Abstract Background National guidelines recommend use of high-intensity statins after hospitalization for coronary heart disease (CHD) events. Objectives This study sought to estimate the proportion ...of Medicare beneficiaries filling prescriptions for high-intensity statins after hospital discharge for a CHD event and to analyze whether statin intensity before hospitalization is associated with statin intensity after discharge. Methods We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries between 65 and 74 years old. Beneficiaries were included in the analysis if they filled a statin prescription after a CHD event (myocardial infarction or coronary revascularization) in 2007, 2008, or 2009. High-intensity statins included atorvastatin 40 to 80 mg, rosuvastatin 20 to 40 mg, and simvastatin 80 mg. Results Among 8,762 Medicare beneficiaries filling a statin prescription after a CHD event, 27% of first post-discharge fills were for a high-intensity statin. The percent filling a high-intensity statin post-discharge was 23.1%, 9.4%, and 80.7%, for beneficiaries not taking statins pre-hospitalization, taking low/moderate-intensity statins, and taking high-intensity statins before their CHD event, respectively. Compared with beneficiaries not on statin therapy pre-hospitalization, multivariable adjusted risk ratios for filling a high-intensity statin were 4.01 (3.58–4.49) and 0.45 (0.40–0.52) for participants taking high-intensity and low/moderate-intensity statins before their CHD event, respectively. Only 11.5% of beneficiaries whose first post-discharge statin fill was for a low/moderate-intensity statin filled a high-intensity statin within 365 days of discharge. Conclusions The majority of Medicare beneficiaries do not fill high-intensity statins after hospitalization for CHD.
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.
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.
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.
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.
Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled hypertension despite the use of three or more antihypertensive medication classes or controlled hypertension while treated ...with four or more antihypertensive medication classes. We evaluated the association of aTRH with incident stroke, coronary heart disease (CHD), and all-cause mortality. Participants from the population-based REasons for Geographic And Racial Differences in Stroke (REGARDS) Study treated for hypertension with aTRH (n = 2043) and without aTRH (n = 12,479) were included. aTRH was further categorized as controlled aTRH (≥4 medication classes and controlled hypertension) and uncontrolled aTRH (≥3 medication classes and uncontrolled hypertension). Over a median of 5.9, 4.4, and 6.0 years of follow-up, the multivariable adjusted hazard ratio for stroke, CHD, and all-cause mortality associated with aTRH versus no aTRH was 1.25 (0.94-1.65), 1.69 (1.27-2.24), and 1.29 (1.14-1.46), respectively. Compared with controlled aTRH, uncontrolled aTRH was associated with CHD (hazard ratio, 2.33; 95% confidence interval, 1.21-4.48), but not stroke or mortality. Comparing controlled aTRH with no aTRH, risk of stroke, CHD, and all-cause mortality was not elevated. aTRH was associated with an increased risk for coronary heart disease and all-cause mortality.
Background Lipid-lowering guidelines endorse a low-density lipoprotein cholesterol goal of <100 mg/dL for people with coronary heart disease (CHD). A more stringent threshold of <70 mg/dL is ...recommended for those with CHD and “very high-risk” conditions such as diabetes mellitus, metabolic syndrome, or cigarette smoking. Whether chronic kidney disease (CKD) confers a similar risk for recurrent CHD events is unknown. Methods and Results We evaluated the risk for recurrent CHD events and all-cause mortality among 3,938 participants ≥45 years with CHD in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Chronic kidney disease was defined by estimated glomerular filtration rate <60 mL/min per 1.73 m2 or urinary albumin to creatinine ratio ≥30 mg/g. Participants were categorized by the presence or absence of CKD and any very high-risk condition. Over a median of 4.1 years, the crude incidence (95% CI) of recurrent CHD events were 12.1 (9.0-15.2), 18.9 (15.5-22.3), 35.0 (25.4-44.6), and 34.2 (28.2-40.3) among those without CKD or high-risk conditions; very high-risk conditions alone; and CKD alone and both CKD and very high-risk conditions. After multivariable adjustment, compared with those without CKD or very high-risk conditions, the hazard ratio (95% CI) for recurrent CHD events was 1.45 (1.02-2.05), 2.24 (1.50-3.34), and 2.10 (1.47-2.98) among those with very high-risk conditions alone, CKD alone, and both CKD and very high-risk conditions, respectively. Results were consistent for all-cause mortality. Conclusions Chronic kidney disease is associated with risk for recurrent CHD events that approximates or is larger than other established very high-risk conditions.
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.
Background Low adherence to antihypertensive medication is an important barrier to achieving blood pressure control. Few data are available for medication adherence in adults with chronic kidney ...disease (CKD). Study Design Cross-sectional. Setting & Participants 3,936 and 9,129 participants with and without CKD using antihypertensive medication in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study, respectively. CKD was defined as albuminuria with albumin excretion ≥30 mg/g or estimated glomerular filtration rate <60 mL/min/1.73 m2. Outcomes Medication adherence and uncontrolled hypertension. Measurements Medication adherence was assessed using a validated 4-item scale. Blood pressure was measured 2 times by trained staff. Results In REGARDS participants with and without CKD, 1,426 (36.2%) and 2,421 (26.5%) had uncontrolled hypertension with blood pressure ≥140/90 mm Hg, and 2,656 (67.5%) and 5,627 (61.6%), ≥130/80 mm Hg. Also, 27.7% of those with CKD and 27.9% of those without CKD responded “yes” to ever forgetting to take their medication and 4.4% and 4.2%, respectively, responded yes to being careless about taking their medication. Also, 5.7% and 5.3% responded yes to missing taking medication when they felt better, and 4.2% and 3.6%, to missing it when they felt sick. Overall, 23.3% and 23.7% of participants with and without CKD responded yes to 1 adherence question, whereas 7.7% and 7.2%, respectively, responded yes to 2 or more adherence questions. In those with CKD, the multivariable adjusted ORs for uncontrolled hypertension (blood pressure ≥140/90 mm Hg) for individuals answering yes to 1 and 2 or more versus 0 adherence questions were 1.26 (95% CI, 1.05-1.51) and 1.49 (95% CI, 1.12-1.98), respectively. Analogous ORs for systolic/diastolic blood pressure ≥130/80 mm Hg were 1.06 (95% CI, 0.78-1.45) and 1.20 (95% CI, 0.88-1.64). Limitations Pharmacy fill data were not available. Conclusions Individuals with CKD had similarly poor medication-taking behaviors as those without CKD.
Abstract Atrial premature complexes (APCs) serve as acute triggers for atrial fibrillation (AF), but it is currently unknown whether the association between APCs and AF varies by race or sex. We ...examined the association between APCs and AF in 13,840 (mean age=63±8.4 years; 56% women; 37% black) participants from the REasons for Geographic And Racial Differences in Stroke study. APCs were detected on baseline electrocardiograms (2003-2007). Incident AF was identified by study-scheduled electrocardiograms and self-reported history at a follow-up examination. Logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (CI) for the association between APCs and incident AF. A total of 950 (6.9%) participants had APCs at the baseline visit. After a median follow-up of 9.4 years, 1,015 (7.3%) incident AF cases were detected. APCs were associated with an increased risk of AF (OR=1.92, 95%CI=1.57, 2.35). The relationship between APCs and AF did not vary by race (interaction p-value=0.56) or sex (interaction p-value=0.66). In conclusion, APCs detected on a routine electrocardiogram are associated with an increased risk for AF development, and this association does not vary by race or sex. The findings of this analysis suggest that the AF risk associated with atrial ectopy does not account for the differential risk of AF that is observed in whites compared with blacks, and in men compared with women.
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