Coronary Heart Disease Mortality Declines in the United States From 1979 Through 2011: Evidence for Stagnation in Young Adults, Especially Women

Background— Coronary heart disease (CHD) mortality rates have fallen dramatically over the past 4 decades in the Western world. However, recent data from the United States and elsewhere suggest a plateauing of CHD incidence and mortality among young women. We therefore examined recent trends in CHD mortality rates in the United States according to age and sex. Methods and Results— We analyzed mortality data between 1979 and 2011 for US adults ≥25 years of age. We calculated age-specific CHD mortality rates and compared estimated annual percentage changes during 3 approximate decades of data (1979–1989, 1990–1999, and 2000–2011). We then used Joinpoint regression modeling to assess changes in trends over time on the basis of inflection points of the mortality rates. Adults ≥65 years of age showed consistent mortality declines, which became even steeper after 2000 (women, −5.0%; men, −4.4%). In contrast, young men and women (<55 years of age) initially showed a clear decline in CHD mortality from 1979 until 1989 (estimated annual percentage change, −5.5% in men and −4.6% in women). However, the 2 subsequent decades saw stagnation with minimal improvement. Notably, young women demonstrated no improvements between 1990 and 1999 (estimated annual percentage change, 0.1%) and only −1% estimated annual percentage change since 2000. Joinpoint analyses provided consistent results. Conclusions— The dramatic decline in CHD mortality since 1979 conceals major heterogeneities. CHD death rates in older groups are now falling steeply. However, young adults have experienced frustratingly small decreases in CHD mortality rates since 1990. The drivers of these major differences in CHD mortality trends by age and sex merit urgent study

PREVALENCE AND CHARACTERISTICS OF PATIENTS ELIGIBLE FOR CATHETER–BASED RENAL ARTERIAL DENERVATION IN AN ACADEMIC CARDIOLOGY CLINIC

The largest published study of renal denervation (RDN), SYMPLICITY HTN–2, demonstrated significant blood pressure (BP) reduction in eligible patients with resistant hypertension. Given the strict inclusion and exclusion criteria of SYMPLICITY HTN–2, we sought to determine its generalizabilit

Abstract 246: Challenges in Defining Resistant Hypertension: Prevalence Among Hypertensive Outpatients Varies With Inclusion of Diuretic Use and Medication Dosing

Background: Resistant hypertension (RH) is defined as BP above goal despite the use of 3 antihypertensive agents of different classes, or BP controlled on 4 agents, ideally maximally dosed and including a diuretic. RH studies have used varying interpretations of this definition, with prevalence estimates ranging from 3% to 30%. This study characterizes RH when different definitions are used in the same population. METHODS: We calculated the prevalence of RH among consecutive hypertensive outpatients presenting to an academic cardiology clinic over 6 months using 4 increasingly stringent definitions of RH. These included 1) SBP>140 (130 if DM or CKD) on three medications or controlled on four medications regardless of dosage; 2) Definition 1 including a diuretic; 3) SBP>140 (130 if DM or CKD) on three maximally-dosed medications (per JNC-7) or controlled on four medications, at least three which are maximally dosed; and 4) Definition 3 including a diuretic. We compared demographic and clinical characteristics of patients with and without RH using chi-square and t tests. Results: Among 1761 hypertensive outpatients, 46 (2.6%), 374 (21.2%), 602 (34.2%), and 739 (42.6%) were using 0, 1, 2, and ≥3 medications, respectively; 856 (47.6%) were using a diuretic-containing regimen. Overall, 500 patients (28.4%) had RH by Definition 1, which decreased to 402 patients (22.8%) using Definition 2 which required a diuretic. However, with inclusion of medication dosage, the number of patients with RH decreased to 29 (1.7%) using Definition 3, and 24 (1.4%) using Definition 4. RH using Definition 1 was associated with African-American race, female sex, coronary disease, diabetes, congestive heart failure, stroke, and end-stage renal disease (p Conclusion: RH represents a small proportion of the overall hypertensive population when a strict definition of RH including maximal medication dosing and/or the presence of a diuretic is applied. These findings suggest that some patients with RH by more inclusive definitions may benefit from optimization of antihypertensive therapy. Consistent definitions of RH should be applied in the future to ensure that RH is adequately identified and so RH treatment interventions and pathophysiology may be consistently compared

Prevalence of resistant hypertension and eligibility for catheter-based renal denervation in hypertensive outpatients.

BACKGROUND Studies of endovascular renal denervation (RDN) have demonstrated significant blood pressure reduction in eligible patients with resistant hypertension. These trials have used stringent inclusion and exclusion criteria in patient enrollment, potentially selecting for a small subset of patients with resistant hypertension. In this study, we examined the changes in estimated prevalence of resistant hypertension when using increasingly stringent definitions of resistant hypertension in a fixed population and assessed the generalizability of RDN when applying study criteria to a community-based hypertensive population. METHODS A retrospective chart review was done of hypertensive outpatients. Four increasingly stringent interpretations of the American Heart Association definition of resistant hypertension were used to calculate prevalence estimates. Patients eligible for RDN were identified using criteria from SYMPLICITY HTN-3. Demographic and clinical characteristics were compared. RESULTS We identified 1,756 hypertensive outpatients; 55.0% were male, 53.9% were white, and subjects had a mean age of 66.6 ± 12.5 years and a body mass index (BMI) of 30.1 ± 10.7 kg/m(2). Only 14 (0.8%) were eligible for RDN. Among these patients, 10 (71.4%) were female and all were black, with a mean age of 69.9 ± 8.8 and BMI of 35.7 ± 6.6. Congestive heart failure was more common in patients eligible for RDN. CONCLUSIONS Patients eligible for RDN based on published studies represent an exceedingly small proportion of the total hypertensive population. Further studies are necessary to determine if the benefits of RDN can be generalized to a broader range of hypertensive patients than those included in previous trials

AN AGGREGATE OF PATHWAY-RELATED BIOMARKERS PREDICT RISK OF ACUTE MYOCARDIAL INFARCTION AND DEATH

Activation of diverse pathophysiologic processes that include thrombotic, inflammatory, and immune pathways contribute to plaque rupture and adverse outcomes in CAD. We hypothesized that an aggregate biomarker risk score comprised of C-reactive protein (CRP), fibrin degradation products (FDP)

Comparison of autonomic stress reactivity in young healthy versus aging subjects with heart disease.

BackgroundThe autonomic response to acute emotional stress can be highly variable, and pathological responses are associated with increased risk of adverse cardiovascular events. We evaluated the autonomic response to stress reactivity of young healthy subjects and aging subjects with coronary artery disease to understand how the autonomic stress response differs with aging.MethodsPhysiologic reactivity to arithmetic stress in a cohort of 25 young, healthy subjects ( 55 years) with CAD was evaluated using electrocardiography, impedance cardiography, and arterial pressure recordings. Stress-related changes in the pre-ejection period (PEP), which measures sympathetic activity, and high frequency heart rate variability (HF HRV), which measures parasympathetic activity, were analyzed as primary outcomes.ResultsMental stress reduced PEP in both groups (pDiscussionPEP decreases with stress regardless of health and age status, implying increased sympathetic function. Its decline with stress may be attenuated in CAD. The HF HRV (parasympathetic) stress reactivity is more variable and attenuated in younger individuals; perhaps this is related to a protective parasympathetic reflex.Trial registrationClinicalTrials.gov Identifier: NCT02657382