Faculty Bibliography

BACKGROUND: The relationship between systolic blood pressure (BP) and the risk of cardiovascular events is complex. In patients with chronic coronary artery disease, a J-shaped relationship has been shown, such that there is an increased risk of events both at high and low BP. The current coronary artery disease risk prediction models, however, considers a linear relationship between presenting BP and outcomes in patients presenting with acute coronary syndromes. METHODS: We evaluated 139,194 patients with non-ST-segment elevation acute coronary syndromes in the Can Rapid risk stratification of Unstable anigina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) quality improvement initiative. The presenting systolic BP was summarized as 10-unit increments. Primary outcome was a composite of in-hospital events all-cause mortality, reinfarction, and stroke. Secondary outcomes were each of these outcomes considered separately. RESULTS: From the cohort of 139,194 patients, 9,566 (6.87%) patients had a primary outcome (death/reinfarction or stroke) of which 5,910 (4.25%) patients died, 3,724 (2.68%) patients had reinfarction, and 1,079 (0.78%) patients had a stroke during hospitalization. There was an inverse association between presenting systolic BP and the risk of primary outcome, all-cause mortality, and reinfarction such that there was an exponential increase in the risk with lower presenting systolic BP even after controlling for baseline variables. However, there was no clear relationship between stroke and lower presenting systolic BP. CONCLUSIONS: In contrast to longitudinal impacts, there is a BP paradox on acute outcomes such that a lower presenting BP is associated with increased risk of in-hospital cardiovascular events. These associations should be considered in acute coronary syndrome prognostic models

Evidence-based guidelines call for advanced and definitive therapy for patients with non-ST-elevation myocardial infarction (NSTEMI). It is not known whether these guidelines are follow more diligently when patients arrive in the ED during regular hours, during which hospital resources including cardiology consultation may be more readily available. To determine whether patients with NSTEMI who present to the ED outside of usual hours have prolonged times to advanced and definitive therapy and poorer short-term outcomes.We examined NSTEMI patients from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) national quality improvement initiative (January 2001-April 2003) and compared demographics, risk profiles, intensity of medical management, and timing and intensity of intervention by whether presentation occurred during usual or off hours. We analyzed 34,297 NSTEMI presentations; 15,090 (44%) occurred during usual hours; 19,207 (56%) occurred during off hours. Off-hours-presenting patients had generally higher cardiac risk and received initial ECGs more quickly than patients who presented during usual hours (median 15 minutes vs. 18 minutes, P < 0.0001), and received similar (although suboptimal) medical management. In contrast, those who presented during off hours were less likely to receive timely diagnostic angiography, PCI, and bypass surgery (cath: median 32.9 hours vs. 24.3 hours, P < 0.0001; PCI: 28.6 hours vs. 23.6 hours, P < 0.0001). Despite these differences, in-hospital outcomes were similar. Time of patient presentation has a modest impact on the timeliness of intervention in NSTEMI but was not associated with lower mortality. Although intensity of medical management was similar between groups, it was generally lower than current guidelines recommend, indicating potential for improvement in NSTEMI outcomes, regardless of time of presentation

BACKGROUND: The echocardiography literature to date has considered cardiac death and myocardial infarction (MI) as a combined end point. The purposes of the present study were to evaluate the differential prognosis of nonfatal MI versus cardiac death in patients undergoing stress echocardiography and to effectively risk stratify patients using the appropriate combination of functional, ischemic, and infarction data. METHODS: The authors evaluated 3,259 patients (mean age, 59 +/- 13 years; 48% men) undergoing stress echocardiography. Follow-up (mean, 2.8 +/- 1.1 years) for confirmed nonfatal MI (n = 91) and cardiac death (n = 105) was obtained. RESULTS: Multivariate analysis showed that the strongest predictor of cardiac death was a low ejection fraction (chi(2) = 37.3, P < .0001), and the strongest predictor of nonfatal MI was the extent of ischemia (chi(2) = 12.3, P < .0001). The relationship between ejection fraction and cardiac death rate was an exponential curve (y = 16.91e(-0.50x); r = -0.99, P < .0001). Among patients with ejection fractions > 30% (the low-risk to intermediate-risk groups), peak wall motion score index (WMSI) was able to further risk stratify patients into a very low risk group (peak WMSI = 1.0; cardiac death rate, 0.26% per year) and a higher risk group (peak WMSI > 1.7; cardiac death rate, 2.56% per year). However, patients with ejection fractions < 30% had high cardiac death risk regardless of peak WMSI category. CONCLUSIONS: In patients referred for stress echocardiography, the integration of functional information (on the basis of ejection fraction) and ischemic and infarction data (on the basis of WMSI) effectively risk stratifies patients for the outcome-specific end points of cardiac death and nonfatal MI

Hypertension and dyslipidemia are two of the most commonly co-occurring cardiovascular risk factors which together cause an increase in coronary heart disease-related events that is more than simply additive for anticipated event rates with each condition. Data have shown that even relatively small reductions in both blood pressure and cholesterol levels can lead to large reductions in the risk for cardiovascular events. However, though there are robust data on the beneficial effect of concomitant reduction in these risk factors, the reality is that this is achieved in <10% of patients. There is nonadherence with prescribed therapies with up to 50% of patients stopping their medications of their own volition for a variety of reasons. There is a reasonable evidence base to suggest that simplifying drug regimens and reducing pill burden will enhance patient adherence. The fixed-dose combination containing the antihypertensive agent amlodipine besylate and the statin atorvastatin is the first combination of its kind, which is both efficacious and safe and could potentially improve medication compliance, thereby improving the outcomes in these patients