Faculty Bibliography

The objective of this study was to determine short- and long-term cardiovascular outcomes in unselected patients with diabetes mellitus (DM) with acute ischemic chest pain (AICP). In patients with DM presenting to the emergency department with AICP, short-term cardiovascular outcomes remain discordant between trials and registries, whereas long-term outcomes are not well-described. A consecutive cohort of all residents of Olmsted County, Minnesota, presenting with AICP from January 1, 1985, to December 31, 1992, was followed for a median duration of 16.6 years. The primary outcome was long-term all-cause mortality. Other outcomes included a composite of death, myocardial infarction, stroke, and revascularization (major adverse cardiovascular and cerebrovascular events [MACCEs]) as well as heart failure (HF) events at 30 days and at a median of 7.3 years, respectively. Of the 2,271 eligible patients, 336 (14.8%) were classified with DM. The crude 30-day MACCE rate was 10.1% in patients with DM and 6.1% in those without DM (p = 0.007). HF events were more common in patients with DM at 30 days (9.8% vs 3.1%, p <0.001). At 7.3 years, patients with DM were more likely to experience MACCEs and HF events than those without DM (71.2% vs 45.1%, unadjusted hazard ratio 2.15%, 95% confidence interval 1.87 to 2.48, p <0.001, and 45.1% vs 18.2%, p <0.001, respectively). Over the follow-up period, 272 patients with DM (81.9%) died, compared with 936 (49.2%) without DM (p <0.001). In conclusion, DM is associated with a higher short-term risk for MACCEs and HF and a higher long-term risk for mortality in unselected patients with AICP. DM should be included as a high-risk variable in national acute coronary syndrome guidelines.

Using the results of the JUPITER trial, a recent report estimated that up to 11 million older United States (US) adults with C-reactive protein (CRP) levels > or =2 mg/L not currently recommended statins may benefit from treatment. However, the need to measure CRP in making this treatment decision has not been evaluated. Using data from 887 older US men and women (men > or =50 years old, women > or =60 years old) not currently on or recommended statin therapy participating in the National Health and Nutrition Examination Survey 2003 to 2006, we determined the sensitivity, specificity, and positive and negative predictive values of patient characteristics in identifying the presence of CRP > or =2 mg/L. If CRP > or =2 mg/L were included as an indication for statin therapy, then 90% of older US adults would be recommended treatment. Patients with CRP > or =2 mg/L were more likely (p <0.05) to be current smokers, obese, and have chronic kidney disease. However, characteristics (including demographics, cigarette smoking, obesity, chronic kidney disease, and metabolic syndrome) had low positive predictive values (<70%) for identifying patients with CRP > or =2 mg/L and negative predictive values (<60%) for those with CRP <2 mg/L. In conclusion, these findings suggest patient characteristics cannot be easily used to identify patients with CRP > or =2 mg/L. Given the demonstrated benefits of statin therapy, cost of measuring CRP, and large percentage of older US adults with high CRP, universal statin therapy for older US adults warrants investigation.

BACKGROUND: Few data are available on the association of high-sensitivity C-reactive protein (hs-CRP) and mortality independent of low-density lipoprotein (LDL) cholesterol in patients undergoing percutaneous coronary intervention (PCI). METHODS: Consecutive patients (N = 8,834) undergoing PCI between October 28, 2002, and December 31, 2006, were followed through June 30, 2007 (average and maximum follow-up of 1.9 and 4.6 years, respectively). High-sensitivity CRP levels were classified into 4 groups: <1.0, 1.0 to 2.9, 3.0 to 9.9, and > or =10 mg/L. RESULTS: All-cause mortality rates were 14.4, 17.5, 25.7, and 56.4 per 1,000 person-years in patients with hs-CRP levels of <1.0, 1.0 to 2.9, 3.0 to 9.9, and > or =10 mg/L, respectively. Compared with patients with hs-CRP <1.0 mg/L, the hazard ratios of mortality after multivariable adjustment, including LDL cholesterol, associated with hs-CRP levels of 1.0 to 2.9, 3.0 to 9.9, and > or =10 mg/L were 1.27 (95% CI 0.91-1.75), 1.70 (95% CI 1.26-2.29), and 2.99 (95% CI 2.24-3.99), respectively (P trend < .001). After multivariable adjustment, trends of higher all-cause mortality at higher hs-CRP were present for patients with LDL cholesterol <70, 70 to 99, and > or =100 mg/dL (each P < .001). A test for interaction between LDL cholesterol and hs-CRP on all-cause mortality was not significant (P = .30). CONCLUSIONS: High-sensitivity CRP levels provide significant incremental prognostic information for all-cause mortality in long-term follow-up independent of LDL cholesterol.

Imaging has had an important role in cardiovascular disease over the past decade, with the increasing reliance on imaging outcomes as surrogates for clinical end points. Clinical trials now show a trend towards the use of functional, rather than anatomical, imaging modalities. Use of these powerful tools needs to be optimized in the design of cardiovascular trials. In the future, imaging modalities will be fundamental to research and drug development and an increased emphasis will be placed on the relationship between the results of imaging studies and clinical outcomes.

The metabolic syndrome is a clustering of cardiovascular risk factors and is associated with an increased risk of developing diabetes, cardiovascular disease, and kidney disease. Epidemiologic studies have demonstrated differences in prevalence by age, gender, and ethnicity. The prevalence of the metabolic syndrome increases with age through the sixth decade of life among men and seventh decade among women. Most, but not all, studies reported a higher prevalence of the metabolic syndrome among women compared with men. Although the metabolic syndrome is more common among Mexican Americans compared with non-Hispanic whites and blacks, among men the metabolic syndrome is more common among non-Hispanic whites than non-Hispanic blacks; the reverse is true among women. Understanding the basic pathophysiology underlying the metabolic syndrome may help explain the age, gender, and ethnic differences in its prevalence and guide preventive and therapeutic efforts.