068). Major bleeding occurred in 7% and 10% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.73, 95% CI 0.44 to 1.22, p = 0.229). In conclusion, warfarin use was associated with decreased mortality in septuagenarian patients with AF but had no association with hospitalization or major bleeding.

Methods: Of the 5795 community-dwelling adults ≥65 years in the Cardiovascular Health Study, 5273 had data on OH and were also free of prevalent HF at baseline. OH was deined as a drop of ≥20 mm Hg in systolic blood pressure (BP) and/or ≥10 mm Hg in diastolic BP from the supine to the standing position at 3 minutes. Propensity scores for OH were calculated for each of the 5273 participants and were used to assemble a cohort of 3510 participants (883 and 2627 of those with and without OH respectively) who were balanced on 40 baseline characteristics. Cox regression models were used to estimate the association of OH with centrally-adjudicated incident HF.

Category: 21. Myocardial Function/Heart Failure—Clinical Pharmacological TreatmentSession-Poster Board Number: 1017-43Authors: Ali Ahmed, Yan Zhang, Marjan Mujib, Tarun Arora, Margaret Feller, Meredith Kilgore, Inmaculada Aban, Thomas Love, Richard Allman, Gregg Fonarow, UAB, Birmingham, AL, VAMC, Birmingham, ALBackground: Beta-blockers (BB) reduce mortality in systolic heart failure (HF). However, evidence of their beneits is unclear in diastolic HF. We tested the hypothesis that BB use would lower mortality in diastolic HF enrolled into the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) registry.Methods: Of the 9165 unique OPTIMIZE-HF patients hospitalized with acute diastolic HF (LVEF ≥45%) linked with Medicare outcomes data, 5434 (59%) were prescribed BBs at discharge. Propensity scores for BB use were estimated for each of the 9165 patients and were used to assemble a cohort of 3382 pairs of patients receiving and not receiving BBs who were balanced on 38 baseline characteristics.Results: Patients (n=6764) had a mean (SD) age of 78 (11) years, 65% were women, 12% were African American, and a mean (SD) LVEF of 0.58 (0.09) %. During ~6 years of follow-up, all-cause mortality occurred in 69% and 72% of matched patients receiving and not receiving BBs respectively (HR when BB use was compared with its non-use, 0.90; 95% CI, 0.85-0.96; p

We studied the impact of baseline systolic blood pressure (SBP) on outcomes in patients with mild to moderate chronic systolic and diastolic heart failure (HF) in the Digitalis Investigation Group trial using a propensity-matched design. Of 7,788 patients, 7,785 had baseline SBP data and 3,538 had SBP ≤ 120 mm Hg. Propensity scores for SBP ≤ 120 mm Hg, calculated for each of the 7,785 patients, were used to assemble a matched cohort of 3,738 patients with SBP ≤ 120 and >120 mm Hg who were well-balanced in 32 baseline characteristics. All-cause mortality occurred in 35% and 32% of matched patients with SBPs ≤ 120 and >120 mm Hg respectively, during 5 years of follow-up (hazard ratio [HR] when SBP ≤ 120 was compared to >120 mm Hg 1.10, 95% confidence interval [CI] 0.99 to 1.23, p = 0.088). HRs for cardiovascular and HF mortalities associated with SBP ≤ 120 mm Hg were 1.15 (95% CI 1.01 to 1.30, p = 0.031) and 1.30 (95% CI 1.08 to 1.57, p = 0.006). Cardiovascular hospitalization occurred in 53% and 49% of matched patients with SBPs ≤ 120 and > 120 mm Hg, respectively (HR 1.13, 95% CI 1.03 to 1.24, p = 0.008). HRs for all-cause and HF hospitalizations associated with SBP ≤ 120 mm Hg were 1.10 (95% CI 1.02 to 1.194, p = 0.017) and 1.21 (95% CI 1.07 to 1.36, p = 0.002). In conclusion, in patients with mild to moderate long-term systolic and diastolic HF, baseline SBP ≤ 120 mm Hg was associated with increased cardiovascular and HF mortalities and all-cause, cardiovascular, and HF hospitalizations that was independent of other baseline characteristics.

Background: The relationship between stage of chronic kidney disease (CKD) and incident heart failure (HF) remains unclear. Methods: Of the 5,795 community-dwelling adults ≧65 years in the Cardiovascular Health Study, 5,450 were free of prevalent HF and had baseline estimated glomerular filtration rate (eGFR: ml/min/1.73 m2) data. Of these, 898 (16%) had CKD 3A (eGFR 45–59 ml/min/1.73 m2) and 242 (4%) had CKD stage ≧3B (eGFR 2). Data on baseline proteinuria were not available and 4,310 (79%) individuals with eGFR ≧60 ml/min/1.73 m2 were considered to have no CKD. Propensity scores estimated separately for CKD 3A and ≧3B were used to assemble two cohorts of 1,714 (857 pairs with CKD 3A and no CKD) and 557 participants (148 CKD ≧3B and 409 no CKD), respectively, balanced on 50 baseline characteristics. Results: During 13 years of follow-up, centrally-adjudicated incident HF occurred in 19, 24 and 38% of pre-match participants without CKD (reference), with CKD 3A [unadjusted hazard ratio (HR) 1.40; 95% confidence interval (CI) 1.20–1.63; p < 0.001] and with CKD ≧3B (HR 3.37; 95% CI 2.71–4.18; p < 0.001), respectively. In contrast, among matched participants, incident HF occurred in 23 and 23% of those with CKD 3A and no CKD, respectively (HR 1.03; 95% CI 0.85–1.26; p = 0.746), and 36 and 28% of those with CKD ≧3B and no CKD, respectively (HR 1.44; 95% CI 1.04–2.00; p = 0.027). Conclusions: Among community-dwelling older adults, CKD is a marker of incident HF regardless of stage; however, CKD ≧3B, not CKD 3A, has a modest independent association with incident HF.

Aims Abnormally low right ventricular ejection fraction (RVEF) is a predictor of poor outcomes in chronic heart failure (HF) patients with low left ventricular ejection fraction (LVEF). However, little is known about the relationship between LVEF and RVEF in these patients. Methods and results Of the 2707 Beta-blocker Evaluation of Survival Trial (BEST) participants with ambulatory chronic HF, New York Heart Association class III–IV symptoms, and LVEF ≤35%, 2008 patients had gated-equilibrium radionuclide angiographic data on baseline LVEF and RVEF. Patients were categorized into quartiles by LVEF ≥29% (n= 507), 23–28% (n= 513), 17–22% (n= 538), and

The impact of baseline systolic blood pressure (SBP) on outcomes in patients with advanced chronic systolic heart failure (HF) has not been studied using a propensity-matched design. Of the 2,706 participants in the Beta-Blocker Evaluation of Survival Trial (BEST) with chronic HF, New York Heart Association class III to IV symptoms and left ventricular ejection fractionor =35%, 1,751 had SBPor =120 mm Hg (median 108, range 70 to 120) and 955 had SBP120 mm Hg (median 134, range 121 to 192). Propensity scores for SBP120 mm Hg, calculated for each patient, were used to assemble a matched cohort of 545 pairs of patients with SBPsor =120 and120 mm Hg who were balanced in 65 baseline characteristics. Matched Cox regression models were used to estimate associations between SBPor =120 mm Hg and outcomes over 4 years of follow-up. Matched participants had a mean age +/- SD of 62 +/- 12 years, 24% were women, and 24% were African-American. HF hospitalization occurred in 38% and 32% of patients with SBPsor =120 and120 mm Hg, respectively (hazard ratio 1.33 SBPor =120 was compared to120 mm Hg, 95% confidence interval 1.04 to 1.69, p = 0.023). All-cause mortality occurred in 28% and 30% of matched patients with SBPsor =120 and120 mm Hg, respectively (hazard ratio 1.13 SBPor =120 compared to120 mm Hg, 95% confidence interval 0.86 to 1.49, p = 0.369). In conclusion, in patients with advanced chronic systolic HF, baseline SBPor =120 mm Hg is associated with increased risk of HF hospitalization, but had no association with all-cause mortality.

Ventricular arrhythmias are relatively common in ST-elevation myocardial infarction (STEMI). However, there are limited data on contemporary trends in the incidence of ventricular tachycardia (VT) and ventricular fibrillation (VF) in STEMI and association of VT and VF with outcomes in patients with

Heart failure (HF) is the leading cause of 30-day all-cause readmission, the reduction of which is a goal of the Affordable Care Act. Prior studies (AHA 2013) suggest that beta-blockers and aldosterone antagonists may not lower 30-day all-cause readmission in HF and reduced EF (HFrEF). In the