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The prevalence of systemic hypertension and its cardiovascular consequences is higher in African-Americans than in whites. Low to moderate intensity aerobic exercise lowers blood pressure (BP) in African-American patients with severe hypertension. It is not known whether such exercise can improve lipid metabolism in these patients. Thirty-six African-American men with established essential hypertension, aged 35 to 76 years, were randomly assigned to an exercise (n = 17) or no exercise (n = 19) group. The exercise group exercised for 16 weeks, 3 times/week, at 60% to 80% of maximum heart rate. After 16 weeks, peak oxygen uptake in the exercise group improved (21+/-4 vs 23+/-3 ml/kg/min; p <0.001). Body weight did not change. Exercise intensity correlated with high-density lipoprotein (HDL) cholesterol changes from baseline to 16 weeks (r = 0.65; p <0.01) and was the strongest predictor of these changes (R2 = 0.4; p = 0.009). Lipoprotein-lipid changes in the 2 randomized groups did not differ significantly. A 10% increase in HDL cholesterol--42+/-19 versus 46+/-19 mg/dl; p = 0.003--noted in 10 patients who exercised > or = 75% of maximal heart rate suggested the existence of an exercise intensity threshold. Thus low to moderate intensity aerobic exercise may not be adequate to modify lipid profiles favorably in patients with severe hypertension. However, substantial changes in HDL cholesterol were noted in patients exercising at intensities > or = 75% of age-predicted maximum heart rate, suggesting an exercise-intensity threshold. [ABSTRACT FROM AUTHOR]

Objective: Recent evidence suggests that hydroxychloroquine use is not associated with higher 1-year risk of long QT syndrome (LQTS) in patients with rheumatoid arthritis (RA). Less is known about its long-term risk, the examination of which was the objective of this study., Methods: We conducted a propensity score-matched active-comparator safety study of hydroxychloroquine in 8,852 veterans (mean age 64 ± 12 years, 14% women, 28% Black) with newly diagnosed RA. A total of 4,426 patients started on hydroxychloroquine and 4,426 started on another nonbiologic disease-modifying antirheumatic drug (DMARD) and were balanced on 87 baseline characteristics. The primary outcome was LQTS during 19-year follow-up through December 31, 2019., Results: Incident LQTS occurred in 4 (0.09%) and 5 (0.11%) patients in the hydroxychloroquine and other DMARD groups, respectively, during the first 2 years. Respective 5-year incidences were 17 (0.38%) and 6 (0.14%), representing 11 additional LQTS events in the hydroxychloroquine group (number needed to harm 403; [95% confidence interval (95% CI)], 217-1,740) and a 181% greater relative risk (95% CI 11%-613%; P = 0.030). Although overall 10-year risk remained significant (hazard ratio 2.17; 95% CI 1.13-4.18), only 5 extra LQTS occurred in hydroxychloroquine group over the next 5 years (years 6-10) and 1 over the next 9 years (years 11-19). There was no association with arrhythmia-related hospitalization or all-cause mortality., Conclusions: Hydroxychloroquine use had no association with LQTS during the first 2 years after initiation of therapy. There was a higher risk thereafter that became significant after 5 years of therapy. However, the 5-year absolute risk was very low, and the absolute risk difference was even lower. Both risks attenuated during longer follow-up. These findings provide evidence for long-term safety of hydroxychloroquine in patients with RA., (© 2022 American College of Rheumatology. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: Implantable cardioverter-defibrillators (ICDs) improve outcomes in patients with heart failure (HF) with left ventricular ejection fraction (LVEF) ≤35%. Less is known about whether outcomes varied between the 2 noninvasive imaging modalities used to estimate LVEF-2-dimensional echocardiography (2DE) and multigated acquisition radionuclide ventriculography (MUGA)-which use different principles (geometric vs count-based, respectively)., Objective: The purpose of this study was to examine whether the effect of ICD on mortality in patients with HF and LVEF ≤35% varied on the basis of LVEF measured by 2DE or MUGA., Methods: Of the 2521 patients with HF with LVEF ≤35% in the Sudden Cardiac Death in Heart Failure Trial, 1676 (66%) were randomized to either placebo or ICD, of whom 1386 (83%) had LVEF measured by 2DE (n = 971) or MUGA (n = 415). Hazard ratios (HRs) and 97.5% confidence intervals (CIs) for mortality associated with ICD were estimated overall, checking for interaction, and within the 2 imaging subgroups., Results: Of the 1386 patients in the present analysis, all-cause mortality occurred in 23.1% (160 of 692) and 29.7% (206 of 694) of patients randomized to ICD or placebo, respectively (HR 0.77; 97.5% CI 0.61-0.97), which is consistent with that in 1676 patients in the original report. HRs (97.5% CIs) for all-cause mortality in the 2DE and MUGA subgroups were 0.79 (0.60-1.04) and 0.72 (0.46-1.11), respectively (P = .693 for interaction). Similar associations were observed for cardiac and arrhythmic mortalities., Conclusion: We found no evidence that in patients with HF and LVEF ≤35%, the effect of ICD on mortality varied by the noninvasive imaging method used to measure LVEF., (Copyright © 2023 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objective: Hydroxychloroquine (HCQ) may prolong the QT interval, a risk factor for torsade de pointes, a potentially fatal ventricular arrhythmia. This study was undertaken to examine the cardiovascular safety of HCQ in patients with rheumatoid arthritis (RA)., Methods: We conducted an active comparator safety study of HCQ in a propensity score-matched cohort of 8,852 US veterans newly diagnosed as having RA between October 1, 2001 and December 31, 2017. Patients were started on HCQ (n = 4,426) or another nonbiologic disease-modifying antirheumatic drug (DMARD; n = 4,426) after RA diagnosis, up to December 31, 2018, and followed up for 12 months after therapy initiation, up to December 31, 2019., Results: Patients had a mean ± SD age of 64 ± 12 years, 14% were women, and 28% were African American. The treatment groups were balanced with regard to 87 baseline characteristics. There were 3 long QT syndrome events (0.03%), 2 of which occurred in patients receiving HCQ. Of the 56 arrhythmia-related hospitalizations (0.63%), 30 occurred in patients in the HCQ group (hazard ratio [HR] associated with HCQ 1.16 [95% confidence interval (95% CI) 0.68-1.95]). All-cause mortality occurred in 144 (3.25%) and 136 (3.07%) of the patients in the HCQ and non-HCQ groups, respectively (HR associated with HCQ 1.06 [95% CI, 0.84-1.34]). During the first 30 days of follow-up, there were no long QT syndrome events, 2 arrhythmia-related hospitalizations (none in the HCQ group), and 13 deaths (6 in the HCQ group)., Conclusion: Our findings indicate that the incidence of long QT syndrome and arrhythmia-related hospitalization is low in patients with RA during the first year after the initiation of HCQ or another nonbiologic DMARD. We found no evidence that HCQ therapy is associated with a higher risk of adverse cardiovascular events or death., (© 2021, American College of Rheumatology.)

Background: Age is the strongest predictor of atrial fibrillation (AF), yet little is known about AF incidence in the oldest old., Hypothesis: AF incidence declines after age 90 years, and morbidity is compressed into a brief period at the end of life., Methods: In this retrospective, longitudinal cohort study of patients (born 1905-1935), we examined cumulative lifetime incidence of AF and its impact on mortality. Data included records from 1 062 610 octogenarians, 317 161 nonagenarians, and 3572 centenarians. Kaplan-Meier curves were used to estimate cumulative incidence of AF by age group, incidence rates were compared using log-rank tests, and Cox proportional hazards model was used to estimate unadjusted hazard ratios. The primary outcome was AF incidence at age > 80 years; the secondary outcome was mortality., Results: The cumulative AF incidence rate was 5.0% in octogenarians, 5.4% in nonagenarians, and 2.3% in centenarians. Octogenarians and nonagenarians had a higher risk of AF incidence compared to centenarians (adjusted hazard ratio 8.74, 95% confidence interval [CI]: 6.31-12.04; and 2.98, 95% CI: 2.17-4.1, respectively). The lowest hazard ratio for mortality in patients with AF compared to those without was 2.3 (95% CI: 2.3-2.4) in patients who were on antiplatelet and anticoagulant medication and had a score of 0 on the Elixhauser comorbidity index score., Conclusions: Although AF incidence increased with age, being a centenarian was associated with reduced incidence and compression of morbidity. Patients with AF had a higher adjusted mortality rate. However, data suggest that a regimen of anticoagulants and antiplatelets may reduce risk of mortality in patients over 80 with an AF diagnosis., (© 2018 Wiley Periodicals, Inc.)

Aims: To examine associations of below-target and target dose of enalapril, an angiotensin-converting enzyme (ACE) inhibitor, with outcomes in patients with heart failure and reduced ejection fraction (HFrEF) in the Studies of Left Ventricular Dysfunction (SOLVD) Treatment trial., Methods and Results: Two thousand five hundred and sixty-nine patients with HFrEF (ejection fraction ≤35%) were randomized to below-target (5-10 mg/day) dose placebo (n = 1284) or enalapril (n = 1285). One month post-randomization, blind up-titration to target (20 mg/day) dose was attempted for both study drugs in 2458 patients. Among the 1444 patients who achieved dose up-titration (placebo, n = 748; enalapril, n = 696; mean dose for both groups, 20.0 mg/day), target dose enalapril (vs. target dose placebo) was associated with a 9% absolute lower risk of the combined endpoint of heart failure hospitalization or all-cause mortality [adjusted hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.60-0.81; P < 0.001] during 4 years of follow-up. Among the 1014 patients who could not achieve target dose (placebo, n = 486; enalapril, n = 528; mean dose for both groups, 8.8 mg/day), below-target dose enalapril (vs. below-target dose placebo) was associated with a 12% absolute lower risk of the combined endpoint of heart failure hospitalization or all-cause mortality (adjusted HR 0.68; 95% CI 0.57-0.81; P < 0.001). Among the 1224 patients receiving enalapril, target (vs. below-target) dose had no association with the combined endpoint of heart failure hospitalization or all-cause mortality (adjusted HR 1.04; 95% CI 0.87-1.23; P = 0.695)., Conclusion: In patients with HFrEF, the clinical benefits of ACE inhibitors appear to be similar at both below-target and target doses., (© 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.)

Background: Digoxin use has been shown to be associated with a lower risk of 30-day all-cause hospital readmissions in older patients with heart failure (HF). In the current study, we examined this association among long-term care (LTC) residents hospitalized for HF., Methods: Of the 8049 Medicare beneficiaries discharged alive after hospitalization for HF from 106 Alabama hospitals, 545 (7%) were LTC residents, of which 227 (42%) received discharge prescriptions for digoxin. Propensity scores for digoxin use, estimated for each of the 545 patients, were used to assemble a matched cohort of 158 pairs of patients receiving and not receiving digoxin who were balanced on 29 baseline characteristics. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with digoxin among matched patients were estimated using Cox regression models., Results: Matched patients (n = 316) had a mean age of 83 years, 74% were women, and 18% African American. Thirty-day all-cause readmission occurred in 21% and 20% of patients receiving and not receiving digoxin, respectively (HR, 1.02; 95% CI, 0.63-1.66). Digoxin had no association with all-cause mortality (HR, 0.90; 95% CI, 0.48-1.70), HF readmission (HR, 0.90; 95% CI, 0.38-2.12), or a combined endpoint of all-cause readmission or all-cause mortality (HR, 0.97; 95% CI, 0.65-1.45) at 30 days. These associations remained unchanged at 1 year postdischarge., Conclusions: The lack of an association between digoxin and 30-day all-cause readmission in older nursing home residents hospitalized for HF is intriguing and needs to be interpreted with caution given the small sample size., (Published by Elsevier Inc.)

Background: Isolated systolic hypertension (ISH) is common in older adults and is a risk factor for incident heart failure (HF). We examined the association of systolic-diastolic hypertension (SDH) with incident HF and other outcomes in older adults., Methods: In the Cardiovascular Health Study (CHS), 5776 community-dwelling adults≥65years had data on baseline systolic and diastolic blood pressure (SBP and DBP). We excluded those with DBP<60mmHg (n=821), DBP≥90 and SBP<140mmHg (n=28), normal BP, taking anti-hypertensive drugs (n=1138), normal BP, not taking anti-hypertensive drugs, history of hypertension (n=193), and baseline HF (n=101). Of the remaining 3495, 1838 had ISH (SBP≥140 and DBP<90mmHg) and 240 had SDH (SBP≥140 and DBP≥90mmHg). The main outcome was centrally-adjudicated incident HF over 13years of follow-up., Results: Participants had a mean (±SD) age of 73 (±6)years, 57% were women, and 16% African American. Incident HF occurred in 25%, 22% and 11% of participants with ISH, SDH and no hypertension, respectively. Compared to no hypertension, multivariable-adjusted hazard ratios (HR) and 95% confidence intervals (CI) for incident HF associated with ISH and SDH were 1.86 (1.51-2.30) and 1.73 (1.23-2.42), respectively. Cardiovascular mortality occurred in 22%, 24% and 9% of those with ISH, SDH and no hypertension, respectively with respective multivariable-adjusted HRs (95% CIs) of 1.88 (1.49-2.37) and 2.30 (1.64-3.24)., Conclusion: Among older adults with hypertension, both SDH and ISH have similar associations with incident HF and cardiovascular mortality., (Published by Elsevier B.V.)

Background: Accurate prediction of mortality for patients admitted to the intensive care units (ICUs) is an important component of medical care. However, little is known about the role of multimorbidity in predicting end of life for high-risk and vulnerable patients., Objective: The aim of the study was to derive and validate a multimorbidity risk model in an attempt to predict all-cause mortality at 6 and 12 months posthospital discharge., Methods: This is a retrospective, observational, clinical cohort study. Data were collected on 442,692 ICU patients who received care through the Veterans Administration between January 2003 and December 2013. The primary outcome was all-cause mortality at 6 and 12 months posthospital discharge. We divided the data into derivation (80%) and validation (20%) sets. Using multivariable logistic regression models, we compared prognostic models based on age, principal diagnosis groups, physiological markers, immunosuppressants, comorbidity categories, and a newly developed multimorbidity index (MMI) based on 5695 comorbidities. The cross-validated area under the receiver operating characteristic curve (AUC) was used to report the accuracy of predicting all-cause mortality at 6 and 12 months of hospital discharge., Results: The average age of patients was 68.87 years (standard deviation = 12.1), 95.9% were males, 44.9% were widowed, divorced, or separated. The relative order of accuracy in predicting mortality was the MMI (AUC = 0.84, CI = 0.83-0.84), VA Inpatient Evaluation Center index (AUC = 0.80, CI = 0.79-0.81), principal diagnosis groups (AUC = 0.74, CI = 0.73-0.74), comorbidities (AUC = 0.69, CI = 0.68-0.70), physiological markers (AUC = 0.65, CI = 0.64-0.65), age (AUC = 0.60, CI = 0.60-0.61),and immunosuppressant use (AUC = 0.59, CI = 0.58-0.59)., Conclusions: The MMI improved the accuracy of predicting short- and long-term all-cause mortality for ICU patients. Further prospective studies are needed to validate the index in different clinical settings and test generalizability of results in patients outside the VA system of care.

Background: Heart failure is the leading cause for 30-day all-cause readmission. We examined the impact of 30-day all-cause readmission on long-term outcomes and cost in a propensity score-matched study of hospitalized patients with heart failure., Methods: Of the 7578 Medicare beneficiaries discharged with a primary diagnosis of heart failure from 106 Alabama hospitals (1998-2001) and alive at 30 days after discharge, 1519 had a 30-day all-cause readmission. Using propensity scores for 30-day all-cause readmission, we assembled a matched cohort of 1516 pairs of patients with and without a 30-day all-cause readmission, balanced on 34 baseline characteristics (mean age 75 years, 56% women, 24% African American)., Results: During 2-12 months of follow-up after discharge from index hospitalization, all-cause mortality occurred in 41% and 27% of matched patients with and without a 30-day all-cause readmission, respectively (hazard ratio 1.68; 95% confidence interval 1.48-1.90; P <.001). This harmful association of 30-day all-cause readmission with mortality persisted during an average follow-up of 3.1 (maximum, 8.7) years (hazard ratio 1.33; 95% confidence interval 1.22-1.45; P <.001). Patients with a 30-day all-cause readmission had higher cumulative all-cause readmission (mean, 6.9 vs 5.1; P <.001), a longer cumulative length of stay (mean, 51 vs 43 days; P <.001), and a higher cumulative cost (mean, $38,972 vs $34,025; P = .001) during 8.7 years of follow-up., Conclusions: Among Medicare beneficiaries hospitalized for heart failure, 30-day all-cause readmission was associated with a higher risk of subsequent all-cause mortality, higher number of cumulative all-cause readmission, longer cumulative length of stay, and higher cumulative cost., (Published by Elsevier Inc.)

Background: Heart failure is the leading cause for 30-day all-cause readmission, the reduction of which is a goal of the Affordable Care Act. There is a growing interest in understanding the impact of evidence-based heart failure therapy on 30-day all-cause readmission. In the current study, we examined the impact of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEI-ARBs) on 30-day all-cause readmission in heart failure., Methods: Of the 1384 hospitalized Medicare beneficiaries with heart failure and left ventricular ejection fraction <45% discharged alive from 106 Alabama hospitals (1998-2001) without prior ACEI-ARB use and without known contraindications to ACEI-ARB use; 734 received new predischarge prescriptions for these drugs. Using propensity scores for ACEI-ARB initiation, we assembled a matched cohort of 477 pairs of patients balanced on 32 baseline characteristics (mean age 75 years, 46% women, 26% African American)., Results: Thirty-day all-cause readmissions occurred in 18% and 24% of matched patients receiving and not receiving ACEI-ARBs, respectively (hazard ratio [HR] 0.74; 95% confidence interval [CI], 0.56-0.97; P = .030). ACEI-ARB use was also associated with lower risk of 30-day all-cause mortality (HR 0.56; 95% CI, 0.33-0.98; P = .041) and of the combined endpoint of 30-day all-cause readmission or 30-day all-cause mortality (HR 0.73; 95% CI, 0.56-0.94; P = .017). All associations remained significant at 1 year post discharge., Conclusions: Among hospitalized patients with heart failure and reduced ejection fraction, the use of ACEI-ARBs was associated with a significantly lower risk of 30-day all-cause readmission and 30-day all-cause mortality; both beneficial associations persisted during long-term follow-up., Competing Interests: None, (Published by Elsevier Inc.)

Aims: Octogenarians have the highest incidence of heart failure (HF) that is not fully explained by traditional risk factors. We explored whether lack of pneumococcal vaccination is associated with higher risk of incident HF among octogenarians., Methods and Results: In the Cardiovascular Health Study (CHS), 5290 community-dwelling adults, ≥65 years of age, were free of baseline HF and had data on pneumococcal vaccination. Of these, 851 were octogenarians, of whom, 593 did not receive pneumococcal vaccination. Multivariable-adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for associations of lack of pneumococcal vaccination with incident HF and other outcomes during 13 years of follow-up were estimated using Cox regression models, adjusting for demographics and other HF risk factors including influenza vaccination. Octogenarians had a mean (±SD) age of 83 (±3) years; 52% were women and 17% African American. Overall, 258 participants developed HF and 662 died. Lack of pneumococcal vaccination was associated with higher relative risk of incident HF (aHR, 1.37; 95% CI, 1.01-1.85; P  = 0.044). There was also higher risk for all-cause mortality (aHR, 1.23; 95% CI, 1.02-1.49; P  = 0.028), which was mostly driven by cardiovascular mortality (aHR, 1.45; 95% CI, 1.06-1.98; P  = 0.019). Octogenarians without pneumococcal vaccination had a trend toward higher risk of hospitalization due to pneumonia (aHR, 1.34; 95% CI, 0.99-1.81; P  = 0.059). These associations were not observed among those 65-79 years of age., Conclusions: Among community-dwelling octogenarians, lack of pneumococcal vaccination was associated with a significantly higher independent risk of incident HF and mortality, and trend for higher pneumonia hospitalization.

Background: In the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT), a significant fraction of the patients with congestive heart failure ultimately did not die suddenly of arrhythmic causes. Patients with CHF will benefit from better tools to identify if implantable cardioverter-defibrillator (ICD) therapy is needed., Objectives: We aimed to identify predictor variables from baseline SCD-HeFT patients' R-R intervals that correlate to arrhythmic sudden cardiac death (SCD) and mortality and to design an ICD therapy screening test., Methods: Ten predictor variables were extracted from prerandomization Holter data from 475 patients enrolled in the ICD arm of the SCD-HeFT by using novel and traditional heart rate variability methods. All variables were correlated to SCD using the Mann-Whitney-Wilcoxon test and receiver operating characteristic analysis. ICD therapy screening tests were designed by minimizing the cost of false classifications. Survival analysis, including log-rank test and Cox models, was also performed., Results: A short-term fractal exponent, α1, and a long-term fractal exponent, α2, from detrended fluctuation analysis, the ratio of low- to high-frequency power, the number of premature ventricular contractions per hour, and the heart rate turbulence slope are all statistically significant for predicting the occurrences of SCD (P < .001) and survival (log-rank, P < .01). The most powerful multivariate predictor tool using the Cox proportional hazards regression model was α2 with a hazard ratio of 0.0465 (95% confidence interval 0.00528-0.409; P < .01)., Conclusion: Predictor variables extracted from R-R intervals correlate to the occurrences of SCD and distinguish survival functions among patients with ICDs in SCD-HeFT. We believe that SCD prediction models should incorporate Holter-based R-R interval analysis to refine ICD patient selection, especially to exclude patients who are unlikely to benefit from ICD therapy., (Copyright © 2015 Heart Rhythm Society. All rights reserved.)

Background: According to the 2004 Surgeon General's Report on Health Consequences of Smoking, after >15 years of abstinence, the cardiovascular risk of former smokers becomes similar to that of never-smokers. Whether this health benefit of smoking cessation varies by amount and duration of prior smoking remains unclear., Methods and Results: Of the 4482 adults ≥65 years without prevalent heart failure (HF) in the Cardiovascular Health Study, 2556 were never-smokers, 629 current smokers, and 1297 former smokers with >15 years of cessation, of whom 312 were heavy smokers (highest quartile; ≥32 pack-years). Age-sex-race-adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for centrally adjudicated incident HF and mortality during 13 years of follow-up were estimated using Cox regression models. Compared with never-smokers, former smokers as a group had similar risk for incident HF (aHR, 0.99; 95% CI, 0.85-1.16) and all-cause mortality (aHR, 1.08; 95% CI, 0.96-1.20), but former heavy smokers had higher risk for both HF (aHR, 1.45; 95% CI, 1.15-1.83) and mortality (aHR, 1.38; 95% CI, 1.17-1.64). However, when compared with current smokers, former heavy smokers had lower risk of death (aHR, 0.64; 95% CI, 0.53-0.77), but not of HF (aHR, 0.97; 95% CI, 0.74-1.28)., Conclusions: After >15 years of smoking cessation, the risk of HF and death for most former smokers becomes similar to that of never-smokers. Although this benefit of smoking cessation is not extended to those with ≥32 pack-years of prior smoking, they have lower risk of death relative to current smokers., (© 2015 American Heart Association, Inc.)

Background: Heart failure (HF) is the leading cause for hospital readmission. Hospice care may help palliate HF symptoms but its association with 30-day all-cause readmission remains unknown., Methods and Results: Of the 8032 Medicare beneficiaries hospitalized for HF in 106 Alabama hospitals (1998-2001), 182 (2%) received discharge hospice referrals. Of the 7850 patients not receiving hospice referrals, 1608 (20%) died within 6 months post discharge (the hospice-eligible group). Propensity scores for hospice referral were estimated for each of the 1790 (182+1608) patients and were used to match 179 hospice-referral patients with 179 hospice-eligible patients who were balanced on 28 baseline characteristics (mean age, 79 years; 58% women; 18% non-white). Overall, 22% (1742/8032) died in 6 months, of whom 8% (134/1742) received hospice referrals. Among the 358 matched patients, 30-day all-cause readmission occurred in 5% and 41% of hospice-referral and hospice-eligible patients, respectively (hazard ratio associated with hospice referral, 0.12; 95% confidence interval, 0.06-0.24). Hazard ratios (95% confidence intervals) for 30-day all-cause readmission associated with hospice referral among the 126 patients who died and 232 patients who survived 30-day post discharge were 0.03 (0.04-0.21) and 0.17 (0.08-0.36), respectively. Although 30-day mortality was higher in the hospice referral group (43% versus 27%), it was similar at 90 days (64% versus 67% among hospice-eligible patients)., Conclusions: A discharge hospice referral was associated with lower 30-day all-cause readmission among hospitalized patients with HF. However, most patients with HF who died within 6 months of hospital discharge did not receive a discharge hospice referral., (© 2015 American Heart Association, Inc.)

Background: Improvement teams make causal inferences, but the methods they use are based on statistical associations. This article shows how data and statistical models can be used to help improvement teams make causal inferences and find the root causes of problems., Methods: This article uses attribution data, competing risk survival analysis, and Bayesian network probabilities to analyze excessive emergency department (ED) stays within one hospital. We use data recorded by ED clinicians that attributed the cause of excessive ED stays to 23 causes for the 70 049 ED visits between March 2011 and April 2014. We use competing risk survival analysis to identify contribution of each cause to the delay. We use Bayesian network models to analyze interaction among different causes of excessive stays and find the root causes of this problem., Results: This article shows the utility of causal analysis to help improvement teams focus on the root causes of problems. For the example analyzed in the article, most causes for patients' excessive ED stays were related to the hospital operations outside the ED. Therefore, improvement projects inside the ED such as expanding ED, increasing staff at the ED, or improving operations are less likely to have a positive impact on reducing excessive ED stays. On the contrary, interventions that improve hospital occupancy (better discharge, expansion of beds, etc) or improve laboratory response times are more likely to result in positive outcomes.

Aims: Normal body mass index (BMI) is associated with lower mortality and may be achieved by physical activity (PA), healthy eating (HE), or both. We examined the association of PA and HE with mortality and incident heart failure (HF) among 2040 community-dwelling older adults aged ≥ 65 years with baseline BMI 18.5 to 24.99 kg/m 2 during 13 years of follow-up in Cardiovascular Health Study., Methods and Results: Baseline PA was defined as ≥500 weekly metabolic equivalent task-minutes (MET-minutes) and HE as ≥5 daily servings of vegetable and fruit intake. Participants were categorized into 4 groups: (1) PA-/HE- (n=384); (2) PA+/HE- (n=992); (3) PA-/HE+ (n=162); and (4) PA+/HE+ (n=502). Participants had a mean age of 74 (±6) years, mean BMI of 22.6 (±1.5) kg/m 2 , 61% were women, and 4% African American. Compared with PA-/HE-, age-sex-race-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality for PA-/HE+, PA+/HE-, and PA+/HE+ groups were 0.96 (0.76-1.21), 0.61 (0.52-0.71) and 0.62 (0.52-0.75), respectively. These associations remained unchanged after multivariable adjustment and were similar for cardiovascular and non-cardiovascular mortalities. Respective demographic-adjusted HRs (95% Cis) for incident HF among 1954 participants without baseline HF were 1.21 (0.81-1.81), 0.71 (0.54-0.94) and 0.71 (0.51-0.98). These later associations lost significance after multivariable-adjustment., Conclusion: Among community-dwelling older adults with normal BMI, physical activity, regardless of healthy eating, was associated with lower risk of mortality and incident HF, but healthy eating had no similar protective association in this cohort.

Background: Characteristics and outcomes of patients with heart failure and reduced ejection fraction receiving care at Veterans Affairs (VA) versus non-VA hospitals have not been previously reported., Methods and Results: In the randomized controlled Beta-blocker Evaluation of Survival Trial (BEST; 1995-1999), of the 2707 (bucindolol=1353; placebo=1354) patients with heart failure and left ventricular ejection fraction ≤35%, 918 received care at VA hospitals, of which 98% (n=898) were male. Of the 1789 receiving care at non-VA hospitals, 68% (n=1216) were male. Our analyses were restricted to these 2114 male patients. VA patients were older with higher symptom and comorbidity burdens. There was no significant between-group difference in unadjusted primary end point of 2-year all-cause mortality (35% VA versus 32% non-VA; hazard ratio associated with VA hospitals, 1.09; 95% confidence interval, 0.94-1.26), which remained unchanged after adjustment for age and race (hazard ratio, 1.00; 95% confidence interval, 0.86-1.16) or multivariable adjustment, including cardiovascular morbidities (hazard ratio, 0.94; 95% confidence interval, 0.80-1.10). There was no between-group difference in cause-specific mortalities or hospitalizations. Chronic kidney disease, pulmonary edema, left ventricular ejection fraction <20%, and peripheral arterial disease were significant predictors of mortality for both groups. African America race, New York Heart Association class IV symptoms, atrial fibrillation, and right ventricular ejection fraction <20% were associated with higher mortality among non-VA hospital patients only; however, these differences from VA patients were not significant., Conclusions: Patients with heart failure and reduced ejection fraction receiving care at VA hospitals were older and sicker; yet their risk of mortality and hospitalization was similar to younger and healthier patients receiving care at non-VA hospitals., Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT00000560., (© 2014 American Heart Association, Inc.)

In Beta-Blocker Evaluation of Survival Trial (BEST) bucindolol significantly reduced mortality among Caucasians with systolic heart failure (HF) but not among African Americans. Whether this differential effect can be explained by racial differences in baseline characteristics has not been previously examined. Of the 2708 BEST participants, 627 were African Americans. Because African Americans were more likely to be younger and women, we used age-sex-adjusted hazard ratios (HR) and 95% confidence intervals (CI) to estimate their outcomes (vs. Caucasians). A step-wise multivariable-adjusted model using 24 baseline characteristics was used to identify variables associated with between-race outcome differences and propensity-matching was used to determine independence of associations. Age-sex-adjusted HR for all-cause mortality for African Americans during 2 years of mean follow-up was 1.27. African Americans were more likely to have lower right ventricular ejection fraction. African Americans had no association with mortality among propensity-matched patients. The higher risk of death among African Americans in BEST may in part be due to their lower RVEF which may in part explain the lack of response to bucindolol among these patients. Future studies need to examine the role of low RVEF on the effect of beta-blockers in patients with systolic HF., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Atrial fibrillation (AF) and heart failure (HF), common in older adults, are associated with poor outcomes. However, little is known about their impact, independent of each other. We studied 5,673 community-dwelling adults aged ≥ 65 years in the Cardiovascular Health Study. Baseline prevalent AF and HF were centrally adjudicated, and 116 patients had AF only, 219 had HF only, 39 had both, and 5,263 had neither. The Cox proportional hazards model was used to estimate age-gender-race-adjusted hazard ratio (aHR) and 95% confidence intervals (CIs) for all-cause, cardiovascular (CV), and non-CV mortalities. Participants had a mean age of 73 years (± 6 years), 58% were women, and 15% African-American. During 13 years of follow-up, all-cause mortality occurred in 43%, 66%, 74%, and 85% of those with neither, AF only, HF only, and both, respectively. Compared with neither, aHR (95% CIs) for all-cause mortality associated with AF only, HF only, and both was 1.36 (1.08 to 1.72), 2.31 (1.97 to 2.71), and 3.04 (2.15 to 4.29), respectively. Similar associations were observed with CV mortality, but HF only also had greater non-CV mortality (aHR 1.72, 95% CI 1.35 to 2.18). Compared with AF alone, aHR (95% CIs) associated with HF alone for all-cause, CV, and non-CV mortalities was 1.69 (1.29 to 2.23), 1.73 (1.20 to 2.51), and 1.64 (1.09 to 2.46), respectively. Compared with HF alone, those with both conditions had greater CV but not all-cause mortality. In conclusion, community-dwelling older adults with AF have greater mortality than those without but lesser than those with HF, and both conditions were associated with greater CV and all-cause mortalities, whereas only those with HF had greater non-CV mortality., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background and Objective: This study describes progression to death for patients with congestive heart failure (CHF)., Methods: We used SAS procedure Proc Traj to fit a semiparametric model to longitudinal data on prognosis of patients with CHF in the 12 months prior to death. Data were collected on 744 patients with CHF in 2010 at Bay Pines VA Healthcare System; 386 subjects had sufficient data points (minimum of five encounters) to trace their risk in 12 months prior to death. The prognosis of the patient was calculated using the comorbidities of the patient., Results: Unexpected death occurred in 20.5% of patients; all remaining patients had a gradual progression toward death. For 13.3% of patients, progression toward death started 12 months prior to death. For 29.9% of patients, increased risk started at 6 months prior to death. For 36.3% of patients, it started 3 months prior to death. One month prior to death, 79.5% of the patients had a more than 97% chance of mortality. It may be possible to use progression toward death over 3 consecutive months as a predictor of need for hospice consultation., Conclusions: Five typical illness trajectories have been described for patients with progressive heart failure. The needs of patients and their caregivers are likely to vary according to the trajectory patients are following. Contrary to reports in the literature about unexpected death in patients with CHF, the majority of decedents in our study had a predictable and gradual progression toward death. Recognizing these trajectories may help clinicians implement an appropriate plan to meet the needs of patients and their caregivers.

Background: Hypertension treatment and control remain low worldwide. Strategies to improve blood pressure control have been implemented in the United States and around the world for several years. This study was designed to assess improvement in blood pressure control over a 10-year period in a large cohort of patients in the Department of Veterans Affairs., Methods and Results: A cohort of 582 881 hypertensive patients and 260 924 normotensive individuals treated in 15 Department of Veterans Affairs medical centers between 2000 and 2010 were examined. Strategies used system-wide included blood pressure control as a performance measure, automatic notification to healthcare providers, electronic reminders, and a systematic revisit schedule. The main outcome measure was the percentage of hypertensive patients whose hypertension was controlled and the level of blood pressure each month. In the hypertensive cohort (mean age 62.9±13.4 years, 96.0% male), 52.3% of patients were white, 25.1% were black, and 21.1% were Hispanic. Blood pressure control rates improved from 45.7% in September 2000 to 76.3% in August 2010. Improvements were similar across ethnic, racial, age, and sex groups. Average systolic/diastolic blood pressure decreased from 142.6/77.1 mm Hg in 2000 to 131.2/74.8 mm Hg in 2010, a decrease of 11.3/2.3 mm Hg (P<0.0001 for both). Systolic and diastolic blood pressures were lower in summer than in winter, and this trend continued through 2010. On average, control rates increased by 3.0% per year and were 6.8% higher in summer than in winter., Conclusions: High rates of blood pressure control can be achieved in all age and ethnic groups and in both sexes.

Background: Heart failure is associated with ventricular tachyarrhythmias (VT/VF). Fluid accumulation during worsened heart failure may trigger VT/VF. Increased intrathoracic impedance has been correlated with fluid accumulation during heart failure. Implanted defibrillators capable of daily measures of intrathoracic impedance allow correlation of impedance with occurrence of VT/VF. We hypothesized that VT/VF episodes are preceded by decreases in intrathoracic impedance. The goal was to identify the relationship of intrathoracic impedance measured by implanted cardioverter defibrillators to the occurrence of VT/VF., Method: Implanted defibrillator follow-up data were obtained retrospectively. Those with Medtronic OptiVol (Medtronic Inc., Minneapolis, MN, USA), storing averaged daily and reference impedance values, were reviewed for VT/VF episodes. Impedance changes in the week leading up to VT/VF were analyzed., Results: A total of 317 VT/VF episodes in a cohort of 121 patients' follow-up data were evaluated. Averaged daily intrathoracic impedance declined preceding 64% of VT/VF episodes, with an average decline of 0.46 +/- 0.35 Ohms from the day before the VT/VF episodes. However, the mean values of the averaged daily and reference impedance did not change significantly. A novel measure, DeltaTI, the sum of the daily differences between the averaged daily and reference impedance, was negative preceding 66% of VT/VF episodes (P < 0.001). The mean DeltaTI was -4.0 +/- 1.3 Ohms, which was significantly lower than the theoretically expected value of zero Ohms (P < 0.01)., Conclusion: (1) Averaged daily impedance declined preceding 64% of VT/VF episodes, but the overall decline was of small magnitude; (2) a novel measure, DeltaTI, was negative preceding 66% of VT/VF episodes, and significantly below zero.

Background. Right ventricular pacing (RVP) has been associated with adverse outcomes, including heart failure and death. Minimizing RVP has been proposed as a therapeutic goal for a variety of pacing devices and indications. Objective. Quantify survival according to frequency of RVP in veterans with pacemakers. Methods. We analyzed electrograms from transtelephonic monitoring of veterans implanted with pacemakers between 1995 and 2005 followed by the Eastern Pacemaker Surveillance Center. We compared all cause mortality and time to death between patients with less than 20% and more than 80% RVP. Results. Analysis was limited to the 7198 patients with at least six trans-telephonic monitoring records (mean = 21). Average follow-up was 5.3 years. Average age at pacemaker implant was significantly lower among veterans with <20% RVP (67 years versus 72 years; P < .0001). An equal proportion of deaths during follow-up were noted for each group: 126/565 patients (22%) with <20% RVP and 1113/4968 patients (22%) with >80% RVP. However, average post-implant survival was 4.3 years with <20% RVP versus 4.7 years with >80% RVP (P < .0001). Conclusions. Greater frequency (>80%) of RVP was not associated with higher mortality in this population of veterans. Those veterans utilizing <20% RVP had a shortened adjusted survival rate (P = .0016).

Angiotensin-converting enzyme (ACE) inhibitors have been extensively used for the treatment of patients with cardiovascular disease, but several concerns have been raised about their efficacy in African American (AA) patients with heart failure, hypertension, and left ventricular hypertrophy. In this study the authors assessed the effect of ACE inhibitors on total and cardiovascular mortality in high-risk AA patients with angiographically proven coronary artery disease (CAD). This was a retrospective analysis of 810 AA men who underwent diagnostic coronary angiography between 1995 and 2003. All patients had demonstrable CAD and had undergone a complete ischemic workup. Follow-up was from 3 to 10 years. ACE inhibitors were administered to 237 patients, while the remaining 537 patients were not taking ACE inhibitors. Patients taking ACE inhibitors had significantly more comorbidities (hypertension, diabetes, left ventricular hypertrophy, heart failure, severe CAD) at baseline, compared with patients not taking ACE inhibitors (P<.05 for all comorbidities). Despite the unfavorable baseline profile, patients taking ACE inhibitors had significantly lower mortality from CAD during follow-up than patients who were not taking ACE inhibitors (P=.006). Stroke mortality rates were similar in both groups. Cox regression analysis showed an 80% higher relative risk in patients not receiving ACE inhibitors. These data indicate a substantial benefit from ACE inhibitor therapy in high-risk AA patients with CAD., (2009 Wiley Periodical, Inc.)

Background: Defibrillator implanters have adopted different approaches to managing failures of multicomponent implanted cardioverter defibrillator (ICD) leads. Although recent publications identified single-component failures as common mechanisms of failure, there are no published data regarding how best to manage these failures., Methods: An internet-based survey was conducted to identify current management strategies. Questions were asked regarding isolated failure of a high-voltage coil or of a pace/sense electrode, in order to identify the frequency of various techniques to correct these failures., Results: A worldwide query collected strategies from 376 physicians identifying themselves as ICD-implanting physicians. Replies came from 28 countries, with the USA accounting for 83.2%. The survey was completed by 85.6% of respondents. Implant experience was >10 years for 61.1%, 3-10 years for 29.1%, and <3 years for 10.4%. When the right ventricular coil failed, 52% abandoned and 48% explanted the failed lead. In superior vena cava coil failure, 61.2% chose to simply exclude this coil, using the other intact lead components. For pace/sense defects, 53.1% chose to implant a new pace/sense lead or switch sensing electrodes, using the intact lead components. Medical literature (76.1%), personal experience (67.6%), and professional guidelines (63.7%) were strong decision-making influences., Conclusions: (1) Management decisions for single-component failures of ICD leads are complex; (2) Significant differences in management strategy exist among physicians; (3) Medical literature and professional guidelines are strong influences for these decisions; (4) A lead failure registry could help identify reasons for such differences and help guide management.

Background: Prehypertension is associated with increased risk for mortality, a fact that generated a debate regarding the use of antihypertensive therapy in prehypertensives. Increased exercise capacity is associated with lower mortality risk, but little is known about its effects in prehypertensives. Thus, we evaluated the association between exercise capacity and all-cause mortality in prehypertensives., Methods: A graded exercise test was performed in 4,478 prehypertensive men at the Veterans Affairs Medical Centers in Washington, DC and Palo Alto, CA. Four fitness categories (quartiles) were defined based on peak metabolic equivalents (METs) achieved. All-cause mortality was assessed for both younger (10 METs). The trends were similar but more pronounced among younger than older individuals., Conclusions: A strong, inverse and graded association between exercise capacity and all-cause mortality was observed in prehypertensive individuals. The protective effects of increased fitness were more pronounced in younger than older individuals, suggesting that age should be more closely considered when assessing fitness and mortality relationships.

Introduction: Information regarding the effect of exercise capacity on mortality risk in individuals with high-normal blood pressure is severely limited. Thus, we evaluated the association of exercise capacity and all-cause mortality in individuals with high-normal blood pressure., Methods: Exercise test was performed in 1727 males with high-normal blood pressure at two Veteran sites (Washington, DC, and Palo Alto, CA). Fitness status was assessed in metabolic equivalents (METs) at exercise peak. All-cause mortality was recorded for a mean follow-up period of 9.8+/-6.0 years., Results: Exercise capacity was inversely associated with all-cause mortality, and the association was independent of traditional cardiovascular risk factors. For each 1 MET increase in exercise capacity, the adjusted mortality risk was reduced by 13%, underscoring the strong predictive value of exercise capacity that was confirmed by ROC analysis. Data analysis according to fitness levels revealed a threshold level of 4 METs, over which the mortality risk was progressively reduced by 30% (hazard ratio=0.70; CI 0.51-0.95) for those who achieved 4.1-6.0 METs and 61% (hazard ratio=0.39; CI 0.26-0.57) for those who achieved 8.1-10 METs. No additional reductions in risk were noted until the MET level achieved exceeded 12 METs., Conclusions: We observed a strong, inverse, graded and independent association between exercise capacity and all-cause mortality in individuals with high-normal blood pressure. Our findings indicate that a shift of the fitness curve to the right is associated with significant survival benefits, and even slight differences in fitness levels are associated with substantial reductions in mortality risk.

The Sotalol-Amiodarone Fibrillation Efficacy Trial (SAFE-T) is a randomized, double-blind, multicenter, placebo-controlled trial in which the effects of sotalol and amiodarone in maintaining stability of sinus rhythm are being examined in patients with persistent atrial fibrillation at 20 Veterans Affairs medical centers. The time to the occurrence of atrial fibrillation or flutter in patients with atrial fibrillation converted to sinus rhythm is the primary outcome measure, with a number of parameters as secondary end points. SAFE-T had randomized 665 patients when enrollment terminated on October 31, 2001. Follow-up of patients continued until October 31, 2002, for a maximum period of 54 months and a minimum period of 12 months for all patients.

Although the value of heart rate variability (HRV) for risk stratification after acute myocardial infarction has been demonstrated, the value of low HRV as a predictor of sudden cardiac death in patients with ischemic cardiomyopathy has not been shown convincingly to date. We retrospectively analyzed electrocardiographic data from 179 patients in the Veterans Affairs' Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure to determine if HRV (expressed as the SD of the normal-to-normal RR intervals [SDNN]) would be useful as a predictor of overall mortality and sudden death. Because our goal was to identify high-risk patients, we compared patients in the lowest quartile of HRV with the remaining patients. Among the 127 patients meeting inclusion criteria, SDNN <65.3 ms (the lowest quartile) was the sole independent factor predictive of survival in a multivariate model (p = 0.0001). A Cox proportional-hazards model revealed that each increase of 10 ms in SDNN conferred a 20% decrease in risk of mortality (p = 0.0001). Furthermore, patients with SDNN <65.3 ms had a significantly increased risk of sudden death (p = 0.016). Thus, HRV was the sole independent predictor of overall mortality and was significantly associated with sudden death in this population.

Background and Objectives: It has been suggested that prolongation of the QRS duration (>120 ms) is an independent risk factor for mortality in patients with cardiomyopathy. The purpose of this study was to examine the association between QRS duration and survival in patients with heart failure., Methods: We performed a retrospective analysis to examine the association between QRS prolongation (> or =120 ms) and mortality. The study population included 669 patients with heart failure. Two groups, on the basis of baseline QRS duration <120 milliseconds or > or =120 milliseconds, were identified. The groups were compared with respect to total mortality and sudden death. Subgroups were also stratified by right bundle branch block and left bundle branch block, ejection fraction (EF) <30% and > or =30% to 40%, ischemic and nonischemic cardiomyopathy, amiodarone and placebo., Results: Prolonged QRS was associated with a significant increase in mortality (49.3% vs 34.0%, P =.0001) and sudden death (24.8% vs 17.4%, P =.0004). Left bundle branch block was associated with worse survival (P =.006) but not sudden death. In patients with an EF <30%, QRS prolongation continued to be associated with a significant increase in mortality (51.6% vs 41.1%, P =.01) and sudden death (28.8% vs 21.1%, P =.02). In those with an EF of 30% to 40%, QRS prolongation was associated with a significant increase in mortality (42.7% vs 23.3%, P =.0036) but not in sudden death (13.3% vs 12.0%, P =.625). After adjustment for baseline variables, independent predictors of mortality were found to be prolongation of QRS (P =.0028, risk ratio 1.46) and depressed EF (P =.0001, risk ratio 0.965). Age, type of cardiomyopathy, and drug treatment group were not predictive of mortality., Conclusion: QRS prolongation is an independent predictor of both increased total mortality and sudden death in patients with heart failure.

Background: The aim of the present study was to assess the prognostic value of novel repolarization descriptors from the 12-lead ECG in a large cohort of US veterans., Methods and Results: Male US veterans (n=813) with cardiovascular disease had digital 12-lead ECGs recorded at the VA Medical Center, Washington, DC, between 1984 and 1991. The patient series was retrospectively compiled in 1991; follow-up was prospectively assessed until 2000. Novel ECG variables characterizing repolarization and the T-wave loop were automatically analyzed. Of 772 patients with technically analyzable data, 252 patients (32.6%) died after a mean follow-up of 10.4 +/- 3.8 years. Direct comparison between dead and alive patients showed that the so-called T-wave residua (the absolute and relative amount of nondipolar contents within the T wave) predicted mortality (111 900 +/- 164 700 versus 85 600 +/- 144 800 between dead and alive patients, P<0.0002; and 0.43 +/- 0.62% versus 0.33 +/- 0.56%, P<0.0005 for the absolute and relative T-wave residuum, respectively). On Cox regression analysis entering age, left ventricular ejection fraction, echocardiographic left ventricular hypertrophy, and either of the T-wave residua, risk prediction was independent for the absolute (P=0.022) and for the relative (P=0.006) T-wave residuum, respectively, with age (P<0.0001), presence of left ventricular hypertrophy (P=0.002), and left ventricular ejection fraction (P=0.004) also being predictors of survival., Conclusions: The heterogeneity of myocardial repolarization, measured by the so-called T-wave residuum in the ECG, confers long-term independent prognostic information in US veterans with cardiovascular disease.

In light of evolving pacemaker technology and increasing interest in multisite pacing, the Committee on the Development of Position Statements (CDPS) of the North American Society of Pacing and Electrophysiology (NASPE) created an ad hoc Pacemaker Mode Code Task Force in April 2001 under the chairmanship of David L. Hayes, MD, for the purpose of bringing the NASPE/British Pacing and Electrophysiology Group (BPEG) Generic Pacemaker Code (NBG Code) up to date. The task force, whose members are the authors of this article, designed a revised NBG Code in which three major issues were taken into account. First, it was recognized that all modern pacemakerpulse generators are capable of extensive bidirectional communication with an external programming device, making them "communicating" pulse generators as defined by the current (1987) NBG Code. Second, it was decided that a means of providing basic information regarding the location of multisite pacing would be a useful ingredient of the NBG Code. Third, in view of the extensive antibradycardia pacing capabilities common in modern implantable cardioverter defibrillators and the availability of the NASPE/BPEG Defibrillator Code (NBD Code), it was considered unnecessary for the NBG Code to address the presence or absence of antitachycardia features. The resulting updated version of the NBG Code as described herein was endorsed by the BPEG on September 20, 2001 and adopted by the NASPE Board of Trustees on October 18, 2001. The structure of the revised NBG Code differs from that of the previous version in two respects alone: Position IV specifies only the presence or absence of rate modulation, and Position V specifies only the location or absence of multisite pacing (i.e., biatrial or biventricular pacing with at least two stimulation sites in each case) more than one stimulation site in any single cardiac chamber, or any combination of these. The revised NBG Code is deliberately configured to avoid confusion with earlier mode codes, and it is the authors' hope that it will serve as an enhanced resource for communication among those engaged in every phase of the multidisciplinary practice of cardiac rhythm management.

The VA Medical Center in Washington, DC, was the nexus for a number of computerization projects that were initiated by the Department of Veterans Affairs. The culmination of these initiatives is a software package that presents the complete electronic patient record in an easy-to-use graphic user interface. This record combines text data from the legacy data base, diagnostic images from patient procedures, electrocardiograms from a commercial server, an Internet connection, and a hospital web site with pertinent reference information. The information is available in over 1000 places in the hospital and can be accessed remotely using a remote access server. The computerization of the medical record has improved hospital efficiency, has made physician access to patient information more reliable, has opened new opportunities for patient education, and has given healthcare providers more time to care for patients., (Copyright 2001 American Cancer Society.)

Objective: The purpose of the study was to identify clinical predictors of progression of aortic stenosis., Background: The natural history of valvular aortic stenosis includes a latency period followed by an unpredictable progression. Recent investigations have shown an association between risk factors for atherosclerosis and the presence of aortic stenosis. The authors hypothesized that atherosclerosis risk factors are also associated with the progression of aortic stenosis., Methods: In a retrospective study, patients with a diagnosis of aortic stenosis were identified by continuous wave Doppler and a follow-up study of at least 6 months. Clinical data at the time of the index echocardiogram were obtained from review of patients' medical records. Independent risk factors for the progression of aortic stenosis were identified by stepwise logistic regression analysis., Results: One hundred twenty-three patients were identified, and complete data were obtained for 87 patients (mean age, 70.7 +/- 10 years; men, 81%; mean follow-up, 2.54 +/- 1.6 years). The initial gradient was mild in 61% of patients and moderate in 31%. The mean rate of progression was 6.3 +/- 13 mm Hg/year. Mild aortic stenosis in 36% of patients at the time of the index echocardiogram progressed to moderate or severe over an average of 2.9 +/- 2.0 years. Independent clinical factors associated with a progression of 5 mm Hg/year or greater included a history of smoking (relative risk [RR] = 3.06; 95% confidence interval [CI] = 1.09-8.61; p = 0.034) and body mass index (RR = 1.16; 95% CI = 1.03-1.30; p = 0.013). Hypertension, diabetes, cholesterol, age, gender, and coronary artery disease were not independently associated with progression., Conclusions: Body mass index and a history of smoking are independent predictors of significant progression of aortic stenosis, defined as > 5 mm Hg/year. The rate of progression of aortic stenosis is variable. However, a substantial number of patients have progression of even initially mild aortic stenosis within a relatively short period of time. The effect of controlling atherosclerosis risk factors on the rate of progression of aortic stenosis remains to be determined.

Background: Many reports in the literature have found the use of invasive cardiac procedures in black patients to be less common than in white patients. These reports tend to have small numbers of black patients compared with white patients or rely on the information contained in claims or administrative data., Methods and Results: Cardiac catheterization reports were reviewed in a Veterans Administration hospital that serves a large number of black patients. After review of the medical histories and hemodynamic and angiographic findings in 726 black and 734 white male veterans, data were collected to determine recommended and actual therapy. Death was assessed after a 4- to 10-year follow-up period. White patients were more likely to have significant coronary artery lesions than black patients. Multivariate analysis showed that the likelihood of patients actually having percutaneous transluminal coronary angioplasty or coronary artery bypass surgery did not differ by ethnicity when controlling for disease extent or severity. Coronary artery bypass surgery was associated with decreased mortality rates for both black and white patients. Although short-term death in blacks was not different from whites, blacks had an increased long-term risk for death., Conclusions: After coronary angiography, black veterans and white veterans appear to undergo revascularization procedures related to the severity of disease. The decreased long-term life expectancy of black men as compared with whites is not necessarily explained by the presence of or treatment for coronary artery disease in this population.

Objectives: To test the hypothesis that post-shock dispersion of repolarization (PSDR) is higher in T wave shocks that induce ventricular fibrillation (VF) than in those that do not, as well as in implantable cardioverter defibrillator (ICD) defibrillation shocks which fail to terminate VF when compared with those that are successful., Background: Ventricular fibrillation has been linked to the presence of dispersion of repolarization, which facilitates reentry. Most of the studies have been done in animals, and the mechanism underlying the generation and termination of VF in humans is speculative and remains to be determined., Methods: Monophasic action potentials (MAPs) were recorded simultaneously from the right ventricular outflow tract (RVOT) and the right ventricular apex (RVA) in 27 patients who underwent implantation and testing of an ICD. T wave shocks were used to induce VF while the termination was attempted using internal defibrillator shocks. The post-shock repolarization time (PSRT) was measured in both the RVA and RVOT MAPs, and the difference between the two recordings was defined as the PSDR. The averages of PSDR were compared between the successful and unsuccessful inductions and terminations of VF., Results: T wave shocks that induced VF generated a greater PSDR (93.4 +/- 85.1 ms) than the unsuccessful ones (45.1 +/- 55.9 ms, p < 0.001). On the other hand, shocks that failed to terminate VF were associated with a greater PSDR (59.9 +/- 41.2 ms) than shocks that terminated VF (21.1 +/- 20.1 ms), p < 0.001., Conclusions: A high PSDR following a T wave shock is associated with induction of VF; while following a defibrillating shock, it is associated with its failure and the continuation of VF. Conversely, a low PSDR is associated with failure of a T wave shock to induce VF and successful termination of VF by a defibrillating shock.

Patients with congestive heart failure frequently have ventricular arrhythmias on ambulatory electrocardiographic recordings and sudden cardiac death is seen in almost 50% of such patients. Many antiarrhythmic agents have been approved to suppress the arrhythmia in an effort to improve survival. Some sodium-channel blockers not only failed to improve survival but have been shown to be harmful. This led to the development of potassium-channel blockers, such as d-sotalol, amiodarone, dofetilide, and azimilide. d-Sotalol was associated with excess mortality in patients with left ventricular dysfunction; amiodarone seems to be potentially beneficial; and dofetilide has a neutral effect on mortality. The Sudden Cardiac Death Heart Failure Trial (SCD HEFT) is testing the implantable cardioverter defibrillator (ICD) against amiodarone and placebo. The ICDs appear to be superior to antiarrhythmic drugs in certain high-risk patients, although not proved in unstratified patients with heart failure.

Tumor necrosis factor-alpha (TNF-alpha) has been implicated in the pathogenesis of congestive heart failure and may be associated with an increase in mortality. A recent in vitro study showed that amiodarone decreases TNF-alpha production by human blood mononuclear cells in response to lipopolysaccharide. However, no previous clinical studies have determined the effect of chronic amiodarone therapy on TNF-alpha levels. Thus, the purpose of this study was to determine whether amiodarone affects TNF-alpha levels in patients with ischemic and nonischemic cardiomyopathy. TNF-alpha levels were analyzed by an enzyme-linked immunoassay using plasma samples at baseline, 1, and 2 years of follow-up in New York Heart Association class III patients (n = 40 in each of the placebo and amiodarone groups, mean ejection fraction 0.25+/-0.09) who were randomized in the Congestive Heart Failure-Survival Trial of Antiarrhythmic Therapy, a multicenter, double-blind, placebo-controlled study in which the effect of amiodarone on survival was investigated. TNF-alpha levels were elevated in both groups of patients at baseline, 6.6+/-3.1 and 7.7+/-5.3 pg/ml in the amiodarone and placebo groups, respectively (p = 0.3). There were no significant differences in demographic or clinical variables between the 2 groups. Amiodarone treatment was associated with a significant increase in TNF-alpha levels in patients with ischemic cardiomyopathy, 12.7+/-12.5 and 6.8+/-3.7 pg/ml in the amiodarone and placebo groups, respectively (p = 0.03) at 1 year. No change in TNF-alpha levels was observed in patients with nonischemic cardiomyopathy. In contrast to the in vitro data, amiodarone treatment is associated with an increase in TNF-alpha levels in patients with ischemic cardiomyopathy. This increase is not associated with an adverse effect on survival.

Objectives: This study sought to determine the prevalence and significance of nonsustained ventricular tachycardia (NSVT) in patients with premature ventricular contractions (PVCs) and heart failure treated with vasodilator therapy., Background: Heart failure patients with ventricular arrhythmia and NSVT have a significantly increased risk of premature cardiac death. Recently there has been the question of whether these arrhythmias are expressions of a severely compromised ventricle or are they independent risk factors. We, therefore, determined the prevalence and significance of NSVT in patients with PVCs and heart failure and on vasodilator therapy., Methods: Twenty-four hour ambulatory recordings were done at randomization, at 2 weeks, at months 1, 3, 6, 9 and 12 and then every 6 months in 674 patients with heart failure and on vasodilator therapy. The median period of follow-up was 45 months (range 0 to 54)., Results: Nonsustained ventricular tachycardia was present in 80% of all patients. Patients without (group 1) and with (group 2) NSVT were balanced for variables: age, etiology of heart disease, New York Heart Association (NYHA) functional class, use of amiodarone and diuretics and left ventricular diameter by echocardiogram. However, group 1 patients had significantly less beta-adrenergic blocking agent use and higher ejection fraction (EF) (p < 0.002 and p < 0.001, respectively). Survival analysis for all deaths showed a greater risk of death among group 2 patients (p=0.01). Similarly, sudden death was increased in group 2 patients (p=0.02, risk ratio 1.8). After adjusting for the above variables, only EF (p=0.001) and NYHA class (p=0.01) were shown to be independent predictors of survival. Nonsustained ventricular tachycardia showed a trend (p=0.07) as an independent predictor for all-cause mortality but not for sudden death. Only EF was an independent predictor for sudden death., Conclusions: Nonsustained ventricular tachycardia is frequently seen in patients with heart failure and may be associated with worsened survival by univariate analysis. However, after adjusting other variables, especially for EF, NSVT was not an independent predictor of all-cause mortality or sudden death. These results have serious implications in that suppression of these arrhythmias may not improve survival.

Electrocardiograms were recorded at baseline and regular intervals in 53 patients with myotonic dystrophy who were followed for a mean of 6.3 +/- 4.0 years. Patients with cardiac events had a significantly prolonged PR interval (p <0.001), a later age of onset of neuromuscular symptoms (p <0.05), and were older (p <0.005).

Objectives: The purpose of this study was to evaluate the pulmonary effects of amiodarone in patients with heart failure, in those with chronic obstructive pulmonary disease (COPD) and in those undergoing a surgical procedure., Background: Amiodarone has been known to cause pulmonary complications; especially in those with COPD and in those undergoing a surgical procedure., Methods: Patients receiving vasodilator therapy for congestive heart failure were prospectively randomized to placebo or amiodarone at 800 mg/day for 14 days, 400 mg/day for 50 weeks and then 300 mg/day thereafter. Chest X-ray film and pulmonary function tests with diffuse capacity of carbon monoxide (DLCO) were obtained at baseline and annually. The power to detect a 20% difference in DLCO at 1 year exceeded 90% in all patients and in those with COPD (two-sided alpha = 0.05). The sample allowed a 75% power to detect pulmonary complications (1% vs. 5%) between the two treatment groups., Results: There was no difference in baseline characteristics between patients randomized to amiodarone (n = 269) or placebo (n = 250). The DLCO measurements at randomization were 18.3 +/- 6.9 and 17.7 +/- 7.6 ml/min per mm Hg for the amiodarone and placebo groups, respectively (p = 0.3). At 1 and 2 years, DLCO measurements were 17.7 +/- 7.0 and 18.3 +/- 7.7 ml/min per mm Hg for the amiodarone group and 17.9 +/- 7.2 and 18.2 +/- 7.2 for the placebo group, respectively. There were no significant differences between the groups, with corresponding p values of 0.73 ad 0.96 at years 1 and 2, respectively. Among patients with COPD, DLCO measurements at randomization were 17.9 +/- 6.7 and 15.8 +/- 6.8 ml/min per mm Hg for the amiodarone and placebo groups, respectively. At years 1 and 2, DLCO measurements were 16.6 +/- 7.8 and 17.8 +/- 9.5 ml/min per mm Hg for the amiodarone group and 16.5 +/- 6.6 and 16.3 +/- 7.0 ml/min per mm Hg for the placebo group, with corresponding p values of 0.95 and 0.48, respectively. There was no difference in survival free of noncardiac or perioperative deaths between patients assigned to amiodarone or placebo. Pulmonary fibrosis was diagnosed in four patients (1.1%) treated with amiodarone and in three patients (0.8%) receiving placebo., Conclusions: Our study shows that amiodarone can be safely used, with an acceptable pulmonary toxicity, in patients with heart failure.

Some antiarrhythmic drugs have been shown to influence the circadian pattern of sudden cardiac death (SCD). The effect of chronic amiodarone therapy on this pattern is unknown. This study determines the circadian pattern of deaths in the Congestive Heart Failure-Survival Trial of Antiarrhythmic Therapy (CHF-STAT) and compares the distribution of SCD between the amiodarone and the placebo arms of the trial. CHF-STAT was a multicenter trial that determined whether amiodarone reduces mortality in patients with heart failure and asymptomatic ventricular arrhythmias. The time of death was retrospectively analyzed in patients who died from pump failure and SCD. In patients who died suddenly, the circadian pattern of deaths was compared between patients receiving amiodarone and those receiving placebo. In CHF-STAT, 274 patients died during follow-up. The time of death was available in 65 of the 74 patients who died from pump failure, and in 96 of the 139 patients who died suddenly. There was a circadian variation of all SCDs compared with other deaths with a distinct peak during the morning (p = 0.04). A similar morning peak of sudden cardiac death was found in both the amiodarone (n = 42) and the placebo (n = 54) groups, and the overall circadian pattern did not differ between them (p = 0.16). In contrast, death from pump failure occurred equally distributed over time. Thus, SCD occurs predominantly during the morning, whereas death from heart failure does not exhibit a morning peak. Amiodarone does not influence the circadian pattern of SCD.

Hypertensive patients are likely to have an exaggerated blood pressure (BP) response during physical exertion. When moderate aerobic exercise was added to medical antihypertensive therapy in patients with severe hypertension, excessive elevations in BP during physical exertion were attenuated even with a modest reduction in BP at rest.

Nonthoracotomy defibrillator systems can be implanted with a lower morbidity and mortality, compared to epicardial systems. However, implantation may be unsuccessful in up to 15% of patients, using a monophasic waveform. It was the purpose of this study to prospectively examine the efficacy of a second chest patch electrode in a nonthoracotomy defibrillator system. Fourteen patients (mean age 62 +/- 11 years, ejection fraction = 0.29 +/- 0.12) with elevated defibrillation thresholds, defined as > or = 24 J, were studied. The initial lead system consisted of a right ventricular electrode (cathode), a left innominate vein, and subscapular chest patch electrode (anodes). If the initial defibrillation threshold was > or = 24 J, a second chest patch electrode was added. This was placed subcutaneously in the anterior chest (8 cases), or submuscularly in the subscapular space (6 cases). This resulted in a decrease in the system impedance at the defibrillation threshold, from 72.3 +/- 13.3 omega to 52.2 +/- 8.6 omega. Additionally, the defibrillation threshold decreased from > or = 24 J, with a single patch, to 16.6 +/- 2.8 J with two patches. These changes were associated with successful implantation of a nonthoracotomy defibrillator system in all cases. In conclusion, the addition of a second chest patch electrode (using a subscapular approach) will result in lower defibrillation thresholds in patients with high defibrillation thresholds, and will subsequently increase implantation rates for nonthoracotomy defibrillators.