Long-term Mortality for Older Diabetics Hospitalized with Acute Myocardial Infarction

Diabetics have higher mortality after myocardial infarction (MI), yet little is known regarding the impact of quality of care on long-term survival in older post-MI diabetics. Using data from the Cooperative Cardiovascular Project (CCP), a national cohort of 234,769 Medicare patients aged 65 or older hospitalized with confirmed AMI between 1994-1995, we assessed differences in 10-year mortality outcomes between diabetics and non-diabetics using Cox proportional regression. To account for quality of care, a composite measure among ideal candidates was constructed and entered into the final model adjusting for use of aspirin & beta-blocker on admission/discharge, angiotensin-converting enzyme inhibitors at discharge, reperfusion within 6 hours of admission, and smoking counseling at discharge. We also assessed the relationship between insulin use, sulfonylureas/biguanides, and statin therapy and long-term mortality within the diabetic cohort. The final study sample included 203,658 cases: 32% were diabetics. Compared to non-diabetics, diabetics were younger (75 vs. 76, p\u3c0.001), female (53% vs. 47%, p\u3c0.001), had more comorbidities, and unlikely to receive evidence-based care (59% vs. 64%, p\u3c0.001). The unadjusted HR for mortality among diabetics vs. non-diabetics was 1.38 (95% CI: 1.37-1.40). After adjusting for demographics, past medical history, procedures during hospitalization, medications on admission/discharge, and quality of care, the HR was 1.29 (95% CI: 1.27-1.31). Among diabetics, those on insulin or oral hypoglycemic therapy during the initial hospitalization for AMI had the highest risk of mortality during the last 7 years, after adjustment for demographics, clinical characteristics, and quality of care (HR insulin=1.30, 95% CI: 1.25-1.35; HR oral hypoglycemics=1.11, 95% CI: 1.08-1.15) whereas those on statin therapy were not at increased risk (HR statin=0.95, 95% CI: 0.90-1.02). As compared to non-diabetics, older diabetics had a 29% increase in mortality even after adjusting for demographics, clinical variables during hospitalization, and quality of care (HR=1.29, 95% CI: 1.27-1.31). Additionally, within the diabetic cohort, the risk of long-term mortality was highest among those on insulin or oral hypoglycemic therapy during initial hospitalization for AMI. Our study demonstrates that neither patient characteristics nor quality of care fully account for the poor outcomes among diabetics suggesting that metabolic risk factors associated with diabetes ultimately require therapies beyond those currently recommended for post-MI patients

Launching the New American College of Cardiology Research Network: Advancing High-Value Collaborative Research via “Innovative Networking”

The landscape of research and academic medicine is changing significantly, especially for the early career professional (ECP) cardiologist. The recent viewpoint paper in the Journal detailing the challenges of the early career academic cardiologist crystallizes this complex situation. Although there is a clear desire to conduct research among those surveyed, there are major obstacles to achieving a successful research career. Two of the major challenges identified by ECPs are a lack of collaborators and a lack of research mentors to assist in generating the needed data to produce a competitive grant application. As identified by the survey, a lack of collaborators and mentors negatively affects one’s ability to achieve viable research funding. The most vulnerable are cardiology fellows and junior investigators who are new to research, especially those with nontraditional research interests, who can struggle to find mentorship within their institutions. Those who are new to research must often rely on informal networking with speakers who are invited to give grand rounds within their institution or at national conferences. For a minority, these haphazard meetings may turn into successful long-term research collaborations, but for many, they unfortunately do not. Additionally, for ECPs already involved in research, there is inadequate access to new techniques and innovations as a direct result of the absence of comprehensive and collaborative research-oriented networks. For example, short-term access to expensive equipment or needed reagents may be the limiting factor in one’s research endeavors. Indeed, as highlighted in a recent Leadership Page in the Journal, there is little national investment in research networks, leading to many inefficiencies and unnecessary delays

Role of Ambulatory and Home Blood Pressure Monitoring in Clinical Practice: A Narrative Review

Hypertension, a common risk factor for cardiovascular disease, is usually diagnosed and treated based on blood pressure readings obtained in the clinic setting. Blood pressure may differ considerably when measured inside versus outside of the clinic setting. Over the past several decades, evidence has accumulated on the following 2 approaches for measuring blood pressure outside of the clinic: ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). Both of these methods have a stronger association with cardiovascular disease outcomes than clinic blood pressure measurement. Controversy exists about whether ABPM or HBPM is superior for estimating risk for cardiovascular disease and under what circumstances these methods should be used in clinical practice for assessing blood pressure outside of the clinic. This review describes ABPM and HBPM procedures, the blood pressure phenotypic measurements that can be ascertained, and the evidence that supports the use of each approach to measuring blood pressure outside of the clinic. It also describes barriers to the successful implementation of ABPM and HBPM in clinical practice, proposes core competencies for the conduct of these procedures, and highlights important areas for future research

Is Isolated Nocturnal Hypertension A Reproducible Phenotype?

BACKGROUND: Isolated nocturnal hypertension (INH), defined as nocturnal without daytime hypertension on ambulatory blood pressure (BP) monitoring (ABPM), has been observed to be associated with an increased risk of cardiovascular disease (CVD) events and mortality. The aim of this study was to determine the short-term reproducibility of INH. METHODS: The Improving the Detection of Hypertension Study enrolled a community-based sample of adults (N = 282) in upper Manhattan without CVD, renal failure, or treated hypertension. Each participant completed two 24-hour ABPM recordings (ABPM1: first recording and ABPM2: second recording) with a mean ± SD time interval of 33 ± 17 days between recordings. Daytime hypertension was defined as mean awake systolic/diastolic BP ≥ 135/85 mm Hg; nocturnal hypertension as mean sleep systolic/diastolic BP ≥ 120/70 mm Hg; INH as nocturnal without daytime hypertension; isolated daytime hypertension (IDH) as daytime without nocturnal hypertension; day and night hypertension (DNH) as daytime and nocturnal hypertension, and any ambulatory hypertension as having daytime and/or nocturnal hypertension. RESULTS: On ABPM1, 26 (9.2%), 21 (7.4%), and 50 (17.7%) participants had INH, IDH, and DNH, respectively. On ABPM2, 24 (8.5%), 19 (6.7%), and 54 (19.1%) had INH, IDH, and DNH, respectively. The kappa statistics were 0.21 (95% confidence interval (CI) 0.04-0.38), 0.25 (95% CI 0.06-0.44), and 0.65 (95% CI 0.53-0.77) for INH, IDH, and DNH respectively; and 0.72 (95% CI 0.63-0.81) for having any ambulatory hypertension. CONCLUSIONS: Our results suggest that INH and IDH are poorly reproducible phenotypes, and that ABPM should be primarily used to identify individuals with daytime hypertension and/or nocturnal hypertension

Association Between High Perceived Stress Over Time and Incident Hypertension in Black Adults: Findings From the Jackson Heart Study.

Background Chronic psychological stress has been associated with hypertension, but few studies have examined this relationship in blacks. We examined the association between perceived stress levels assessed annually for up to 13 years and incident hypertension in the Jackson Heart Study, a community-based cohort of blacks. Methods and Results Analyses included 1829 participants without hypertension at baseline (Exam 1, 2000-2004). Incident hypertension was defined as blood pressure≥140/90 mm Hg or antihypertensive medication use at Exam 2 (2005-2008) or Exam 3 (2009-2012). Each follow-up interval at risk of hypertension was categorized as low, moderate, or high perceived stress based on the number of annual assessments between exams in which participants reported "a lot" or "extreme" stress over the previous year (low, 0 high stress ratings; moderate, 1 high stress rating; high, ≥2 high stress ratings). During follow-up (median, 7.0 years), hypertension incidence was 48.5%. Hypertension developed in 30.6% of intervals with low perceived stress, 34.6% of intervals with moderate perceived stress, and 38.2% of intervals with high perceived stress. Age-, sex-, and time-adjusted risk ratios (95% CI) associated with moderate and high perceived stress versus low perceived stress were 1.19 (1.04-1.37) and 1.37 (1.20-1.57), respectively (P trend<0.001). The association was present after adjustment for demographic, clinical, and behavioral factors and baseline stress (P trend=0.001). Conclusions In a community-based cohort of blacks, higher perceived stress over time was associated with an increased risk of developing hypertension. Evaluating stress levels over time and intervening when high perceived stress is persistent may reduce hypertension risk

On the Nose

A 67-year-old man presented with a 3-day history of chest tightness, wheezing, coughing, and dyspnea. He had a history of asthma but had not had major exacerbations for 20 years. He did not have fever, sputum production, hemoptysis, orthopnea, or edema

Differences in night-time and daytime ambulatory blood pressure when diurnal periods are defined by self-report, fixed-times, and actigraphy: Improving the Detection of Hypertension study

To determine whether defining diurnal periods by self-report, fixed-time or actigraphy produce different estimates of nighttime and daytime ambulatory blood pressure (ABP)

A comprehensive review on the exergy analysis of combined cycle power plants

The arriving optimum improvement of a thermodynamic system of energy conversion such as a combined cycle power plant (CCPP) is complicated due to the existence of different factors. Energy and exergy analysis is utilized as effective methods to determine both the quantity and quality of the energy sources. This paper reviews the latest thermodynamics analysis on each system components of a CCPP independently and determine the exergy destruction of the plant. A few layouts of the CCPP plant from different locations considered as case studies. In fact, the most energy losses occurred in the condenser compared with the plant components. It found that in the combustion chamber (CC) the highest exergy destruction occurred. The ambient temperature causes an evident decrement in the power production by the gas turbine (GT). The result has proved that besides energy, exergy analysis is an efficient way to the assessment of the performance of the CCPP by recommending a more advantageous configuration of the CCPP plant, which would lead to reductions in fuel required and emissions of air pollutants

Physical Activity and Incident Hypertension in African Americans: The Jackson Heart Study

There is limited empirical evidence to support the protective effects of physical activity in the prevention of hypertension among African Americans. The purpose of this study was to examine the association of physical activity with incident hypertension among African Americans. We studied 1311 participants without hypertension at baseline enrolled in the Jackson Heart Study, a community-based study of African Americans residing in Jackson, Mississippi. Overall physical activity, moderate–vigorous physical activity, and domain-specific physical activity (work, active living, household, and sport/exercise) were assessed by self-report during the baseline examination (2000–2004). Incident hypertension, assessed at examination 2 (2005–2008) and examination 3 (2009–2013), was defined as the first visit with systolic/diastolic blood pressure ≥140/90 mm Hg or self-reported antihypertensive medication use. Over a median follow-up of 8.0 years, there were 650 (49.6%) incident hypertension cases. The multivariable-adjusted hazard ratios (95% confidence interval) for incident hypertension comparing participants with intermediate and ideal versus poor levels of moderate–vigorous physical activity were 0.84 (0.67–1.05) and 0.76 (0.58–0.99), respectively (P trend=0.038). A graded, dose–response association was also present for sport/exercise-related physical activity (Quartiles 2, 3, and 4 versus Quartile 1: 0.92 [0.68–1.25], 0.87 [0.67–1.13], 0.75 [0.58–0.97], respectively; P trend=0.032). There were no statistically significant associations observed for overall physical activity, or work, active living, and household-related physical activities. In conclusion, the results of the current study suggest that regular moderate–vigorous physical activity or sport/exercise-related physical activity may reduce the risk of developing hypertension in African Americans

Adiponectin/resistin levels and insulin resistance in children: a four country comparison study

There are few reports on the effects of ethnicity or gender in the association between adipocytokines and insulin resistance in children of different ages. This study assessed associations between serum concentrations of adiponectin/resistin and parameters of insulin resistance in children from 4 different countries. A total of 2,290 children were analyzed in this study; each was from one of 4 different countries (Japan, Thailand, Italy and USA), and grouped according to age (8–11 years old in Group 1 and 12–15 years old in Group 2). Adioponectin was higher in female than in male children, and in Group 1 than in Group 2. Generally, adiponectin was lower in Asian as compared to Italian and American children. These tendencies remained even after adjustment for body mass index (BMI) or waist circumstance (WC). Among older children (Group 2), resistin was higher in female than in male children. Significant correlations by non-parametric univariate correlation coefficients and Spearman’s rank correlation coefficients were found between adiponectin and homeostasis model assessment of insulin resistance (HOMA-IR), and fasting serum insulin levels in young Japanese, Italian, and American female children(p < 0.01, p < 0.05, p < 0.05, respectively). Correlations between serum adiponectin and HOMA-IR were also found among older male Italian, American, and Thai children (p < 0.05, p < 0.001, p < 0.001, respectively). In multiple regression analysis by forced entry method, adiponectin correlated with HOMA-IR in Italian and American male children, and in all older female children regardless of country of origin. There was no correlation between resistin and markers of insulin resistance in children from any of the countries. We conclude that serum adiponectin concentrations are lower in Asian as compared to Italian and American children, and that adiponectin but not resistin contributes to differences in markers for insulin resistance in children from different populations