Background Few contemporary studies examine trends in recurrent coronary heart disease (CHD) events and mortality after acute myocardial infarction (AMI) and whether these trends vary by race or sex. ...Methods We used data from the national 5% random sample of Medicare fee-for-service beneficiaries for 1999 to 2010. We included beneficiaries who experienced an AMI ( International Classification of Disease ICD 9 410.xx, except 410.x2) between January 1, 2001, and December 31, 2009. Each beneficiary's first AMI was included as their index event. Outcomes included all-cause mortality, recurrent AMI, and recurrent CHD events during the 365 days after discharge for the index AMI. To examine secular trends, we pooled calendar years into 3 periods (2001-2003, 2004-2006, and 2007-2009). Results Among 48,688 beneficiaries with index AMIs from 2001 to 2009, we observed decreases in the age-adjusted rates for mortality (−3.8% for each 3-year period, 95% CI −6.1% to −1.6%, P trend = .001), recurrent AMI (−15.0%, 95% CI −18.6% to −11.2%, P trend < .001), and recurrent CHD events (−11.1%, 95% CI −14.0% to −8.0%, P trend < .001) in the 365 days after the index AMI. In 2007 to 2009, blacks had excess risk relative to whites for mortality and recurrent AMI (black/white incidence rate ratio of 1.38 for mortality 95% CI 1.21-1.57 and 1.38 for recurrent AMI 95% CI 1.07-1.79). Conclusions Despite overall favorable trends in lower mortality and recurrent events after AMI, efforts are needed to reduce racial disparities.
Objectives In a nonclinical trial setting, we sought to determine the proportion of individuals with coronary artery disease (CAD) with optimal risk factor levels based on the COURAGE (Clinical ...Outcomes Utilizing Revascularization and Aggressive DruG Evaluation) trial. Background In the COURAGE trial, the addition of percutaneous coronary intervention (PCI) to optimal medical therapy did not reduce the risk of death or myocardial infarction in stable CAD patients but resulted in more revascularization procedures. Methods The REGARDS (REasons for Geographic And Racial Differences in Stroke) study is a national prospective cohort study of 30,239 African-American and white community-dwelling individuals older than 45 years of age who enrolled in 2003 through 2007. We calculated the proportion of 3,167 participants with self-reported CAD meeting 7 risk factor goals based on the COURAGE trial: 1) aspirin use; 2) systolic blood pressure <130 mm Hg and diastolic blood pressure <85 mm Hg (<80 mm Hg if diabetic); 3) low-density lipoprotein cholesterol <85 mg/dl, high-density lipoprotein cholesterol >40 mg/dl, and triglycerides <150 mg/dl; 4) fasting glucose <126 mg/dl; 5) nonsmoking status; 6) body mass index <25 kg/m2 ; and 7) exercise ≥4 days per week. Results The mean age of participants was 69 ± 9 years; 33% were African American and 35% were female. Overall, the median number of goals met was 4. Less than one-fourth met ≥5 of the 7 goals, and 16% met all 3 goals for aspirin, blood pressure, and low-density lipoprotein cholesterol. Older age, white race, higher income, more education, and higher physical functioning were independently associated with meeting more goals. Conclusions There is substantial room for improvement in risk factor reduction among U.S. individuals with CAD.
Abstract Background Data prior to 2011 suggest that a low percentage of patients hospitalized for acute coronary syndromes filled high-intensity statin prescriptions upon discharge. Black-box ...warnings, generic availability of atorvastatin, and updated guidelines may have resulted in a change in high-intensity statin use. Objectives The aim of this study was to examine trends and predictors of high-intensity statin use following hospital discharge for myocardial infarction (MI) between 2011 and 2014. Methods Secular trends in high-intensity statin use following hospital discharge for MI were analyzed among patients 19 to 64 years of age with commercial health insurance in the MarketScan database (n = 42,893) and 66 to 75 years of age with U.S. government health insurance through Medicare (n = 75,096). Patients filling statin prescriptions within 30 days of discharge were included. High-intensity statins included atorvastatin 40 or 80 mg and rosuvastatin 20 or 40 mg. Results The percentage of beneficiaries whose first statin prescriptions filled following hospital discharge for MI were for high-intensity doses increased from 33.5% in January through March 2011 to 71.7% in October through November 2014 in MarketScan and from 24.8% to 57.5% in Medicare. Increases in high-intensity statin use following hospital discharge occurred over this period among patients initiating treatment (30.6% to 72.0% in MarketScan and 21.1% to 58.8% in Medicare) and those taking low- or moderate-intensity statins prior to hospitalization (from 27.8% to 62.3% in MarketScan and from 12.6% to 45.1% in Medicare). In 2014, factors associated with filling high-intensity statin prescriptions included male sex, filling beta-blocker and antiplatelet agent prescriptions, and attending cardiac rehabilitation within 30 days following discharge. Conclusions The use of high-intensity statins following hospitalization for MI increased progressively from 2011 through 2014.
Study objective The first hour after the onset of out-of-hospital traumatic injury is referred to as the “golden hour,” yet the relationship between time and outcome remains unclear. We evaluate the ...association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality. Methods This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged ≥15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was inhospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders. Results There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio OR 1.00; 95% confidence interval CI 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings. Conclusion In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.
Guidelines recommend lifestyle modification for patients with coronary heart disease (CHD). Few data demonstrate which lifestyle modifications, if sustained, reduce recurrent CHD and mortality risk ...in cardiac patients after the postacute rehabilitation phase. We determined the association between ideal lifestyle factors and recurrent CHD and all-cause mortality in REasons for Geographic and Racial Differences in Stroke study participants with CHD (n = 4,174). Ideal lifestyle factors (physical activity ≥4 times/week, nonsmoking, highest quartile of Mediterranean diet score, and waist circumference <88 cm for women and <102 cm for men) were assessed through questionnaires and an in-home study visit. There were 447 recurrent CHD events and 745 deaths over a median 4.3 and 4.5 years, respectively. After multivariable adjustment, physical activity ≥4 versus no times/week and non-smoking versus current smoking were associated with reduced hazard ratios (HRs; 95% confidence interval CI) for recurrent CHD (HR 0.69, 95% CI 0.54 to 0.89 and HR 0.50, 95% CI 0.39 to 0.64, respectively) and death (HR 0.71, 95% CI 0.59 to 0.86 and HR 0.53, 95% CI 0.44 to 0.65, respectively). The multivariable-adjusted HRs (and 95% CIs) for recurrent CHD and death comparing the highest versus lowest quartile of Mediterranean diet adherence were 0.77 (95% CI 0.55 to 1.06) and 0.84 (95% CI 0.67 to 1.07), respectively. Neither outcome was associated with waist circumference. Comparing participants with 1, 2, and 3 versus 0 ideal lifestyle factors (non-smoking, physical activity ≥4 times/week, and highest quartile of Mediterranean diet score), the HRs (and 95% CIs) were 0.60 (95% CI 0.44 to 0.81), 0.49 (95% CI 0.36 to 0.67), and 0.38 (95% CI 0.21 to 0.67), respectively, for recurrent CHD and 0.65 (95% CI 0.51 to 0.83), 0.57 (95% CI 0.43 to 0.74), and 0.41 (95% CI 0.26 to 0.64), respectively, for death. In conclusion, maintaining smoking cessation, physical activity, and Mediterranean diet adherence is important for secondary CHD prevention.
Background The International Diabetes Federation (IDF) and Adult Treatment Panel (ATP) III define metabolic syndrome (MetSyn) differently, with unclear implications for cardiovascular disease (CVD) ...risk. Methods We examined 22,719 participants in the REGARDS study. We classified participants as: no MetSyn, MetSyn by ATP-III and IDF criteria, MetSyn by ATP-only, or MetSyn by IDF-only. To assess current CVD, we determined the odds of self-reported CVD by MetSyn category using multivariable logistic regression, controlling for socio-demographic and behavioral factors. To estimate future coronary heart disease risk, we calculated Framingham risk scores (FRS). Results Overall, 10,785 individuals (47%) had MetSyn. Of these, 79% had MetSyn by both definitions, 6% by ATP-only, and 14% by IDF-only. Compared to those without MetSyn, ATP-only individuals had the highest odds of current CVD and of having a FRS >20%. Also compared to those without MetSyn, IDF-only individuals had 43% higher odds of current CVD and 2-fold increased odds of having a FRS >20%. Conclusions Consistent with previous reports, ATP-III MetSyn criteria identified individuals with increased odds of CVD and elevated future coronary heart disease risk. However, the IDF definition identified a clinically important number of additional individuals at excess CVD risk.
Abstract Background Evidence is mixed regarding whether diabetes confers equivalent risk of coronary heart disease (CHD) as prevalent CHD. We investigated whether diabetes and severe diabetes are ...coronary heart disease (CHD) risk equivalents. Methods At baseline, participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study (black and white US adults ≥45 years old recruited 2003–2007) were categorized as having prevalent CHD only (self-reported or electrocardiogram evidence) (n = 3043), diabetes only (self-reported or elevated glucose) (n = 4012), diabetes and prevalent CHD (n = 1529) and neither diabetes nor prevalent CHD (n = 17,155). Participants with diabetes using insulin and/or with albuminuria (urinary albumin-to-creatinine ratio ≥ 30 mg/g) were categorized as having severe diabetes. Participants were followed through 2011 for CHD events (myocardial infarction or fatal CHD). Results During a mean follow-up of 5 years, 1385 CHD events occurred. The hazard ratios (HRs) of CHD events comparing participants with diabetes only, diabetes and prevalent CHD and neither diabetes nor prevalent CHD to those with prevalent CHD were 0.65 (95% CI: 0.54, 0.77), 1.54 (95% CI: 1.30, 1.83) and 0.41 (95% CI: 0.35, 0.47), respectively, after adjustment for demographics and risk factors. Compared to participants with prevalent CHD, the HR of CHD events for participants with severe diabetes was 0.88 (95% CI: 0.72, 1.09). Conclusions Participants with diabetes had lower risk of CHD events than those with prevalent CHD. However, participants with severe diabetes had similar risk as those with prevalent CHD. Diabetes severity may need consideration when deciding whether diabetes is a CHD risk equivalent.
Length of stay (LOS), 30-day mortality, and 30-day readmission rates have not been compared between Medicare beneficiaries with heart failure (HF) with reduced ejection fraction (HFrEF) and ...beneficiaries with heart failure with preserved ejection fraction (HFpEF), although HFpEF is common in patients with HF. To determine whether type of HF (HFrEF or HFpEF) was associated with LOS, 30-day mortality, and 30-day readmission, we used a cohort of 19,477 Medicare beneficiaries admitted to the hospital and discharged alive with a primary discharge diagnosis of HF between 2007 and 2011. Gamma regression, Poisson regression, and Cox proportional hazards with a competing risk for death were used to model LOS, 30-day mortality, and 30-day readmission rate, respectively. All models were adjusted for HF severity, co-morbidities, demographics, nursing home residence, and calendar year of admission. Beneficiaries with HFpEF had an LOS 0.02 days shorter than beneficiaries with HFrEF and a nearly identical 30-day readmission rate. Thirty-day mortality was 10% lower in beneficiaries with HFpEF versus HFrEF. In conclusion, readmission rates were as high in those with HFpEF as they are in those with HFrEF, with comparable LOS in the hospital.
Objectives Our purpose was to determine factors independently associated with cardiac rehabilitation referral, which are currently not well described at a national level. Background Substantial ...numbers of eligible patients are not referred to cardiac rehabilitation at hospital discharge despite proven reductions in mortality and national guideline recommendations. Methods We used data from the American Heart Association's Get With The Guidelines program, analyzing 72,817 patients discharged alive after a myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft surgery between January 2000 and September 2007 from 156 hospitals. We identified factors associated with cardiac rehabilitation referral at discharge and performed multivariable logistic regression, adjusted for clustering, to identify which factors were independently associated with cardiac rehabilitation referral. Results Mean age was 64.1 ± 13.0 years, 68% were men, 79% were white, and 30% had diabetes, 66% hypertension, and 52% dyslipidemia; mean body mass index was 29.1 ± 6.3 kg/m2 , and mean ejection fraction 49.0 ± 13.6%. All patients were admitted for coronary artery disease (CAD), with 71% admitted for myocardial infarction. Overall, only 40,974 (56%) were referred to cardiac rehabilitation at discharge, ranging from 53% for myocardial infarction to 58% for percutaneous coronary intervention and to 74% for coronary artery bypass graft patients. Older age, non–ST-segment elevation myocardial infarction, and the presence of most comorbidities were associated with decreased odds of cardiac rehabilitation referral. Conclusions Despite strong evidence for benefit, only 56% of eligible CAD patients discharged from these hospitals were referred to cardiac rehabilitation. Increased physician awareness about the benefits of cardiac rehabilitation and initiatives to overcome barriers to referral are critical to improve the quality of care of patients with CAD.
Metabolic syndrome (MS) and atrial fibrillation (AF) are associated with increased cardiovascular disease morbidity and mortality. This analysis evaluated the association between MS and AF in the ...REasons for Geographic and Racial Differences in Stroke (REGARDS) study. MS was defined using criteria recommended in the joint interim statement from several international societies. AF was defined by electrocardiogram (ECG) and/or self-report and by ECG alone. In patients with 0, 1, 2, 3, 4, and 5 MS components, prevalences of AF by ECG and/or self-report were 5.5%, 7.7%, 8.2%, 9.2%, 9.6%, and 11.5%, respectively (p for trend <0.001). After multivariable adjustment, each MS component except serum triglycerides was significantly associated with AF. The multivariable-adjusted odds ratio for AF, defined by ECG and/or or self-reported history, comparing those with to those without MS was 1.20 (95% confidence interval 1.10 to 1.29). Results were consistent when AF was defined by ECG alone (odds ratio 1.15, 95% confidence interval 0.92 to 1.39). In conclusion, MS is associated with an increased prevalence of AF. Further studies investigating a potential mechanism for this excess risk are warranted.
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