TEMPORAL TRENDS IN THE POPULATION ATTRIBUTABLE RISK FOR CORONARY HEART DISEASE: ATHEROSCLEROSIS RISK IN COMMUNITIES STUDY

The extent to which relative contributions of traditional cardiovascular factors risk to incident cardiovascular disease (CVD) may have changed over time remains unclear

Yield of Downstream Tests After Exercise Treadmill Testing A Prospective Cohort Study

ObjectivesThe purpose of this study was to estimate the frequency and results of downstream testing after exercise treadmill tests (ETTs).BackgroundThe utility of additional diagnostic testing after ETT is not well characterized.MethodsWe followed consecutive individuals without known coronary artery disease referred for clinical ETT at a large medical center. We measured the frequency and results of downstream imaging tests and invasive angiography within 6 months of ETT and the combined endpoint of survival free from cardiovascular death, myocardial infarction, and coronary revascularization.ResultsAmong 3,656 consecutive subjects who were followed for a mean of 2.5 ± 1.1 years, 332 (9.0%) underwent noninvasive imaging and 84 (2.3%) were referred directly to invasive angiography after ETT. The combined endpoint occurred in 76 (2.2%) patients. The annual incidence of the combined endpoint after negative, inconclusive, and positive ETT was 0.2%, 1.3%, and 12.4%, respectively (p < 0.001). Rapid recovery of electrocardiography (ECG) changes during ETT was associated with negative downstream test results and excellent prognosis, whereas typical angina despite negative ECG was associated with positive downstream tests and adverse prognosis (p < 0.001). Younger age, female sex, higher metabolic equivalents of task achieved, and rapid recovery of ECG changes were predictors of negative downstream tests.ConclusionsAmong patients referred for additional testing after ETT, the lowest yield was observed among individuals with rapid recovery of ECG changes or negative ETT, whereas the highest yield was observed among those with typical angina despite negative ECG or a positive ETT. These findings may be used to identify patients who are most and least likely to benefit from additional testing

Stroke in patients with type 2 diabetes mellitus, chronic kidney disease, and anemia treated with darbepoetin alfa: The trial to reduce cardiovascular events with aranesp therapy (TREAT) experience

More strokes were observed in the Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT) among patients assigned to darbepoetin alfa. We sought to identify baseline characteristics and postrandomization factors that might explain this association

Association of left atrial structure and function with heart failure in older adults

Background: Limited data exist to characterize novel measures of left atrial (LA) structure and function in older adults without prevalent heart failure (HF). Objectives: To assess reference range of LA measures, their associations with N-terminal pro-brain-natriuretic-peptide (NTproBNP) and the related risk for incident HF or death. Methods: We analyzed LA structure [LA maximal and minimal volume indexed by body surface area (LAViMax and LAViMin)] and function [LA emptying fraction, LA reservoir, conduit and contraction strain] in 4901 participants from the Atherosclerosis Risk in Communities (ARIC) study (mean age 75±5 years, 40% male and 19% black) without prevalent HF. We assessed gender-specific 10th and 90th percentile ARIC-based reference limits in 301 participants free of prevalent cardiovascular disease, and related LA measures to NTproBNP and incident HF or death (median follow-up of 5.5 years) in the whole ARIC cohort. Results: Approximately 20% of the overall population had LA abnormalities according to the ARIC-based reference limit. Each LA measure was associated with NTproBNP and, except for LAViMax, with incident HF or death after multivariable adjustment. Results were consistent in participants with normal LAViMax (p for interaction&gt;0.05). LA measures were prognostic for both incident HFpEF or death and incident HFrEF or death. When added to HF risk factors and NTproBNP (baseline C-statistics=0.74) all LA measures, except for LAViMax, significantly enhanced the prognostic accuracy. Conclusion: Novel measures of LA structure and function, but not standard assessment by LAViMax, are associated with increased risk of incident HF or death regardless of measures of LV function and NTproBNP

Longitudinal trajectories in renal function before and after heart failure hospitalization among patients with HFpEF in the PARAGON‐HF trial

Aims: Worsening renal function may impact long-term outcomes in heart failure (HF). However, little is known about the longitudinal trajectories in renal function in relation to the HF hospitalization or how this high-risk clinical event impacts renal outcomes. Methods and Results: In PARAGON-HF, we evaluated the association between recency of prior HF hospitalization (occurring pre-randomization) and subsequent first renal composite outcome: (1) time to ≥50% decline in eGFR ; (2) development of end stage renal disease (ESRD); or (3) death attributable to renal causes. 2,306 (48.1%) patients had a history of prior HF hospitalization. Incident rates of the renal outcome were highest in those most recently hospitalized and decreased with longer time from last hospitalization. Treatment effect on the renal outcome of sacubitril/valsartan vs. valsartan was similar between patients with (HR 0.43; 95% CI: 0.26 to 0.75) and without (HR 0.63; 95% CI: 0.33 to 1.18; Pinteraction = 0.39) a prior history of HF hospitalization and appeared consistent regardless of timing of prior hospitalization for HF (Pinteraction =0.39). Serial eGFR measurements leading up to and after a HF hospitalization (occurring during the study period) and estimated eGFR trajectories using repeated measures regression models with restricted cubic splines were also examined. Patients experiencing a post-randomization HF hospitalization had a significant decline in eGFR prior to hospitalization while patients without HF hospitalization experienced a relatively stable eGFR trajectory (p&lt;0.001). A change in the rate of decline of eGFR trajectory was observed 12-months preceding a HF hospitalization, and continued in the post-discharge window to 12 months following hospitalization. Conclusions: HF hospitalization denotes increased risk for kidney disease progression which continues following recovery from HF decompensation in patients with HF with preserved ejection fraction

Rationale and Design of a Multicenter Echocardiographic Study to Assess the Relationship Between Cardiac Structure and Function and Heart Failure Risk in a Biracial Cohort of Community-Dwelling Elderly Persons: The Atherosclerosis Risk in Communities Study

Heart failure (HF) is an important public health concern particularly among persons over 65 years of age. Women and African Americans are critically understudied populations that carry a sizeable portion of the HF burden. Limited normative and prognostic data exist regarding measures of cardiac structure, diastolic function, and novel measures of systolic deformation in older adults living in the community

Hyperglycaemia, ejection fraction and the risk of heart failure or cardiovascular death in patients with type 2 diabetes and a recent acute coronary syndrome

Aims: Chronic hyperglycaemia, assessed by elevated glycated haemoglobin (A1C), is a known risk factor for heart failure (HF) and cardiovascular (CV) death among subjects with diabetes. Whether this risk varies with left ventricular ejection fraction (LVEF) is unknown. This study evaluated whether A1C influences a composite outcome of either HF hospitalization or CV death differently along the spectrum of LVEF. Methods and results: We assessed the relationships of baseline A1C and LVEF with a composite outcome of either CV death or HF hospitalization in the 4091 patients with type 2 diabetes and a recent acute coronary syndrome enrolled in the ELIXA trial who had available LVEF. We assessed for interaction between A1C and LVEF as continuous variables with respect to this outcome. During a median follow‐up of 25.7 months, 343 patients (8.4%) had HF hospitalization or died of CV causes. In a multivariable model, A1C and LVEF were each associated with an increased risk of HF hospitalization or CV death [adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 1.01–1.21 per 1% higher A1C, and adjusted HR 1.39, 95% CI 1.27–1.51 per 10% lower in LVEF]. Both A1C and LVEF were independently and incrementally associated with risk without evidence of interaction (P for interaction = 0.31). Patients with A1C ≥ 8% and LVEF &lt;40% were at threefold higher risk than those with A1C &lt; 7% and LVEF ≥50% (adjusted HR 3.18, 95% CI 2.03–4.98, P &lt; 0.001). Conclusion: In a contemporary cohort of patients with type 2 diabetes and acute coronary syndrome, baseline chronic hyperglycaemia was associated with an increased risk of HF hospitalization or CV death independently of LVEF