Plasma MCP-1 level and risk for peripheral arterial disease and incident coronary heart disease: Atherosclerosis Risk in Communities study.

Monocyte chemoattractant protein-1 (MCP-1), which mediates the recruitment of monocytes, has been suggested to play a role in atherosclerosis. Because the correlation between circulating MCP-1 and cardiovascular risk has not been thoroughly investigated, we determined the relationship between MCP-1 level and peripheral arterial disease (PAD) or coronary heart disease (CHD). In the Atherosclerosis Risk in Communities (ARIC) study, 209 cases with lower extremity PAD and 412 cases with incident CHD were compared with 733 and 709 subjects without PAD and CHD, respectively. Mean plasma MCP-1 levels were significantly higher in PAD cases (468.7 versus 416.5 pg/mL in non-cases). MCP-1 levels correlated significantly with other inflammatory markers in comparison subjects. Logistic regression analyses showed a significant association of MCP-1 with PAD, independent of traditional CHD risk factors, with an odds ratio of 2.14 (95% CI, 1.28-3.60) for the highest MCP-1 tertile compared with the lowest. Incident CHD risk increased significantly per 1 standard deviation (S.D.) difference in MCP-1 level independent of other cardiovascular risk factors, including inflammatory markers. These data show that MCP-1 is associated with atherosclerotic disease in two vascular beds and suggest that MCP-1 may be a novel target for atherosclerosis therapy.

Impact of implantable cardioverter defibrillators on survival and recurrent hospitalization in advanced heart failure.

BACKGROUND: Although implantable cardioverter defibrillators (ICDs) are increasingly used in advanced (class III/IV) heart failure, their benefits may be limited by death from pump failure and data are limited. The aim of this study was to assess the impact of QRS duration and disease etiology on survival and rehospitalization in advanced heart failure patients with ICDs. METHODS: A retrospective study of 438 patients with heart failure (age 56 +/- 15, ejection fraction 29 +/- 15, 76% class III/IV) discharged between 1996 and 2000 was performed. RESULTS: An ICD was placed in 94 of the 438 patients for nonsustained (51.1%) or sustained (24.4%) ventricular arrhythmia, syncope (16.0%), or prophylaxis (8.5%). Patients with ICDs had a lower mean baseline ejection fraction (25% vs 30%, P = .007) but a trend toward fewer class IV symptoms (33% vs 44%, P = .164). Patients with ICDs had better survival (RR 0.48, P = .001) but increased rehospitalization (RR 1.41, P = .031). In both the ischemic and nonischemic subgroups, survival was superior in patients with ICDs (RR 0.38, P = .003 and RR 0.54, P = .042). Patients with QRS < 120 milliseconds had a trend toward better survival with an ICD (RR 0.42, P = .119) but increased rehospitalization (RR 2.13, P = .021). Patients with QRS > or = 120 milliseconds had better survival with an ICD (RR 0.45, P = .001) without increased risk of rehospitalization (RR 1.22, P = .314). CONCLUSIONS: Patients with advanced heart failure selected to receive ICDs have better survival trends but shorter time to rehospitalization than patients without ICDs. Benefit appears greater for those with prolonged QRS duration.

Trends in prehospital delay time and use of emergency medical services for acute myocardial infarction: experience in 4 US communities from 1987-2000.

BACKGROUND: Prolonged delay in seeking care for acute myocardial infarction (AMI) is associated with decreased use of time-dependent treatments and increased mortality and morbidity. METHODS: Time from symptom onset to arrival at hospital and emergency medical service use were abstracted from medical records of 18,928 patients hospitalized for AMI and captured in the community surveillance component of the ARIC study from 1987 to 2000. A cut point of 4 hours was used to assess clinically relevant delay time recommendations for treatment with current therapies. RESULTS: In 2000, the overall proportion of persons with delays from symptom onset to hospital arrival of > or = 4 hours was 49.5%. Blacks and women consistently delayed longer than whites and men. Between 1987 and 2000, there was no statistically significant change in the proportion of patients delaying > or = 4 hours (relative change +0.6% in men, -7.4% in women, -2.3% in whites, -8.9% in blacks, -7.9% in persons with diabetes, and -0.8% in persons without diabetes); however, there is a noticeable narrowing of gaps between sex, race, and diabetes status over the study period. The percentage of those who used emergency medical services increased significantly over the study period (1987 37.1%, 2000 44.5%, P < or = .0001). CONCLUSIONS: Many patients continue to experience prolonged delays from onset of symptoms to hospital arrival. Delay time for hospitalized AMI changed little in the ARIC communities from 1987 to 2000. New public health strategies should be developed to facilitate rapid access to acute care for AMI.

Chest pain relief by nitroglycerin does not predict active coronary artery disease.

BACKGROUND: The belief that chest pain relief with nitroglycerin indicates the presence of active coronary artery disease is common. However, this hypothesis has not been tested. OBJECTIVE: To define the diagnostic and prognostic value of chest pain relief with nitroglycerin. DESIGN: Prospective observational cohort study. SETTING: Urban community teaching hospital. PATIENTS: 459 consecutive patients with chest pain admitted through the emergency department who received nitroglycerin from emergency services personnel or an emergency department nurse. Follow-up was obtained by telephone contact at 4 months. MEASUREMENTS: Chest pain relief was defined as a decrease of at least 50% in patients' self-reported pain within 5 minutes of the initial dose of sublingual or spray nitroglycerin. Active coronary artery disease was defined as any elevated serum enzyme levels, coronary angiography demonstrating a 70% or greater stenosis, or a positive exercise test result. RESULTS: Nitroglycerin relieved chest pain in 39% of patients (181 of 459). In patients with active coronary artery disease as the likely cause of their chest pain, 35% (49 of 141) had chest pain relief with nitroglycerin. In contrast, in patients without active coronary artery disease, 41% (113 of 275) had chest pain relief (P > 0.2). Four-month clinical outcomes were similar in patients with or without chest pain relief with nitroglycerin (P > 0.2). CONCLUSIONS: These data suggest that, in a general population admitted for chest pain, relief of pain after nitroglycerin treatment does not predict active coronary artery disease and should not be used to guide diagnosis.

Prognostic usefulness of marginal troponin T elevation.

Marginal elevations of troponin T among patients with chest pain are often considered to be insignificant. We sought to define the prognostic value of marginal troponin T elevations in patients presenting to the emergency department with suspected myocardial ischemia. Four hundred twenty-eight consecutive patients presenting to the emergency department with ongoing chest pain were evaluated, followed through their hospital course, and contacted for follow-up 4 months after discharge. Two hundred ninety-nine patients had undetectable troponin T levels (<0.01 microg/L), 76 had marginal troponin T elevations (0.01 to 0.09 microg/L), and 53 had frank troponin T elevations (> or =0.1 microg/L). Patients with either marginally or frank elevated troponin levels were older and more likely to be men, but did not differ from patients with undetectable troponin levels with regard to the prevalence of coronary artery disease risk factors, history of coronary disease, or race. While in the hospital, the undetectable and marginal troponin groups were referred for cardiac testing in equal proportions (58% and 59%, respectively), whereas 87% of the elevated group underwent further testing. After adjustment for possible confounders, a significantly increased rate of death/myocardial infarction/revascularization was observed in the marginal troponin group compared with the undetectable troponin group (p = 0.004). Marginal elevations of troponin T identified a currently underevaluated high-risk subgroup of patients with suspected myocardial ischemia who are more likely to have adverse clinical outcomes than those with undetectable troponin levels.