Revision: review of non-elective hospitalisations of adults with CHD.

Introduction The adult CHD population is increasing and ageing and remains at high risk for morbidity and mortality. In a retrospective single-centre study, we conducted a comprehensive review of non-elective hospitalisations of adults with CHD and explored factors associated with length of stay. METHODS: We identified adults (⩾18 years) with CHD admitted during a 12-month period and managed by the adult CHD service. Data regarding demographics, cardiac history, hospital admission, resource utilisation, and length of stay were extracted. RESULTS: There were 103 admissions of 91 patients (age 37±10 years; 52% female). Of 91 patients, 96% had moderate or complex defects. Of 103 admissions, 45% were through the emergency department. The most common reasons for admission were arrhythmia (37%) and heart failure (28%); 29% of admissions included a stay in the ICU. The mean number of consultations by other services was 2.0. Electrophysiology and anaesthesiology departments were most frequently consulted. After removing outliers, the mean length of stay was 7.9±7.4 days (median=5 days). The length of stay was longer for patients admitted for heart failure (12.2±10.3 days; p=0.001) and admitted directly to the ward (9.6±8.9 days; p=0.009). CONCLUSIONS: Among non-electively hospitalised adults with CHD in a tertiary-care centre, management often entails an interdisciplinary approach, and the length of stay is longest for patients admitted with heart failure. The healthcare system must ensure optimal resources to maintain high-quality care for this expanding patient population.

Surgical revascularization is associated with improved long-term outcomes compared with percutaneous stenting in most subgroups of patients with multivessel coronary artery disease: results from the Intermountain Heart Registry.

BACKGROUND: Coronary artery bypass surgery (CABG) and percutaneous coronary intervention with stenting (PCI-S) are both safe and effective approaches for revascularization in patients with multivessel coronary artery disease. However, conflicting information exists when comparing the efficacy of the two methods. In this study, we examined the outcomes of major adverse cardiovascular events and death for subgroups of typical "real-world" patients undergoing coronary revascularization in the modern era. METHODS AND RESULTS: Patients were included if they were revascularized by CABG or PCI-S, had > or = 5 years of follow-up, and had > or = 2-vessel disease. Patients were followed for an average of 7.0+/-3.2 years for incidence of death and major adverse cardiovascular events (death, myocardial infarction, or repeat revascularization). Multivariate regression models were used to correct for standard cardiac risk factors including age, sex, hyperlipidemia, diabetes mellitus, family history of coronary artery disease, smoking, hypertension, heart failure, and renal failure. Subgroup analyses were also performed, stratified by age, sex, diabetes, ejection fraction, and history of PCI-S, CABG, or myocardial infarction. A total of 6369 patients (CABG 4581; PCI-S 1788) were included. Age averaged 66+/-10.9 years, 76% were male, and 26% were diabetic. Multivariate risk favored CABG over PCI-S for both death (hazard ratio 0.85; P=0.001) and major adverse cardiovascular events (hazard ratio 0.51; P<0.0001). A similar advantage with CABG was also found in most substrata, including diabetes. CONCLUSIONS: In this large observational study of patients undergoing revascularization for multivessel coronary artery disease, a long-term benefit was found, in relationship to both death and major adverse cardiovascular events, for CABG over PCI-S regardless of diabetic status or other stratifications.

Statin therapy is associated with reduced mortality across all age groups of individuals with significant coronary disease, including very elderly patients.

OBJECTIVES: This study evaluated the effect of statin therapy on mortality in individuals with significant coronary artery disease (CAD) stratified by age. BACKGROUND: Hydroxymethylglutaryl coenzyme A reductase inhibitors (statins) significantly reduce morbidity and mortality in individuals with CAD. Unfortunately, the large statin trials excluded individuals over 80 years old, and it is therefore unknown whether very elderly individuals benefit from statins as do younger individuals. METHODS: A cohort of 7,220 individuals with angiographically defined significant CAD (> or =70%) was included. Statin prescription was determined at hospital discharge. Patients were followed up for 3.3 +/- 1.8 years (maximum 6.8). Patients were grouped by age (<65, 65 to 79, and > or =80 years) to determine whether statin therapy reduced mortality in an age-dependent manner. RESULTS: Average age was 65 +/- 12 years; 74% were male; and 31% had a postmyocardial infarction status. Overall mortality was 16%. Elderly patients were significantly less likely to receive statins than younger patients (> or =80 years: 19.8%; 65 to 79 years: 21.1%; <65 years: 28.0%; p < 0.001). Mortality was decreased among statin recipients in all age groups: > or =80 years: 29.5% among patients not taking a statin versus 8.5% of those taking a statin (adjusted hazard ratio [HR] 0.50, p = 0.036); 65 to 79 years: 18.7% vs. 6.0% (HR 0.56, p < 0.001); and <65 years: 8.9% vs. 3.1% (HR 0.70, p = 0.097). CONCLUSIONS: Statin therapy is associated with reduced mortality in all age groups of individuals with significant CAD, including very elderly individuals. Although older patients were less likely to receive statin therapy, they received a greater absolute risk reduction than younger individuals. More aggressive statin use after CAD diagnosis may be indicated, even in older patients.

Frequency of elevation of C-reactive protein in atrial fibrillation.

Inflammation has been implicated in the pathogenesis of cardiovascular diseases. C-reactive protein (CRP), a marker of systemic inflammation, predicts the risk of coronary events and stroke. Atrial fibrillation (AF) is associated with atrial structural changes that may have an inflammatory basis. We tested the hypothesis that CRP is a risk factor for AF. Subjects were those included in the database registry of the Intermountain Heart Collaborative Study from 1994 to 2001. Patients who had >or=1 electrocardiogram that demonstrated AF formed the disease group (n = 347), and those who had neither electrocardiographic nor clinical evidence for AF comprised the control group (n = 2,449). Logistic regression assessed the quartile (Q) of CRP and 13 other clinical and angiographic predictors of AF. Average age was 63 +/- 12 years, 33% were women, and 61% had advanced coronary artery disease. Patients who had AF were older (by 7 years) and more frequently had a history of heart failure than did controls (41% vs 9%). CRP was higher in patients who had AF than in controls (p <0.001). Q-CRP was a univariable predictor of AF (odds ratio 1.39/Q, 95% confidence interval 1.25 to 1.55, p <0.001). Adjusting for age and heart failure decreased the predictive value of Q-CRP to 1.20/Q (95% confidence 1.07 to 1.34, p = 0.002), whereas further adjustment for 11 other variables had little additional effect (odds ratio 1.19/Q, 95% confidence interval 1.06 to 1.33, p = 0.003). Thus, high levels of CRP independently predicted an increased risk of AF among a large, prospectively studied patient cohort that was assessed angiographically. Increased CRP is a new risk marker for AF propensity, and testing therapies that target inflammation should be considered.