Faculty Bibliography
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164
National trends in recurrent AMI hospitalizations 1 year after acute myocardial infarction in Medicare beneficiaries: 1999-2010
BACKGROUND: There are few data characterizing temporal changes in hospitalization for recurrent acute myocardial infarction (AMI) after AMI. METHODS AND RESULTS: Using a national sample of 2 305 441 Medicare beneficiaries hospitalized for AMI from 1999 to 2010, we evaluated changes in the incidence of 1-year recurrent AMI hospitalization and mortality using Cox proportional hazards models. The observed recurrent AMI hospitalization rate declined from 12.1% (95% CI 11.9 to 12.2) in 1999 to 8.9% (95% CI 8.8 to 9.1) in 2010, a relative decline of 26.4%. The observed recurrent AMI hospitalization rate declined by a relative 27.7% in whites, from 11.9% (95% CI 11.8 to 12.1) to 8.6% (95% CI 8.5 to 8.8) versus a relative decline in blacks of 13.6% from 13.2% (95% CI 12.6 to 13.8) to 11.4% (95% CI 10.9 to 12.0). The risk-adjusted rate of annual decline in recurrent AMI hospitalizations was 4.1% (HR 0.959; 95% CI 0.958 to 0.961), and whites experienced a higher rate of decline (HR 0.957, 95% CI 0.956 to 0.959) than blacks (HR 0.974, 95% CI 0.970 to 0.979).The overall, observed 1-year mortality rate after hospitalization for recurrent AMI declined from 32.4% in 1999 to 29.7% in 2010, a relative decline of 8.3% (P<0.05). In adjusted analyses, 1-year mortality after recurrent AMI hospitalization declined 1.8% per year (HR, 0.982; 95% CI 0.980 to 0.985). CONCLUSIONS: In a national sample of Medicare beneficiaries hospitalized for AMI from 1999 to 2010, hospitalization for recurrent AMI decreased, as did subsequent mortality, albeit to a lesser extent. The risk of recurrent AMI hospitalization declined less in black patients than in whites, increasing observed racial disparities by the end of the study period.
PMCID:4323804
PMID: 25249298
ISSN: 2047-9980
CID: 1681772
Left atrial passive emptying function determined by cardiac magnetic resonance predicts atrial fibrillation recurrence after pulmonary vein isolation
BACKGROUND: Although pulmonary vein isolation has become a mainstream therapy for selected patients with atrial fibrillation (AF), late recurrent AF is common and its risk factors remain poorly defined. The purpose of our study was to test the hypothesis that reduced left atrial passive emptying function (LAPEF) as determined by cardiac magnetic resonance has a strong association with late recurrent AF after pulmonary vein isolation. METHODS AND RESULTS: Three hundred forty-six patients with AF referred for cardiac magnetic resonance pulmonary vein mapping before pulmonary vein isolation were included. Maximum LA volumes (VOLmax) and volumes before atrial contraction (VOLbac) were measured; LAPEF was calculated as (VOLmax-VOLbac)/VOLmaxx100. Kaplan-Meier curves were constructed to determine late recurrent AF stratified by LAPEF quintile. Cox proportional hazards regression was used to adjust for known markers of recurrence. During a median follow-up of 27 months, 124 patients (35.8%) experienced late recurrent AF. Patients with recurrence were more likely to have nonparoxysmal AF (75.8% versus 51.4%; P<0.01), higher mean VOLmax (60.2 versus 52.8 mL/m(2); P<0.01), and lower mean LAPEF (19.1% versus 26.0%; P<0.01). Patients in the lowest LAPEF quintile were at highest risk of developing recurrent AF (2-year recurrence for lowest versus highest: 60.5% versus 17.3%; P<0.01). After adjusting for known predictors of recurrence, patients with low LAPEF remained significantly more likely to recur (hazard ratio for lowest versus highest quintile, 3.92; 95% confidence interval, 2.01-7.65). CONCLUSIONS: We found a strong association between LAPEF and recurrent AF after pulmonary vein isolation that persisted after multivariable adjustment.
PMCID:4219259
PMID: 24902586
ISSN: 1941-9651
CID: 1127062
Obesity and sleep apnea are independently associated with adverse left ventricular remodeling and clinical outcome in patients with atrial fibrillation and preserved ventricular function
AIMS: Obesity is associated with the development of atrial fibrillation (AF), and both obesity and AF are independently associated with the development of heart failure with preserved ejection fraction. We tested the hypothesis that sleep apnea (SA) would have a body mass index (BMI) independent association with adverse left ventricular (LV) remodeling and clinical outcomes in patients with AF and preserved LV function. METHODS AND RESULTS: From 720 consecutive patients with AF, 403 patients without myocardial disease (preserved LV function) were identified and followed up for 3.3 +/- 1.5 years. The primary outcome was a combination of all-cause mortality/heart failure hospitalization. Left ventricular mass and LV mass-to-volume ratio were higher in patients with SA and obesity (P < .0001 for all). Body mass index (beta per log = .47; P < .0001) and SA (beta = .05; P = .045) were independently associated with LV mass index. Patients with treated SA had a lower LV mass index (but not LV mass-to-volume ratio) compared with untreated (P = .002). In a best overall multivariable model, SA therapy (beta = -.129; P = .001) and BMI (beta per log = .373; P = .0007) had opposing associations with LV mass index. Sleep apnea (hazard ratio [HR] = 2.94; P = .0004) and BMI (HR per 1 kg/m(2) = 1.08; P = .004) were associated with clinical outcome in unadjusted analysis. Only SA was associated with clinical outcome in a best overall multivariable model (HR = 2.14; P = .02). CONCLUSION: Sleep apnea and obesity are independently associated with adverse LV remodeling and clinical outcomes in patients with preserved LV function, whereas continuous positive airway pressure therapy is associated with a beneficial effect on LV remodeling. Research investigating SA therapies in patients at high risk for LV remodeling and heart failure is warranted.
PMCID:4340237
PMID: 24655713
ISSN: 0002-8703
CID: 1127072
Developing a risk model for in-hospital adverse events following implantable cardioverter-defibrillator implantation: a report from the NCDR (National Cardiovascular Data Registry)
OBJECTIVES: To better inform patients and physicians of the expected risk of adverse events and to assist hospitals' efforts to improve the outcomes of patients undergoing implantable cardioverter-defibrillator (ICD) implantation, we developed and validated a risk model using data from the NCDR (National Cardiovascular Data Registry) ICD Registry. BACKGROUND: ICD prolong life in selected patients, but ICD implantation carries the risk of periprocedural complications. METHODS: We analyzed data from 240,632 ICD implantation procedures between April 1, 2010, and December 31, 2011 in the registry. The study group was divided into a derivation (70%) and a validation (30%) cohort. Multivariable logistic regression was used to identify factors associated with in-hospital adverse events (complications or mortality). A parsimonious risk score was developed on the basis of beta estimates derived from the logistic model. Hierarchical models were then used to calculate risk-standardized complication rates to account for differences in case mix and procedural volume. RESULTS: Overall, 4,388 patients (1.8%) experienced at least 1 in-hospital complication or death. Thirteen factors were independently associated with an increased risk of adverse outcomes. Model performance was similar in the derivation and validation cohorts (C-statistics = 0.724 and 0.719, respectively). The risk score characterized patients into low- and-high risk subgroups for adverse events (/=30 points, 4.2%). The risk-standardized complication rates varied significantly across hospitals (median: 1.77, interquartile range 1.54, 2.14, 5th/95th percentiles: 1.16/3.15). CONCLUSIONS: We developed a simple model that predicts risk for in-hospital adverse events among patients undergoing ICD placement. This can be used for shared decision making and to benchmark hospital performance.
PMCID:3954985
PMID: 24333491
ISSN: 0735-1097
CID: 1127142
Genetic influence on exercise-induced changes in physical function among mobility-limited older adults
To date, physical exercise is the only intervention consistently demonstrated to attenuate age-related declines in physical function. However, variability exists in seniors' responsiveness to training. One potential source of variability is the insertion (I allele) or deletion (D allele) of a 287 bp fragment in intron 16 of the angiotensin-converting enzyme (ACE) gene. This polymorphism is known to influence a variety of physiological adaptions to exercise. However, evidence is inconclusive regarding the influence of this polymorphism on older adults' functional responses to exercise. This study aimed to evaluate the association of ACE I/D genotypes with changes in physical function among Caucasian older adults (n = 283) following 12 mo of either structured, multimodal physical activity or health education. Measures of physical function included usual-paced gait speed and performance on the Short Physical Performance Battery (SPPB). After checking Hardy-Weinberg equilibrium, we used using linear regression to evaluate the genotype*treatment interaction for each outcome. Covariates included clinic site, body mass index, age, sex, baseline score, comorbidity, and use of angiotensin receptor blockers or ACE inhibitors. Genotype frequencies [II (19.4%), ID (42.4%), DD (38.2%)] were in Hardy-Weinberg equilibrium (P > 0.05). The genotype*treatment interaction was statistically significant for both gait speed (P = 0.002) and SPPB (P = 0.020). Exercise improved gait speed by 0.06 +/- 0.01 m/sec and SPPB score by 0.72 +/- 0.16 points among those with at least one D allele (ID/DD carriers), but function was not improved among II carriers. Thus, ACE I/D genotype appears to play a role in modulating functional responses to exercise training in seniors.
PMCID:3949106
PMID: 24423970
ISSN: 1094-8341
CID: 1127122
Effect of beta-blockers on cardiac and pulmonary events and death in older adults with cardiovascular disease and chronic obstructive pulmonary disease
CONTEXT: In older adults with multiple conditions, medications may not impart the same benefits seen in patients who are younger or without multimorbidity. Furthermore, medications given for one condition may adversely affect other outcomes. beta-Blocker use with coexisting cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD) is such a situation. OBJECTIVE: To determine the effect of beta-blocker use on cardiac and pulmonary outcomes and mortality in older adults with coexisting COPD and CVD. DESIGN, SETTING, PARTICIPANTS: The study included 1062 participants who were members of the 2004-2007 Medicare Current Beneficiary Survey cohorts, a nationally representative sample of Medicare beneficiaries. Study criteria included age over 65 years plus coexisting CVD and COPD/asthma. Follow-up occurred through 2009. We determined the association between beta-blocker use and the outcomes with propensity score-adjusted and covariate-adjusted Cox proportional hazards. MAIN OUTCOME MEASURES: The 3 outcomes were major cardiac events, pulmonary events, and all-cause mortality. RESULTS: Half of the participants used beta-blockers. During follow-up, 179 participants experienced a major cardiac event; 389 participants experienced a major pulmonary event; and 255 participants died. Each participant could have experienced any >/=1 of these events. The hazard ratio for beta-blocker use was 1.18 [95% confidence interval (CI), 0.85-1.62] for cardiac events, 0.91 (95% CI, 0.73-1.12) for pulmonary events, and 0.87 (95% CI, 0.67-1.13) for death. CONCLUSION: In this population of older adults, beta-blockers did not seem to affect occurrence of cardiac or pulmonary events or death in those with CVD and COPD.
PMCID:4050644
PMID: 24561758
ISSN: 0025-7079
CID: 1127092
Temporal trends in quality of care among recipients of implantable cardioverter-defibrillators: insights from the National Cardiovascular Data Registry
BACKGROUND: The ICD Registry was established in 2006 in part to measure quality of care in patients undergoing implantation of implantable cardioverter-defibrillators (ICDs); however, whether outcomes have improved since initiation of the registry is unknown. Our objective was to examine changes over time in 3 quality metrics available from the registry. METHODS AND RESULTS: We performed an observational study of 367 153 patients who received new ICD implants from April 2006 to March 2010. Three quality metrics were selected: Adverse events (in-hospital complications or mortality), optimal medical therapy (OMT), and cardiac resynchronization therapy (CRT). OMT was defined as prescription of beta-blocker and either angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in eligible patients. CRT eligibility was determined by QRS >/=120 ms, left ventricular ejection fraction
PMCID:3946506
PMID: 24192798
ISSN: 0009-7322
CID: 1127152
Myocardial extracellular volume expansion and the risk of recurrent atrial fibrillation after pulmonary vein isolation
OBJECTIVES: This study tested whether myocardial extracellular volume (ECV) is increased in patients with hypertension and atrial fibrillation (AF) undergoing pulmonary vein isolation and whether there is an association between ECV and post-procedural recurrence of AF. BACKGROUND: Hypertension is associated with myocardial fibrosis, an increase in ECV, and AF. Data linking these findings are limited. T1 measurements pre-contrast and post-contrast in a cardiac magnetic resonance (CMR) study provide a method for quantification of ECV. METHODS: Consecutive patients with hypertension and recurrent AF referred for pulmonary vein isolation underwent a contrast CMR study with measurement of ECV and were followed up prospectively for a median of 18 months. The endpoint of interest was late recurrence of AF. RESULTS: Patients had elevated left ventricular (LV) volumes, LV mass, left atrial volumes, and increased ECV (patients with AF, 0.34 +/- 0.03; healthy control patients, 0.29 +/- 0.03; p < 0.001). There were positive associations between ECV and left atrial volume (r = 0.46, p < 0.01) and LV mass and a negative association between ECV and diastolic function (early mitral annular relaxation [E'], r = -0.55, p < 0.001). In the best overall multivariable model, ECV was the strongest predictor of the primary outcome of recurrent AF (hazard ratio: 1.29; 95% confidence interval: 1.15 to 1.44; p < 0.0001) and the secondary composite outcome of recurrent AF, heart failure admission, and death (hazard ratio: 1.35; 95% confidence interval: 1.21 to 1.51; p < 0.0001). Each 10% increase in ECV was associated with a 29% increased risk of recurrent AF. CONCLUSIONS: In patients with AF and hypertension, expansion of ECV is associated with diastolic function and left atrial remodeling and is a strong independent predictor of recurrent AF post-pulmonary vein isolation.
PMCID:3900879
PMID: 24290570
ISSN: 1876-7591
CID: 1127032
Adult height and prevalence of coronary artery calcium: the National Heart, Lung, and Blood Institute Family Heart Study
BACKGROUND: Adult height has been hypothesized to be inversely associated with coronary heart disease; however, studies have produced conflicting results. We sought to examine the relationship between adult height and the prevalence of coronary artery calcium (CAC), a direct measure of subclinical atherosclerosis and surrogate marker of coronary heart disease. METHODS AND RESULTS: We evaluated the relationship between adult height and CAC in 2703 participants from the National Heart, Lung, and Blood Institute Family Heart Study who underwent cardiac computed tomography. We used generalized estimating equations to calculate the prevalence odds ratios for the presence of CAC (CAC>0) across sex-specific quartiles of height. The mean age of the sample was 54.8 years, and 60.2% of participants were female. There was an inverse association between adult height and CAC. After adjusting for age, race, field center, waist circumference, smoking, alcohol, physical activity, systolic blood pressure, antihypertensive medications, diabetes mellitus, diabetic medications, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, lipid-lowering medications, and income, individuals in the tallest quartile had 30% lower odds of having prevalent CAC. The odds ratios (95% confidence intervals) for the presence of CAC across consecutive sex-specific quartiles of height were 1.0 (reference), 1.15 (0.86-1.53), 0.95 (0.73-1.22), and 0.70 (0.53-0.93), and P for trend<0.01. There was no evidence of effect modification for the relationship between adult height and CAC by age or socioeconomic status. CONCLUSIONS: The results of our study suggest an inverse, independent association between adult height and CAC.
PMCID:3970195
PMID: 24336983
ISSN: 1941-9651
CID: 1127132
Anti-hypertensive medications and cardiovascular events in older adults with multiple chronic conditions
IMPORTANCE: Randomized trials of anti-hypertensive treatment demonstrating reduced risk of cardiovascular events in older adults included participants with less comorbidity than clinical populations. Whether these results generalize to all older adults, most of whom have multiple chronic conditions, is uncertain. OBJECTIVE: To determine the association between anti-hypertensive medications and CV events and mortality in a nationally representative population of older adults. DESIGN: Competing risk analysis with propensity score adjustment and matching in the Medicare Current Beneficiary Survey cohort over three-year follow-up through 2010. PARTICIPANTS AND SETTING: 4,961 community-living participants with hypertension. EXPOSURE: Anti-hypertensive medication intensity, based on standardized daily dose for each anti-hypertensive medication class participants used. MAIN OUTCOMES AND MEASURES: Cardiovascular events (myocardial infarction, unstable angina, cardiac revascularization, stroke, and hospitalizations for heart failure) and mortality. RESULTS: Of 4,961 participants, 14.1% received no anti-hypertensives; 54.6% received moderate, and 31.3% received high, anti-hypertensive intensity. During follow-up, 1,247 participants (25.1%) experienced cardiovascular events; 837 participants (16.9%) died. Of deaths, 430 (51.4%) occurred in participants who experienced cardiovascular events during follow-up. In the propensity score adjusted cohort, after adjusting for propensity score and other covariates, neither moderate (adjusted hazard ratio, 1.08 [95% CI, 0.89-1.32]) nor high (1.16 [0.94-1.43]) anti-hypertensive intensity was associated with experiencing cardiovascular events. The hazard ratio for death among all participants was 0.79 [0.65-0.97] in the moderate, and 0.72 [0.58-0.91] in the high intensity groups compared with those receiving no anti-hypertensives. Among participants who experienced cardiovascular events, the hazard ratio for death was 0.65 [0.48-0.87] and 0.58 [0.42-0.80] in the moderate and high intensity groups, respectively. Results were similar in the propensity score-matched subcohort. CONCLUSIONS AND RELEVANCE: In this nationally representative cohort of older adults, anti-hypertensive treatment was associated with reduced mortality but not cardiovascular events. Whether RCT results generalize to older adults with multiple chronic conditions remains uncertain.
PMCID:3948696
PMID: 24614535
ISSN: 1932-6203
CID: 1127112
