Moderate-to-severe kidney disease increases risk for sudden cardiac death (SCD). Limited studies have evaluated how mild degrees of kidney dysfunction impact SCD risk.
The purpose of this study was ...to evaluate the association of albuminuria, which is one of the earliest biomarkers of kidney injury, and SCD.
The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study is a prospective, population-based cohort of U.S. adults. Associations between albuminuria, which is categorized using urinary albumin-to-creatinine ratio (ACR), estimated glomerular filtration rate (eGFR), and SCD were assessed independently and in combination.
After median follow-up of 6.1 years, we identified 335 SCD events. Compared to participants with ACR <15 mg/g, those with higher levels had an elevated adjusted risk of SCD (ACR 15-30 mg/g, hazard ratio HR 1.53, 95% confidence interval CI 1.11-2.11; ACR >30 mg/g, HR 1.56, 95% CI 1.17-2.11). In contrast, compared to the group with eGFR >90 mL/min/1.73 m
, the adjusted risk of SCD was significantly elevated only among those with eGFR <45 mL/min/1.73 m
(HR 1.66, 95% CI 1.06-2.58). The subgroup with eGFR <45 mL/min/1.73 m
(n = 1003) comprised 3.7% of REGARDS, whereas ACR 15-30 mg/g (n = 3089 11.3%) and ACR >30 mg/g (n = 4040 14.8% were far more common. In the analysis that combined ACR and eGFR categories, albuminuria consistently identified individuals with eGFR ≥60 mLmin/1.73 m
who were at significantly increased SCD risk.
Low levels of kidney injury as measured by ACR predict an increase in SCD risk.
Abstract Purpose The purpose of the study was to investigate secular changes in coronary heart disease (CHD) incidence and mortality among adults with and without diabetes and to determine the effect ...of increased lipid-lowering medication use and reductions in low-density lipoprotein cholesterol (LDL-C) levels on these changes. Methods We analyzed data on participants aged 45 to 64 years from the Atherosclerosis Risk in Communities Study in 1987–1996 (early period) and the Reasons for Geographic and Racial Differences in Stroke Study in 2003–2009 (late period). Hazard ratios (HRs) for the association of diabetes and period with incident CHD and CHD mortality were obtained after adjustment for sociodemographics cardiovascular risk factors, lipid-lowering medication use, and LDL-C. Results After multivariable adjustment, diabetes was associated with an increased CHD risk during the early (HR = 1.99, 95% confidence interval = 1.59–2.49) and late (HR = 2.39, 95% confidence interval = 1.69–3.35) periods. CHD incidence and mortality declined between the early and late periods for individuals with and without diabetes. Increased use of lipid-lowering medication and lower LDL-C explained 33.6% and 27.2% of the decline in CHD incidence and CHD mortality, respectively, for those with diabetes. Conclusions Although rates have declined, diabetes remains associated with an increased risk of CHD incidence and mortality, highlighting the need for continuing diabetes prevention and cardiovascular risk factor management.
Abstract Purpose To compare the characteristics and prognosis of acute myocardial infarctions (AMIs) that were not the primary reason for hospitalization, and thus not primary discharge diagnosis, to ...AMIs that were the primary reason for hospitalization. Methods Primary discharge diagnoses for Reasons for Geographic and Racial Differences in Stroke study participants (black and white men and women age ≥45 years) with adjudicated AMIs were categorized as “AMI” or “other”. Cox models were used to compare mortality up to 5 years post-AMI between primary discharge diagnoses of AMI and other. Results Of 871 AMIs, primary discharge diagnosis was not AMI in 550 (63%). When primary discharge diagnosis was not AMI, average troponin elevations were smaller and heart failure was more common. Adjusted for participant and hospitalization characteristics, all-cause, coronary heart disease, and cardiovascular disease mortality after AMI were similar between groups (hazard ratios 95% confidence intervals: 1.08 0.80–1.47; 1.29 0.76–2.18; and 0.86 0.58–1.27, respectively). Conclusions Studies limited to individuals with primary discharge diagnosis of AMI may underestimate the burden of AMI and exclude a group with elevated risk of all-cause, coronary heart disease, and cardiovascular disease mortality.
Abstract Early coronary revascularization has been shown to reduce major adverse cardiovascular events in patients with acute coronary syndromes. In patients with stable coronary heart disease (CHD), ...however, coronary revascularization does not reduce death or myocardial infarction compared to intensive medical therapy. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial was the first to study whether coronary revascularization performed in addition to medical therapy, rather than as an alternative, would reduce death or myocardial infarction in patients with stable CHD. Between 1999 and 2004, 2287 patients were enrolled in 50 centers throughout Canada and the United States. After a median follow-up of 4.6 years, revascularization performed in addition to intensive medical therapy did not result in reduced mortality or myocardial infarction compared to medical therapy alone. At the end of follow-up, anginal control was similar in both groups, although patients receiving medical therapy only did require more antianginal medications, and one-third ultimately required revascularization. We review the strengths, limitations, and clinical relevance of the COURAGE trial in the context of the current literature on the benefits of medical management and coronary revascularization in patients with stable CHD.
Abstract Candidates for chronic warfarin therapy often have comorbid conditions such as heart failure (HF) with reduced left ventricular ejection fraction (LVEF). Previous reports have demonstrated ...an increased risk of over-anticoagulation due to reduced warfarin dose requirement in decompensated HF patients. However the influence of LVSD (Left ventricular systolic dysfunction), defined as LVEF <40%, on warfarin response has not been evaluated. Herein, we assess the influence of LVSD on warfarin dose, anticoagulation control (% time in target range; PTTR), and risk of overanticoagulation (INR>4) and major hemorrhage. Of the 1342 patients included in this prospective cohort study, 167 patients (13%) had LVSD. Patients with LVSD required 11% lower warfarin dose compared to those without LVSD (p<0.001) using multivariate linear regression analyses. Using multivariate Cox proportional hazards model, patients with LVSD experienced similar levels of anticoagulation control (PTTR: 51% vs. 54% p=0.15), risk of over-anticoagulation (INR>4; HR: 0.96, 95% CI 0.78-1.19; p=0.71), and risk of major hemorrhage (HR: 1.07; 95% CI: 0.62- 1.85; p=0.80). Addition of LVSD variable in the model increased the variability explained from 40% to 41% for warfarin dose prediction. In conclusion, our results demonstrate that patients with LVSD require lower doses of warfarin. Whether warfarin dosing algorithms incorporating LVSD in determining initial doses improves outcomes needs to be evaluated.
Abstract Background: Most studies of hypothalamic-pituitary-gonadal (HPG) function in illicit drug users either focus on men or do not consider the impact of HIV. Objective: This study investigated ...the relationships between cocaine and/or opiate use, HIV status, and HPG function in both men and women. Methods: Men and women between 18 and 50 years of age were stratified by sex, drug use, and HIV status. Information on demographics, HIV disease and treatment, and illicit drug use patterns was collected. To determine potential effects on HPG function, free testosterone (free T), estradiol, and gonadotropin concentrations were measured. Results: In a total of 197 men and women, free T concentrations were lower in men who used cocaine and/or opiates and in women infected with HIV Gonadotropin concentrations were elevated in seropositive men only. In women who received highly active antiretroviral therapy, HIV infection and illicit drug use had an additive or synergistic impact on free T concentrations. Conclusions: Our data reveal the importance of considering the independent effects of illicit drug use and HIV status for both men and women, so that risks may be identified and potential treatments designed for HPG dysfunction in these groups.
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