The Association of Air Pollution Exposure With Glucose and Lipid Levels: The Role of an Extreme Air Pollution Event Alongside 2 Decades of Moderate Exposure.

Extreme air pollution events and moderate exposure to fine particulate matter (PM2.5) are associated with increased cardiometabolic risk. The World Trade Center (WTC) Health Program general responder cohort includes responders to the WTC disaster. We investigated whether their exposure to this extreme air pollution event (2001) was associated with long-term metabolic outcomes, independently from the associations of intermediate-term PM2.5 exposure later in life (2004-2019). We included 22,447 cohort members with cholesterol (n = 96,155) and glucose (n = 81,599) laboratory results. Self-reported WTC exposure was derived from a questionnaire. PM2.5 exposure was derived from a satellite-based model. We observed an increase of 0.78 mg/dL (95% confidence interval (CI): 0.30, 1.26) in glucose and 0.67 mg/dL (95% CI: 1.00, 2.35) in cholesterol levels associated with an interquartile range increase in PM2.5 averaged 6 months before the study visit. Higher WTC-exposure categories were also associated with higher cholesterol (0.99 mg/dL, 95% CI: 0.30, 1.67, for intermediate exposure) and glucose (0.82 mg/dL, 95% CI: 0.22, 1.43, for high exposure) levels. Most associations were larger among people with diabetes. Extreme air pollution events and intermediate PM2.5 exposure have independent metabolic consequences. These exposures contributed to higher glucose and lipids levels among WTC responders, which may be translated into increased cardiovascular risk.

Pre-term delivery and long-term risk of heart failure in women: a national cohort and co-sibling study.

AIMS: Women who deliver pre-term have higher future risks of hypertension and ischaemic heart disease, but long-term risks of heart failure (HF) are unknown. We examined these risks in a large national cohort. METHODS AND RESULTS: All 2 201 284 women with a singleton delivery in Sweden during 1973-2015 were followed up for inpatient or outpatient HF diagnoses through 2015. Cox regression was used to compute hazard ratios (HRs) for HF associated with pregnancy duration, adjusting for other maternal factors. Co-sibling analyses assessed for confounding by shared familial (genetic and/or environmental) factors. In 48.2 million person-years of follow-up, 19 922 women were diagnosed with HF (median age: 60.7 years). Within 10 years after delivery, the adjusted HR was 2.96 [95% confidence interval (CI): 2.48-3.53] for HF associated with pre-term (gestational age: <37 weeks) compared with full-term (39-41 weeks) delivery. Stratified HRs were 4.27 (2.54-7.17) for extremely pre-term (22-27 weeks), 3.39 (2.57-4.48) for moderately pre-term (28-33 weeks), 2.70 (2.19-3.32) for late pre-term (34-36 weeks), and 1.70 (1.45-1.98) for early term (37-38 weeks). These HRs declined but remained elevated at 10-19 years (pre-term vs. full term: HR: 2.19; 95% CI: 1.94-2.46), 20-29 years (1.80; 1.67-1.95), and 30-43 years (1.56; 1.47-1.66) after delivery, and were not explained by shared familial factors. CONCLUSION: Pre-term and early term delivery were associated with markedly increased future hazards for HF, which persisted after adjusting for other maternal and familial factors and remained elevated 40 years later. Pre-term and early-term delivery should be recognized as risk factors for HF across the life course. KEY QUESTION: What are the long-term hazards for heart failure (HF) across the life course in women who deliver preterm? KEY FINDING: Preterm and early term delivery were associated with ∼3- and 1.7-fold adjusted hazards for HF in the next 10 years vs. full-term delivery. These hazards declined but remained elevated 40 years later, and were not explained by shared familial factors. TAKE HOME MESSAGE: Preterm and early term delivery were associated with increased future hazards for HF, which persisted for 40 years after adjusting for other maternal and familial factors. Preterm and early term delivery should be recognized as lifelong risk factors for HF.

Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis.

BACKGROUND: Self-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most. This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension. METHODS AND FINDINGS: Medline, Embase, and the Cochrane Library were searched for randomised trials comparing self-monitoring to no self-monitoring in hypertensive patients (June 2016). Two reviewers independently assessed articles for eligibility and the authors of eligible trials were approached requesting IPD. Of 2,846 articles in the initial search, 36 were eligible. IPD were provided from 25 trials, including 1 unpublished study. Data for the primary outcomes-change in mean clinic or ambulatory BP and proportion controlled below target at 12 months-were available from 15/19 possible studies (7,138/8,292 [86%] of randomised participants). Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (-3.2 mmHg, [95% CI -4.9, -1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (-1.0 mmHg [-3.3, 1.2]), to a 6.1 mmHg (-9.0, -3.2) reduction when monitoring was combined with intensive support. Self-monitoring was most effective in those with fewer antihypertensive medications and higher baseline sBP up to 170 mmHg. No differences in efficacy were seen by sex or by most comorbidities. Ambulatory BP data at 12 months were available from 4 trials (1,478 patients), which assessed self-monitoring with little or no co-intervention. There was no association between self-monitoring and either lower clinic or ambulatory sBP in this group (clinic -0.2 mmHg [-2.2, 1.8]; ambulatory 1.1 mmHg [-0.3, 2.5]). Results for diastolic blood pressure (dBP) were similar. The main limitation of this work was that significant heterogeneity remained. This was at least in part due to different inclusion criteria, self-monitoring regimes, and target BPs in included studies. CONCLUSIONS: Self-monitoring alone is not associated with lower BP or better control, but in conjunction with co-interventions (including systematic medication titration by doctors, pharmacists, or patients; education; or lifestyle counselling) leads to clinically significant BP reduction which persists for at least 12 months. The implementation of self-monitoring in hypertension should be accompanied by such co-interventions.

The prevalence of metabolic syndrome among law enforcement officers who responded to the 9/11 World Trade Center attacks.

BACKGROUND: Law enforcement officers (LEOs) experience high rates of cardiovascular events compared with the general US population. Metabolic syndrome (MetS) confers an increased risk of cardiovascular disease and all-cause mortality. Data regarding MetS among LEOs are limited. METHODS: We sought to determine the prevalence of MetS and its associated risk factors as well as gender differences among LEOs who participated in the World Trade Center (WTC) Law Enforcement Cardiovascular Screening (LECS) Program from 2008 to 2010. We evaluated a total of 2,497 participants, 40 years and older, who responded to the 9/11 WTC attacks. RESULTS: The prevalence of MetS was 27%, with abdominal obesity and hypertension being the most frequently occurring risk factors. MetS and its risk factors were significantly higher among male compared to female LEOs, except for reduced HDL-cholesterol levels. CONCLUSIONS: MetS is a rising epidemic in the United States, and importantly, approximately one in four LEOs who worked at the WTC site after 9/11 are affected. Am. J. Ind. Med. 59:752-760, 2016. © 2016 Wiley Periodicals, Inc.

Adverse pregnancy outcomes and long term risk of ischemic heart disease in mothers: national cohort and co-sibling study.

OBJECTIVE: To examine the associations between five major adverse pregnancy outcomes and long term risks of ischemic heart disease in mothers. DESIGN: National cohort study. SETTING: Sweden. PARTICIPANTS: All 2 195 266 women with a first singleton delivery in Sweden during 1973-2015. MAIN OUTCOME MEASURES: The main outcome measure was incidence of ischemic heart disease from delivery to 2018, identified from nationwide inpatient and outpatient diagnoses. Cox regression was used to calculate hazard ratios for ischemic heart disease associated with preterm delivery, small for gestational age, pre-eclampsia, other hypertensive disorders of pregnancy, and gestational diabetes, adjusting for other adverse pregnancy outcomes and maternal factors. Co-sibling analyses assessed for confounding by shared familial (genetic and environmental) factors. RESULTS: During 53.6 million person years of follow-up, ischemic heart disease was diagnosed in 83 881 (3.8%) women. All five adverse pregnancy outcomes were independently associated with increased risk of ischemic heart disease. In the 10 years after delivery, adjusted hazard ratios for ischemic heart disease associated with specific adverse pregnancy outcomes were 2.09 (95% confidence interval 1.77 to 2.46) for other hypertensive disorders of pregnancy, 1.72 (1.55 to 1.90) for preterm delivery, 1.54 (1.37 to 1.72) for pre-eclampsia, 1.30 (1.09 to 1.56) for gestational diabetes, and 1.10 (1.00 to 1.21) for small for gestational age. The hazard ratios remained significantly increased even 30-46 years after delivery: 1.47 (1.30 to 1.66) for other hypertensive disorders of pregnancy, 1.40 (1.29 to 1.51) for gestational diabetes, 1.32 (1.28 to 1.36) for pre-eclampsia, 1.23 (1.19 to 1.27) for preterm delivery, and 1.16 (1.13 to 1.19) for small for gestational age. These findings were only partially (<45%) explained by shared familial (genetic or environmental) factors. Women who experienced multiple adverse pregnancy outcomes showed further increases in risk (eg, <10 years after delivery, adjusted hazard ratios associated with 1, 2, or ≥3 adverse pregnancy outcomes were 1.29 (1.19 to 1.39), 1.80 (1.59 to 2.03), and 2.26 (1.89 to 2.70), respectively)). CONCLUSIONS: In this large national cohort, women who experienced any of five major adverse pregnancy outcomes showed an increased risk for ischemic heart disease up to 46 years after delivery. Women with adverse pregnancy outcomes should be considered for early preventive evaluation and long term risk reduction to help prevent the development of ischemic heart disease.

Nurse-led disease management for hypertension control in a diverse urban community: a randomized trial.

BACKGROUND: Treated but uncontrolled hypertension is highly prevalent in African American and Hispanic communities. OBJECTIVE: To test the effectiveness on blood pressure of home blood pressure monitors alone or in combination with follow-up by a nurse manager. DESIGN: Randomized controlled effectiveness trial. PATIENTS: Four hundred and sixteen African American or Hispanic patients with a history of uncontrolled hypertension. Patients with blood pressure ≥150/95, or ≥140/85 for patients with diabetes or renal disease, at enrollment were recruited from one community clinic and four hospital outpatient clinics in East and Central Harlem, New York City. INTERVENTION: Patients were randomized to receive usual care or a home blood pressure monitor plus one in-person counseling session and 9 months of telephone follow-up with a registered nurse. During the trial, the home monitor alone arm was added. MAIN MEASURES: Change in systolic and diastolic blood pressure at 9 and 18 months. KEY RESULTS: Changes from baseline to 9 months in systolic blood pressure relative to usual care was -7.0 mm Hg (Confidence Interval [CI], -13.4 to -0.6) in the nurse management plus home blood pressure monitor arm, and +1.1 mm Hg (95% CI, -5.5 to 7.8) in the home blood pressure monitor only arm. No statistically significant differences in systolic blood pressure were observed among treatment arms at 18 months. No statistically significant improvements in diastolic blood pressure were found across treatment arms at 9 or 18 months. Changes in prescribing practices did not explain the decrease in blood pressure in the nurse management arm. CONCLUSIONS: A nurse management intervention combining an in-person visit, periodic phone calls, and home blood pressure monitoring over 9 months was associated with a statistically significant reduction in systolic, but not diastolic, blood pressure compared to usual care in a high risk population. Home blood pressure monitoring alone was no more effective than usual care.

Obstructive sleep apnoea and left ventricular diastolic dysfunction among first responders to the 9/11 World Trade Center terrorist attack: a cross-sectional study.

OBJECTIVES: Obstructive sleep apnoea (OSA) is often linked to cardiovascular disease. A limited number of studies have reported an association between OSA and left ventricular diastolic dysfunction (LVDD). However, prior studies were performed on small patient populations. Studies have shown a high prevalence of OSA among first responders to the 9/11 World Trade Center (WTC) terrorist attack. We investigated the relationship between OSA and LVDD in a large population of WTC responders. DESIGN: Cross-sectional study. SETTING: One-time screening programme as part of the WTC-CHEST Study (NCT10466218), performed at a quaternary medical centre in New York City, from November 2011 to June 2014. PARTICIPANTS: A total of 1007 participants with mean age of 51 years of mostly non-Hispanic white men were evaluated. Patients from the WTC Health Program-Clinical Center of Excellence, who were over the age of 39 years, were eligible to participate. RESULTS: Evaluation of those without OSA diagnosis showed no significant association with LVDD when comparing those screened (Berlin Questionnaire) as OSA high risk versus OSA low risk (p=0.101). Among those diagnosed with LVDD, there was a significant association when comparing those with and without patient-reported OSA (OR 1.50, 95% CI 1.13 to 2.00, p=0.005), but the significance was not maintained after adjusting for pertinent variables (OR 1.3, 0.94 to 1.75, p=0.119). Notably, comparing those with OSA diagnosis and those low risk of OSA, the OR for LVDD was significant (1.69, 1.24 to 2.31, p=0.001), and after adjusting for waist-hip ratio, diabetes and coronary artery calcium score percentile, the relationship remained significant (OR 1.45, 1.03 to 2.04, p=0.032). CONCLUSION: The strong association of OSA with LVDD in this population may inform future guidelines to recommend screening for LVDD in high-risk asymptomatic patients with OSA.

Sex-Specific Differences in Clinical Outcomes After Percutaneous Coronary Intervention: Insights from the TAILOR-PCI Trial.

Background TAILOR-PCI (Tailored Antiplatelet Initiation to Lessen Outcomes due to decreased Clopidogrel Response After Percutaneous Coronary Intervention) studied genotype-guided selection of antiplatelet therapy after percutaneous coronary intervention versus conventional therapy with clopidogrel. The presence of CYP2C19 loss-of-function alleles in patients treated with clopidogrel may be associated with increased risk for ischemic events. We report a prespecified sex-specific analysis of genotyping and associated cardiovascular outcomes from this study. Methods and Results Associations between sex and major adverse cardiac events (MACE: cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia) and Bleeding Academic Research Consortium (BARC) bleeding at 12 months were analyzed using Cox proportional-hazards models. Among 5276 randomized patients, loss-of-function carriers were observed in ≈36% of both sexes, and >80% of carriers were heterozygotes. At 12 months, after adjustment for baseline differences, risks of MACE (HR , 1.28 [0.97 to 1.68]; P=0.088) and BARC bleeding (hazard ratio [HR], 1.36 [0.91 to 2.05]; P=0.14) were comparable among women and men. There were no significant interactions between sex and treatment strategy for MACE interaction P value (Pint=0.59) or BARC bleeding (Pint=0.47) nor for sex and genotype (MACE Pint=0.15, and BARC bleeding Pint=0.60). Conclusions CYP2C19 loss-of-function alleles were present in ≈1 in 3 women and men. Women had similar adjusted risks of MACE and bleeding as men following percutaneous coronary intervention. Genotype-guided therapy did not significantly reduce the risk of MACE or bleeding relative to conventional therapy for both sexes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01742117.

Pre-Term Delivery and Risk of Ischemic Heart Disease in Women.

BACKGROUND: Women who deliver pre-term have been reported to have increased future risks of cardiometabolic disorders. However, their long-term risks of ischemic heart disease (IHD) and whether such risks are due to shared familial factors are unclear. A better understanding of these risks may help improve long-term clinical follow-up and interventions to prevent IHD in women. OBJECTIVES: The purpose of this study was to determine the long-term risks of IHD in women by pregnancy duration. METHODS: A national cohort study was conducted of all 2,189,190 women with a singleton delivery in Sweden from 1973 to 2015, who were followed up for IHD through the end of 2015. Cox regression was used to compute adjusted hazard ratios (aHRs) for IHD associated with pregnancy duration, and cosibling analyses assessed the influence of shared familial (genetic and/or environmental) factors. RESULTS: In 47.5 million person-years of follow-up, 49,955 (2.3%) women were diagnosed with IHD. In the 10 years following delivery, the aHR for IHD associated with pre-term delivery (<37 weeks) was 2.47 (95% confidence interval [CI]: 2.16 to 2.82), and further stratified was 4.04 (95% CI: 2.69 to 6.08) for extremely pre-term (22 to 27 weeks), 2.62 (95% CI: 2.09 to 3.29) for very pre-term (28 to 33 weeks), 2.30 (95% CI: 1.97 to 2.70) for late pre-term (34 to 36 weeks), and 1.47 (95% CI: 1.30 to 1.65) for early-term (37 to 38 weeks), compared with full-term (39 to 41 weeks). These risks declined but remained significantly elevated after additional follow-up (pre-term vs. full-term, 10 to 19 years: aHR: 1.86; 95% CI: 1.73 to 1.99; 20 to 29 years: aHR: 1.52; 95% CI: 1.45 to 1.59; 30 to 43 years: aHR: 1.38; 95% CI: 1.32 to 1.45). These findings did not appear attributable to shared genetic or environmental factors within families. Additional pre-term deliveries were associated with further increases in risk. CONCLUSIONS: In this large national cohort, pre-term delivery was a strong independent risk factor for IHD. This association waned over time but remained substantially elevated up to 40 years later. Pre-term delivery should be recognized as a risk factor for IHD in women across the life course.

Review of cardiovascular risk factors in women.

BACKGROUND: Although cardiovascular disease (CVD) is the leading cause of death in women in the United States, a knowledge gap persists regarding the mechanisms and management of CVD in women. Before treatment can be optimized, the role of cardiovascular risk factors must be elucidated. OBJECTIVE: This review provides an updated assessment of cardiovascular risk factors in women, with a focus on cardiometabolic risk. METHODS: MEDLINE and Cochrane Library databases, and statistics from the National Health and Nutrition Examination Survey and the American Heart Association, were searched from 1990 to September 2008 using the following terms: cardiovascular risk factors, women, gender, cardiometabolic risk, abdominal obesity, and metabolic syndrome. Publications were classified as English-only original data, reviews, and clinical guidelines. Nonpublished data were excluded. Data were extracted by 2 reviewers independently. RESULTS: Investigators performing multivariable predictive models have estimated that traditional risk factors account for approximately 70% of the variance in estimating cardiovascular events. However, substantial sex differences exist in the prevalence of traditional risk factors as well as in cardiovascular outcomes. Hypertension is more prevalent in men until the age of 59 years, but then contributes to greater morbidity in older women. Low levels of high-density lipoprotein and elevated triglyceride levels pose more of a threat to women, yet high levels of low-density lipoprotein pose equal risk for women and men. The CVD mortality rate is -3 times greater in people with diabetes than in those without diabetes. Among diabetic individuals, CVD mortality is slightly higher in women compared with men. CONCLUSIONS: Increased knowledge of gender-specific risks for CVD has led to national campaigns to educate women. In addition to traditional risk factors, cardiometabolic risk is an important consideration in women. Controversy exists regarding the exact definitions and usefulness of the term metabolic syndrome, but it is clear that the presence of certain factors contributes to increased morbidity and mortality in affected individuals. Abdominal obesity links insulin resistance, dyslipidemia, and hypertension through complex endocrine pathways. Current research is identifying gene x gender interactions, and continued research is necessary to explore the relationship of sex steroids and cardiovascular risk in both men and women.

Cost-effectiveness of nurse-led disease management for heart failure in an ethnically diverse urban community.

BACKGROUND: Randomized, controlled trials have shown that nurse-led disease management for patients with heart failure can reduce hospitalizations. Less is known about the cost-effectiveness of these interventions. OBJECTIVE: To estimate the cost-effectiveness of a nurse-led disease management intervention over 12 months, implemented in a randomized, controlled effectiveness trial. DESIGN: Cost-effectiveness analysis conducted alongside a randomized trial. DATA SOURCES: Medical costs from administrative records, and self-reported quality of life and nonmedical costs from patient surveys. PARTICIPANTS: Patients with systolic dysfunction recruited from ambulatory clinics in Harlem, New York. TIME HORIZON: 12 months. PERSPECTIVE: Societal and payer. INTERVENTION: 12-month program that involved 1 face-to-face encounter with a nurse and regular telephone follow-up. OUTCOME MEASURES: Quality of life as measured by the Health Utilities Index Mark 3 and EuroQol-5D and cost-effectiveness as measured by the incremental cost-effectiveness ratio (ICER). RESULTS OF BASE-CASE ANALYSIS: Costs and quality of life were higher in the nurse-managed group than the usual care group. The ICERs over 12 months were $17,543 per EuroQol-5D-based quality-adjusted life-year (QALY) and $15,169 per Health Utilities Index Mark 3-based QALY (in 2001 U.S. dollars). RESULTS OF SENSITIVITY ANALYSIS: From a payer perspective, the ICER ranged from $3673 to $4495 per QALY. Applying national prices in place of New York City prices yielded a societal ICER of $13,460 to $15,556 per QALY. Cost-effectiveness acceptability curves suggest that the intervention was most likely cost-effective for patients with less severe (New York Heart Association classes I to II) heart failure. LIMITATION: The trial was conducted in an ethnically diverse, inner-city neighborhood; thus, results may not be generalizable to other communities. CONCLUSION: Over 12 months, the nurse-led disease management program was a reasonably cost-effective way to reduce the burden of heart failure in this community.

Association of Preterm Birth With Risk of Ischemic Heart Disease in Adulthood.

IMPORTANCE: Preterm birth has previously been associated with increased risks of hypertension and diabetes, but not ischemic heart disease (IHD), in adulthood. The reasons for this lack of association with IHD despite associations with its risk factors have been elusive, but may be associated with methodologic issues, such as survivor bias, in prior studies. OBJECTIVE: To determine whether preterm birth is associated with an increased risk of IHD in adulthood in a large population-based cohort. DESIGN, SETTING, AND PARTICIPANTS: This national, population-based cohort study included all 2 141 709 persons who were born as singleton live births in Sweden during 1973 to 1994. The data were analyzed in September 2018. EXPOSURES: Gestational age at birth, identified from nationwide birth records in the Swedish Birth Registry. MAIN OUTCOMES AND MEASURES: Ischemic heart disease that was identified from nationwide inpatient and outpatient diagnoses through 2015 (maximum age, 43 years). A Cox regression was used to examine gestational age at birth in association with IHD in adulthood while adjusting for other perinatal and maternal factors. Cosibling analyses assessed for potential confounding by unmeasured shared familial factors. RESULTS: Of 2 141 709 participants, 1 041 906 (48.6%) were female and there were 1921 persons (0.09%) who received a diagnosis of IHD in 30.9 million person-years of follow-up. Gestational age at birth was inversely associated with IHD risk in adulthood. At ages 30 to 43 years, adjusted hazard ratios for IHD associated with preterm (gestational age <37 weeks) and early-term birth (37-38 weeks) were 1.53 (95% CI, 1.20-1.94) and 1.19 (1.01-1.40), respectively, compared with full-term birth (39-41 weeks). Preterm-born women had lower IHD incidence than preterm-born men (15.16 vs 22.00 per 100 000 person-years) but had a higher adjusted hazard ratio (1.93; 95% CI, 1.28-2.90 vs 1.37; 95% CI, 1.01-1.84). These associations did not appear to be explained by shared genetic or environmental factors in families. CONCLUSIONS AND RELEVANCE: In this large national cohort, preterm and early-term birth were associated with an increased IHD risk in adulthood. Persons born prematurely need early evaluation and preventive actions to reduce the risk of IHD.

Hypertension management in minority communities: a clinician survey.

BACKGROUND: Rates of blood pressure (BP) control are lower in minority populations compared to whites. OBJECTIVE: As part of a project to decrease health-related disparities among ethnic groups, we sought to evaluate the knowledge, attitudes, and management practices of clinicians caring for hypertensive patients in a predominantly minority community. DESIGN/PARTICIPANTS: We developed clinical vignettes of hypertensive patients that varied by comorbidity (type II diabetes mellitus, chronic renal insufficiency, coronary artery disease, or isolated systolic hypertension alone). We randomly assigned patient characteristics, e.g., gender, age, race/ethnicity, to each vignette. We surveyed clinicians in ambulatory clinics of the 4 hospitals in East/Central Harlem, NY. MEASUREMENTS: The analysis used national guidelines to assess the appropriateness of clinicians' stated target BP levels. We also assessed clinicians' attitudes about the likelihood of each patient to achieve adequate BP control, adhere to medications, and return for follow-up. RESULTS: Clinicians' target BPs were within 2 mm Hg of the recommendations 9% of the time for renal disease patients, 86% for diabetes, 94% for isolated systolic hypertension, and 99% for coronary disease. BP targets did not vary by patient or clinician characteristics. Clinicians rated African-American patients 8.4% (p = .004) less likely and non-English speaking Hispanic patients 8.1% (p = .051) less likely than white patients to achieve/maintain BP control. CONCLUSIONS: Clinicians demonstrated adequate knowledge of recommended BP targets, except for patients with renal disease. Clinicians did not vary management by patients' sociodemographics but thought African-American, non-English-speaking Hispanic and unemployed patients were less likely to achieve BP control than their white counterparts.

Do ACE inhibitors all provide the same outcomes benefits in high-risk cardiovascular patients?

The Heart Outcomes Prevention (HOPE) trial was the first to demonstrate the benefits of the angiotensin-converting enzyme (ACE) inhibitor ramipril for high-risk cardiovascular patients. Whether the cardioprotective effects seen in HOPE and other trials are specific to distinct ACE inhibitors remains controversial. Evidence of a lack of class effect for ACE inhibitors has policy and financial implications related to reference pricing by insurers and inclusion on pharmacy formularies. Because head-to-head trials comparing the different ACE inhibitors are unforeseen, clinicians and administrators must rely on secondary-level data and observational studies. Only a handful of studies have sought to address the dispute over a class effect among ACE inhibitors, which is reviewed in this article.

The success of recruiting minorities, women, and elderly into a randomized controlled effectiveness trial.

BACKGROUND: Heart failure, a leading cause of hospitalization among elderly people, disproportionately afflicts African-American and other non-White populations. Studies of health care interventions often do not include these groups in proportion to numbers in the patient population. Our objective was to assess whether a randomized controlled effectiveness trial enrolled patients by ethnicity/race, gender, and age in proportion to those eligible. METHODS: We conducted a randomized controlled trial comparing nurse management and usual care among ambulatory heart failure patients at the four hospitals in East and Central Harlem, New York. We incorporated culturally sensitive and age-appropriate strategies to enroll a demographically representative group into the trial. Recruitment proceeded in several steps: identifying patients with billing code and visit criteria, documenting systolic dysfunction, obtaining clinician permission and correct addresses, contacting patients, and enrolling eligible patients. We assessed differences by ethnicity/race and gender at successive steps in the recruitment process, and differences between enrollees and refusals regarding overall health, evaluation of medical care, and difficulty receiving care. RESULTS: We enrolled 406 ambulatory patients by ethnicity/race and gender in proportion to the numbers eligible to be contacted (46% African-American/Black, 33% Hispanic, and 47% female). Among patients contacted, however, those 18 through 74 years were 2.0 to 3.3 times more likely than those > or = 75 years to enroll (p < 0.001). CONCLUSIONS: The recruitment strategy successfully enrolled patients by ethnicity/race, gender, and age through 74 years, but not those > or = 75 years. Registries of patients who refuse to enroll in trials could provide guidance for clinical and public policy.

Why men's hearts break: cardiovascular effects of sex steroids.

Coronary artery disease (CAD) mortality differs in men and women, leading to the speculation that differences in sex steroids contribute to risk. Controlled clinical trials have shown that estrogen replacement is not cardioprotective in certain women, and recent cross-sectional studies associate low testosterone with a greater incidence of CAD in men. Testosterone has demonstrated effects on insulin resistance, obesity, myocardium, coagulation, inflammation, vasodilation, and endothelial function. Imbalance of sex steroids contributes to adverse cardiac effects in men.

Effects of nurse management on the quality of heart failure care in minority communities: a randomized trial.

BACKGROUND: Despite therapies proven effective for heart failure with systolic dysfunction, the condition continues to cause substantial hospitalization, disability, and death, especially among African- American and other nonwhite populations. OBJECTIVE: To compare the effects of a nurse-led intervention focused on specific management problems versus usual care among ethnically diverse patients with systolic dysfunction in ambulatory care practices. DESIGN: Randomized effectiveness trial conducted from September 2000 to September 2002. SETTING: The 4 hospitals in Harlem, New York. PATIENTS: 406 adults (45.8% were non-Hispanic black adults, 32.5% were Hispanic adults, 46.3% were women, and 36.7% were > or =65 years of age) who met eligibility criteria: systolic dysfunction, English- or Spanish-language speakers, community-dwelling patients, and ambulatory care practice patients. INTERVENTION: During a 12-month intervention, bilingual nurses counseled patients on diet, medication adherence, and self-management of symptoms through an initial visit and regularly scheduled follow-up telephone calls and facilitated evidence-based changes to medications in discussions with patients' clinicians. MEASUREMENTS: Hospitalizations (in 406 of 406 patients during follow-up) and self-reported functioning (in 286 of 406 patients during follow-up) at 12 months. RESULTS: At 12 months, nurse management patients had had fewer hospitalizations (143 hospitalizations vs. 180 hospitalizations; adjusted difference, -0.13 hospitalization/person-year [95% CI, -0.25 to -0.001 hospitalization/person-year]) than usual care patients. They also had better functioning: The Short Form-12 physical component score was 39.9 versus 36.3, respectively (difference, 3.6 [CI, 1.2 to 6.1]), and the Minnesota Living with Heart Failure Questionnaire score was 38.6 versus 47.3, respectively (difference, -8.8 [CI, -15.3 to -2.2]). Through 12 months, 22 deaths occurred in each group and percentages of patients who were hospitalized at least once were similar in each group (30.5% of nurse management patients vs. 36.5% of control patients; adjusted difference, -7.1 percentage points [CI, -16.9 to 2.6 percentage points]). LIMITATIONS: Three nurses at 4 hospitals delivered interventions in this modest-sized trial, and 75% of the participants were from 1 site. It is not clear which aspects of the complex intervention accounted for the results. CONCLUSIONS: Nurse management can improve functioning and modestly lower hospitalizations in ethnically diverse ambulatory care patients who have heart failure with systolic dysfunction. Sustaining improved functioning may require continuing nurse contact.

Availability, Use, and Barriers to Cardiac Rehabilitation in LMIC.

BACKGROUND: Cardiac rehabilitation (CR) is a cornerstone of secondary prevention of ischemic heart disease. It is critically important in low- and middle-income countries (LMIC), where the burden of ischemic heart disease is substantial and growing. However, the availability and utilization of CR in LMIC is not systematically known. OBJECTIVES: This study sought to characterize the availability, use, and barriers to the use of CR. METHODS: Electronic databases (Cochrane Library, EMBASE, PubMed, Web of Science) were searched from January 1, 1980 to May 31, 2013 for articles on CR in LMIC. Citations on availability, use, and/or barriers to CR were screened for inclusion by title, abstract, and full text. Data were summarized by region or country to determine the characteristics of CR in LMIC and gaps in the peer-reviewed biomedical publications. RESULTS: Our search yielded a total of 5,805 citations, of which 34 satisfied full inclusion and exclusion criteria. The total number of CR programs available ranged from 1 in Algeria and Paraguay to 51 in Serbia. Referral rates for CR ranged from 5.0% in Mexico to 90.3% in Lithuania. Attendance rates ranged from 31.7% in Bulgaria to 95.6% in Lithuania, and CR attendance was correlated with higher educational background. The most commonly cited barrier to CR in LMIC was lack of physician referral. CONCLUSIONS: Our results illustrate that the published reports reflects heterogeneity of CR availability and use in LMIC. Overall, CR is insufficiently available and underutilized. Further characterization of CR in LMIC, especially in Asia and Africa, is necessary to develop targeted strategies to improve availability and utilization. Patient, physician, and systems factors must be addressed to overcome barriers to participation in CR in LMIC.

Preoperative status and risk of complications in patients with hip fracture.

BACKGROUND: Limited information is available on preoperative status and risks for complications for older patients having surgery for hip fracture. Our objective was to identify potentially modifiable clinical findings that should be considered in decisions about the timing of surgery. METHODS: We conducted a prospective cohort study with data obtained from medical records and through structured interviews with patients. A total of 571 adults with hip fracture who were admitted to 4 metropolitan hospitals were included. RESULTS: Multiple logistic regression was used to identify risk factors (including 11 categories of physical and laboratory findings, classified as mild and severe abnormalities) for in-hospital complications. The presence of more than 1 (odds ratio [OR] 9.7, 95% confidence interval [CI] 2.8 to 33.0) major abnormality before surgery or the presence of major abnormalities on admission that were not corrected prior to surgery (OR 2.8, 95% CI 1.2 to 6.4) was independently associated with the development of postoperative complications. We also found that minor abnormalities, while warranting correction, did not increase risk (OR 0.70, 95% CI 0.28 to 1.73). CONCLUSIONS: In this study of older adults undergoing urgent surgery, potentially reversible abnormalities in laboratory and physical examination occurred frequently and significantly increased the risk of postoperative complications. Major clinical abnormalities should be corrected prior to surgery, but patients with minor abnormalities may proceed to surgery with attention to these medical problems perioperatively.

Arterial Effects of Canakinumab in Patients With Atherosclerosis and Type 2 Diabetes or Glucose Intolerance.

BACKGROUND: Evidence suggests that interleukin (IL)-1ß is important in the pathogenesis of atherosclerosis and its complications and that inhibiting IL-1ß may favorably affect vascular disease progression. OBJECTIVES: The goal of this study was to evaluate the effects of IL-1ß inhibition with canakinumab versus placebo on arterial structure and function, determined by magnetic resonance imaging. METHODS: Patients (N = 189) with atherosclerotic disease and either type 2 diabetes mellitus or impaired glucose tolerance were randomized to receive placebo (n = 94) or canakinumab 150 mg monthly (n = 95) for 12 months. They underwent magnetic resonance imaging of the carotid arteries and aorta. RESULTS: There were no statistically significant differences between canakinumab compared with placebo in the primary efficacy and safety endpoints. There was no statistically significant change in mean carotid wall area and no effect on aortic distensibility, measured at 3 separate anatomic sites. The change in mean carotid artery wall area was -3.37 mm2 after 12 months with canakinumab versus placebo. High-sensitivity C-reactive protein was significantly reduced by canakinumab compared with placebo at 3 months (geometric mean ratio [GMR]: 0.568; 95% confidence interval [CI]: 0.436 to 0.740; p < 0.0001) and 12 months (GMR: 0.56; 95% CI: 0.414 to 0.758; p = 0.0002). Lipoprotein(a) levels were reduced by canakinumab compared with placebo (-4.30 mg/dl [range: -8.5 to -0.55 mg/dl]; p = 0.025] at 12 months), but triglyceride levels increased (GMR: 1.20; 95% CI: 1.046 to 1.380; p = 0.01). In these patients with type 2 diabetes mellitus or impaired glucose tolerance, canakinumab had no effect compared with placebo on any of the measures assessed by using a standard oral glucose tolerance test. CONCLUSIONS: There were no statistically significant effects of canakinumab on measures of vascular structure or function. Canakinumab reduced markers of inflammation (high-sensitivity C-reactive protein and interleukin-6), and there were modest increases in levels of total cholesterol and triglycerides. (Safety & Effectiveness on Vascular Structure and Function of ACZ885 in Atherosclerosis and Either T2DM or IGT Patients; NCT00995930).