Coronary artery disease (CAD) is common and multifactorial. Members of the Church of Jesus Christ of Latter-day Saints (LDS, or Mormons) in Utah may have lower cardiac mortality than other Utahns and ...the US population. Although the LDS proscription of smoking likely contributes to lower cardiac risk, it is unknown whether other shared behaviors also contribute. This study evaluated potential CAD-associated effects of fasting. Patients (n 1 = 4,629) enrolled in the Intermountain Heart Collaborative Study registry (1994 to 2002) were evaluated for the association of religious preference with CAD diagnosis (≥70% coronary stenosis using angiography) or no CAD (normal coronaries, <10% stenosis). Consequently, another set of patients (n 2 = 448) were surveyed (2004 to 2006) for the association of behavioral factors with CAD, with routine fasting (i.e., abstinence from food and drink) as the primary variable. Secondary survey measures included proscription of alcohol, tea, and coffee; social support; and religious worship patterns. In population 1 (initial), 61% of LDS and 66% of all others had CAD (adjusted including for smoking odds ratio OR 0.81, p = 0.009). In population 2 (survey), fasting was associated with lower risk of CAD (64% vs 76% CAD; OR 0.55, 95% confidence interval 0.35 to 0.87, p = 0.010), and this remained after adjustment for traditional risk factors (OR 0.46, 95% confidence interval 0.27 to 0.81, p = 0.007). Fasting was also associated with lower diabetes prevalence (p = 0.048). In regression models entering other secondary behavioral measures, fasting remained significant with a similar effect size. In conclusion, not only proscription of tobacco, but also routine periodic fasting was associated with lower risk of CAD.
Risk stratification tools are needed to select the right candidates for catheter ablation of atrial fibrillation (AF). Both the CHADS2 and CHA2DS2-VASc scores have utility in predicting AF-related ...outcomes and guiding anticoagulation treatment.
We sought to determine whether these risk scores predict long-term outcomes after AF ablation and whether one risk score provides comparatively superior performance.
CHADS2 and CHA2DS2-VASc scores were calculated in 2179 patients who underwent a first ablation procedure for AF enrolled in the Intermountain Heart Collaborative Study. CHADS2 and CHA2DS2-VASc scores were categorized as 0-1, 2-4, and ≥5. Patient outcomes were analyzed over 5 years for AF/atrial flutter recurrence and major adverse cardiovascular events (MACE: composite of death, stroke, and heart failure hospitalization).
The mean age was 65.7 ± 10.5 years, and 61.1% were men. Both scores incrementally predicted risk of AF recurrence, stroke, heart failure, and death at 5 years. Increasing CHADS2 (hazard ratio HR 1.19; P < .001) and CHA2DS2-VASc (HR 1.15; P < .0001) scores were both associated with AF/atrial flutter recurrence. The results were similar for MACE where increasing CHADS2 (HR 1.54; P < .0001) and CHA2DS2-VASc (HR 1.32; P < .0001) scores were associated with risk. When CHADS2 and CHA2DS2-VASc scores were modeled together, only CHA2DS2-VASc scores significantly predicted AF recurrence (HR 1.13; P = .001), but both were associated with MACE.
Both the CHADS2 and CHA2DS2-VASc scores were excellent in stratifying patients for 5-year outcomes after AF ablation. However, the CHA2DS2-VASc score was superior to the CHADS2 score in predicting AF recurrence and AF-related morbidities.
...the leadership of these international organizations recognized the importance of scientific collaboration and writing committee coordination for the benefit of the worldwide cardiology community.
Background Three-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) are one of the most commonly prescribed classes of medications because of their proven cardiovascular benefits. ...However, statin intolerance occurs in 5% to 20% of patients. Understanding the basis for statin intolerance remains a key issue in preventive medicine. Objectives To evaluate the association of statin intolerance with hypothyroidism in a large integrated health care system, including its sex-specific relationship and subsequent statin rechallenge and prescription history. Methods The Intermountain Healthcare electronic medical record database identified patients (n = 2686; males = 1276, females = 1410) with a documentation of intolerance (“allergy”) to at least 1 statin. Age and sex similar controls (n = 8103; males = 3892, females = 4211) were identified among patients prescribed statins without documented intolerance. Patients were evaluated for a history of hypothyroidism, development of hypothyroidism, and statin prescription history up to 5 years of follow-up. Results A total of 30.2% patients (210 males, 16.5%; 602 females, 42.7%) with statin intolerance had a history of hypothyroidism compared with 21.5% of statin-tolerant patients (475 males, 12.2%; 1266 females, 30.1%), for an odds ratio (OR) in the total population of 1.49 (95% confidence interval CI 1.34–1.65; P < .0001); in males, OR was 1.29 (CI 1.07–1.55; P = .001); in females, OR was 1.60 (CI 1.41–1.82; P < .0001). During follow-up, patients with statin intolerance and hypothyroidism were less likely to be on a statin than their statin-intolerant counterparts without hypothyroidism (hazard ratio 0.84; 95% CI 0.75–0.94; P = .002). Conclusions Hypothyroidism is more prevalent in those with statin intolerance, both in males and, especially, in females. People with hypothyroidism are less likely to have a prescription for a statin at follow-up than those without hypothyroidism.
...the effectiveness of the IOM report recommendations must be assessed over time as organizations similar to the ACC and AHA begin the complex process of applying the proposed standards in CPG ...development. ...to harmonize with other CPG classification schema, we now more precisely indicate the strength of the recommendation associated with the Class of Recommendation (COR).
With accelerating healthcare costs and the desire to achieve the best value (health benefit for every dollar spent), there is growing recognition of the need for more explicit and transparent ...assessment of the value of health care. ...from a societal policy perspective, a critical healthcare goal should be to achieve the best possible health outcomes with finite healthcare resources. ...costs may vary widely by practice setting, locality, and nationality, and over time. ...individuals bear the burden of adverse health outcomes, yet costs typically are shared by society (e.g., by families, employers, government, premium payers, fellow employees, taxpayers). Class I recommendations determined to be of low value would not be recommended as performance measures. Because the value of a given care practice will change if the cost or benefit of the practice changes, timely review and updates of guidelines will be even more important when value determinations are included in the guidelines.\n This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document.
Background Serum β-trace protein (BTP) and β2 -microglobulin (B2M) are independently associated with end-stage renal disease (ESRD) and mortality in the general population and high-risk groups with ...diabetes or advanced chronic kidney disease (CKD). Less is known about their associations with outcomes and predictive ability in adults with moderate CKD. Study Design Prospective cohort study. Setting & Participants 3,613 adults from the CRIC (Chronic Renal Insufficiency Cohort) Study (45% women; mean age, 57.9 years; 41.0% non-Hispanic black; 51.9% with diabetes). Predictors BTP and B2M levels with a reciprocal transformation to reflect their associations with filtration, creatinine-based estimated glomerular filtration rate (eGFRcr ), measured GFR, and a 4-marker composite score combining BTP, B2M, creatinine, and cystatin C levels. Predictors were standardized as z scores for comparisons across filtration markers. Outcomes ESRD, all-cause mortality, and new-onset cardiovascular disease. Results During a 6-year median follow-up, 755 (21%) participants developed ESRD, 653 died, and 292 developed new-onset cardiovascular disease. BTP, B2M, and the 4-marker composite score were independent predictors of ESRD and all-cause mortality, and B2M and the 4-marker composite score of cardiovascular events, after multivariable adjustment. These associations were stronger than those observed for eGFRcr ( P vs eGFRcr ≤ 0.02). The 4-marker composite score led to improvements in C statistic and 2.5-year risk reclassification beyond eGFRcr for all outcomes. Limitations Filtration markers measured at one time point; measured GFR available in subset of cohort. Conclusions BTP and B2M levels may contribute additional risk information beyond eGFRcr , and the use of multiple markers may improve risk prediction beyond this well-established marker of kidney function among persons with moderate CKD.
Survivors of acute myocardial infarction (MI) are at high risk for death from both sudden cardiac death and progressive heart failure.
This study sought to determine mortality trends, identify ...markers of risk, and determine whether outcomes in high-risk patients are altered by revascularization during the implantable cardioverter-defibrillator candidacy observation period.
We included 16,793 patients that presented to the catheterization laboratory for acute management of an MI. All patients had 3 years of follow-up to define short- and long-term mortality.
Across the demographics studied there were no significant differences in baseline characteristics over time, with exception of an observed decline in patients with an ejection fraction (EF) ≤0.35. Nonetheless, at study closure 16.3% of all cases had an EF ≤ 0.35. There was a gradual increase in use of percutaneous coronary intervention and coronary artery bypass graft; however, at the end of the study, the highest level of revascularization use was slightly >50%. For the composite, right and left bundle branch block or QRS > 120, the death rates at 1 and 5 years were 31.8% and 46.8%, respectively. These 1- and 5-year mortality rates were increased with an EF ≤ 0.35 (36.0%, 60.2%). Mortality in those with EF ≤ 0.35 exceeded 20% in all groups with conduction system disease at 90 days and was not significantly impacted by percutaneous coronary intervention.
The highest risk for death after MI is in patients with an EF ≤ 0.35 and/or conduction system disease. The mortality risk is most pronounced in the early observation period after MI when patients must wait to be considered for an implantable cardioverter-defibrillator.
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