Lifestyle and cardiovascular mortality in menopausal women: a population-based cohort study.

INTRODUCTION AND OBJECTIVES: There are models for cardiovascular risk prediction in the general population, but the prediction of risk in postmenopausal women has not been specifically studied. This study aimed to determine the association of lifestyle habits and chronic diseases with cardiovascular risk in menopausal women, as well as to build a risk scale. METHODS: Retrospective population-based cohort study using data from the 2011 National Health Survey of Spain as a data source, Women ≥ 50 years were included. The characteristics that best defined the life habits of the study women were collected, as well as their health status and self-reported medical history at the time of the survey. Follow-up data on all-cause mortality were obtained from participants from 2011 to 2017. RESULTS: A total of 5953 women ≥ 50 years of age were included, with a mean age of 66.4 ± 11.4 years. The incidence of cardiovascular mortality in the follow-up period was 4%. Vegetable consumption less than 1 time/week (HR, 1.758), smoking (HR, 1.816) or excess hours of sleep (≥ 9h/day, HR, 1.809), or o have main daily activity sitting most of the time (HR, 2.757) were related to cardiovascular mortality. The predictive model presents an honest C-index in test sample of 0.8407 (95%CI, 0.8025-0.8789). CONCLUSIONS: Life habits such as the consumption of vegetables, daily main activity, sleeping hours or smoking are risk factors for cardiovascular mortality of great relevance among menopausal women. A simple 6-year self-reported risk scale with high predictive capacity is provided.

Prevalence and Postdischarge Incidence of Malignancies in Patients With Acute Coronary Syndrome.

INTRODUCTION AND OBJECTIVES: Malignancies are the second cause of death in developed countries after cardiovascular disease and both share common risk factors. METHODS: This prospective study assessed the prevalence and postdischarge incidence of malignancies in all consecutive patients admitted for an acute coronary syndrome. RESULTS: A total of 1819 patients were included. On admission, the prevalence of malignancies was 3.4%, and 41.9% of the patients were considered disease-free; of the 1731 discharged patients, the incidence was 3.1% (53 cases) and the most common locations were the colon, lung, bladder, and pancreas. Patients with prevalent malignancies were older and had more comorbidities and complications. There were no differences in the revascularization rate, but implantation of drug-eluting stents was less frequent in patients with prevalent malignancies. During follow-up, the median time to diagnosis of incident malignancies was 25 months. On multivariate analysis, independent risk factors were age and current or former smoking. All-cause mortality was much higher in patients with incident (64.2%) or prevalent (40.0%) malignancies. Multivariate analysis showed that prevalent and incident malignancies increased the risk of all-cause mortality by 4-fold. CONCLUSIONS: Among patients admitted for an acute coronary syndrome, 3.8% had a history of malignancy, with less than 50% considered cured. The incidence of new malignancies was 3.4% and both types of malignancies substantially impaired the long-term prognosis.

Time-to-Effect-Based Dosing Strategy for Cryoballoon Ablation in Patients With Paroxysmal Atrial Fibrillation: Results of the plusONE Multicenter Randomized Controlled Noninferiority Trial.

BACKGROUND: The optimal dosage of cryotherapy during cryoballoon ablation of pulmonary veins is still unclear. This trial tested the noninferiority of a novel, individualized, cryotherapy-dosing strategy for each vein. METHODS AND RESULTS: This prospective, randomized, multicenter, noninferiority study included 140 patients with paroxysmal atrial fibrillation, which was refractory to antiarrhythmic drugs. Patients were randomly assigned to a conventional strategy of 180-second cryoballoon applications per vein with a bonus freeze (control group, n=70) or to a shorter-time application protocol, with 1 application that lasted the time required for electric block time to effect plus 60- and a 120-second freeze bonus (study group, n=70). Patients were followed with a long-term monitoring system of 30 days. At 1-year follow-up, no difference was observed in terms of free atrial fibrillation-recurrence rates: 79.4% in control versus 78.3% in study group (Δ=1.15%; 90% confidence interval, -10.33% to 12.63%; P=0.869). Time to effect was detected in 72.1% of veins. The control and study groups had similar mean number of applications per patient (9.6±2 versus 9.9±2.4; P=0.76). Compared with controls, the study group had a significantly shorter cryotherapy time (28.3±7 versus 19.4±4.3 minutes; P<0.001), left atrium time (104±25 versus 92±23 minutes; P<0.01), and total procedure time (135±35 versus 119±31 minutes; P<0.01). No differences were observed in complications or acute reconnections. CONCLUSIONS: The new time-to-effect-based cryotherapy dosage protocol led to shorter cryotherapy and procedure times, with equal safety, and similar acute and 1-year follow-up results, compared with the conventional approach. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT02789358.

Comparative Evaluation of Four Risk Scores for Predicting Mortality in Patients With Implantable Cardioverter-defibrillator for Primary Prevention.

INTRODUCTION AND OBJECTIVES: Several clinical risk scores have been developed to identify patients at high risk of all-cause mortality despite implantation of an implantable cardioverter-defibrillator. We aimed to examine and compare the predictive capacity of 4 simple scoring systems (MADIT-II, FADES, PACE and SHOCKED) for predicting mortality after defibrillator implantation for primary prevention of sudden cardiac death in a Mediterranean country. METHODS: A multicenter retrospective study was performed in 15 Spanish hospitals. Consecutive patients referred for defibrillator implantation between January 2010 and December 2011 were included. RESULTS: A total of 916 patients with ischemic and nonischemic heart disease were included (mean age, 62 ± 11 years, 81.4% male). Over 33.4 ± 12.9 months, 113 (12.3%) patients died (cardiovascular origin in 86 [9.4%] patients). At 12, 24, 36, and 48 months, mortality rates were 4.5%, 7.6%, 10.8%, and 12.3% respectively. All the risk scores showed a stepwise increase in the risk of death throughout the scoring system of each of the scores and all 4 scores identified patients at greater risk of mortality. The scores were significantly associated with all-cause mortality throughout the follow-up period. PACE displayed the lowest c-index value regardless of whether the population had heart disease of ischemic (c-statistic = 0.61) or nonischemic origin (c-statistic = 0.61), whereas MADIT-II (c-statistic = 0.67 and 0.65 in ischemic and nonischemic cardiomyopathy, respectively), SHOCKED (c-statistic = 0.68 and 0.66, respectively), and FADES (c-statistic = 0.66 and 0.60) provided similar c-statistic values (P ≥ .09). CONCLUSIONS: In this nontrial-based cohort of Mediterranean patients, the 4 evaluated risk scores showed a significant stepwise increase in the risk of death. Among the currently available risk scores, MADIT-II, FADES, and SHOCKED provide slightly better performance than PACE.

Prevención primaria con cardiodesfibrilador implantable y terapia de resincronización cardíaca en pacientes ancianos: resultados de un estudio multicéntrico español

Propósito: a la fecha sigue sin haber pruebas en cuanto a los resultados del uso de dispositivos para arritmias ventriculares en pacientes añosos, y menos aun para indicaciones de prevención primaria. La finalidad del estudio fue describir la evolución en términos de la eficacia y seguridad de la terapia con cardiodesfibriladores implantables (CDI) en una gran cohorte de pacientes añosos. Métodos y resultados: estudio multicéntrico retrospectivo realizado en 15 hospitales españoles. Se incluyeron pacientes consecutivos referidos para implante de CDI antes de 2011. Se consideró que 162 de los 1.174 pacientes (13,8%) con 75 años o más eran “añosos”. Comparado con aquellos pacientes <75 años, este subgrupo presentaba más comorbilidades como hipertensión, enfermedad pulmonar obstructiva crónica y falla renal, y más internaciones previas debido a insuficiencia cardíaca (IC). A lo largo de una media de seguimiento de 104,4 ± 3,3 meses, fallecieron 162 pacientes (14%), 120 de los más jóvenes (12,4%) y 42 (24,4%) de los añosos. El análisis de Kaplan-Meier mostró un aumento de la probabilidad de morir con el aumento de la edad (17, 24, 28, y 69% a los 12, 24, 48, y 60 meses de seguimiento en el grupo de pacientes añosos). No hubo diferencias entre la tasa de intervenciones con CDI apropiadas o inapropiadas. Conclusión: en el mundo real, los pacientes añosos constituyen ~15% de los implantes de CDI para prevención primaria de la muerte súbita cardíaca (MSC). Si bien la tasa de terapias apropiadas es similar en los diferentes grupos, el beneficio de CDI se ve atenuado por un mayor aumento del riesgo de mortalidad entre los pacientes que son mayores de 75 años al momento del implante.

Choice of New Oral Anticoagulant Agents Versus Vitamin K Antagonists in Atrial Fibrillation: FANTASIIA Study.

INTRODUCTION: Atrial fibrillation (AF) is associated with an increased risk of thromboembolic events. Many patients with AF receive chronic anticoagulation, either with vitamin K antagonists (VKAs) or with non-VKA oral anticoagulants (NOACs). We sought to analyze variables associated with prescription of NOAC. METHODS: Patients with AF under anticoagulation treatment were prospectively recruited in this observational registry. The sample comprised 1290 patients under chronic anticoagulation for AF, 994 received VKA (77.1%) and 296 NOAC (22.9%). Univariate and multivariate analyses were performed to identify variables associated with use of NOAC. RESULTS: Mean age was 73.8 ± 9.4 years, and 42.5% of the patients were women. The CHA2DS2-VASc score was 0 in 4.9% of the population, 1 in 24.1%, and ≥2 in 71% (median = 4, interquartile range = 2). Variables associated with NOAC treatment were major bleeding (odds ratio [OR] = 3.36; confidence interval [CI] 95%: 1.73-6.51; P < .001), hemorrhagic stroke (OR = 3.19; CI 95% 1.00-10.15, P = .049), university education (OR = 2.44; CI 95%: 1.55-3.84; P < .001), high diastolic blood pressure (OR = 1.02; CI 95%: 1.00-1.03; P = .006), and higher glomerular filtration rate (OR 1.01, CI 95% 1.00-1.01; P = .01). And variables associated with VKA use were history of cancer (OR = 0.46; CI 95%: 0.25-0.85; P = .013) and bradyarrhythmia (OR = 0.40; CI 95% 0.19-0.85; P = .020). CONCLUSION: Medical and social variables were associated with prescription of NOAC. Major bleeding, hemorrhagic stroke, university education, and higher glomerular filtration rate were more frequent among patients under NOAC. On the contrary, patients with history of cancer or bradyarrhythmias more frequently received VKA.

Patients with cardiac disease: Changes observed through last decade in out-patient clinics.

AIM: To describe current profile of patients with cardiovascular disease (CVD) and assessing changes through last decade. METHODS: Comparison of patients with established CVD from two similar cross-sectional registries performed in 1999 (n = 6194) and 2009 (n = 4639). The types of CVD were coronary heart disease (CHD), heart failure (HF) and atrial fibrillation (AF). Patients were collected from outpatient clinics. Investigators were 80% cardiologist and 20% primary care practitioners. Clinical antecedents, major diagnosis, blood test results and medical treatments were collected from all patients. RESULTS: An increase in all risk factors, except for smoking, was observed; a 54.4% relative increase in BP control was noted. CHD was the most prevalent CVD but HF and AF increased significantly, 41.5% and 33.7%, respectively. A significant reduction in serum lipid levels was observed. The use of statins increased by 141.1% as did all cardiovascular treatments. Moreover, the use of angiotensin-renin system inhibitors in patients with HF, beta-blockers in CHD patients or oral anticoagulants in AF patients increased by 83.0%, 80.3% and 156.0%, respectively (P < 0.01). CONCLUSION: The prevalence of all cardiovascular risk factors has increased in patients with CVD through last decade. HF and AF have experienced the largest increases.

Inflammation and apoptosis in hypertension. Relevance of the extent of target organ damage.

INTRODUCTION AND OBJECTIVES: To investigate the relationship between inflammatory and apoptotic parameters and the severity and extent of target organ damage in patients with essential hypertension. METHODS: We studied 159 consecutive patients with treated essential hypertension. An exhaustive evaluation of damage to heart, kidney, and blood vessels was performed and plasma levels of inflammatory (interleukin 6 and soluble receptor of tumor necrosis factor-alpha type 2) and apoptotic markers (soluble receptor of tumor necrosis factor-alpha type 1 and soluble Fas receptor) were determined. Patients were categorized into four groups: a) no organ damage (33 patients); b) 1 organ damaged (52 patients); c) 2 organs damaged (44 patients), and d) 3 organs damaged (30 patients). RESULTS: Serum levels of interleukin 6, soluble receptor of tumor necrosis factor-alpha type 1 and soluble receptor of tumor necrosis factor-alpha type 2 were higher in patients with target organ damage than in hypertensive patients without organ damage. Increasing levels of these molecules were progressively associated with an increase in the number of organs damaged, and the highest levels were observed in the group with damage to 3 organs (heart, kidney, and blood vessels). There were no differences in soluble Fas receptor levels between groups. Logistic regression analysis showed that age, smoking, diabetes mellitus, abdominal circumference, interleukin 6, and soluble receptor of tumor necrosis factor-alpha type 1 were independently related to the number of target organs damaged. CONCLUSIONS: Extensive hypertensive disease with involvement of more target organs was associated with greater inflammatory and apoptotic activation in these hypertensive patients.

Low levels of high-density lipoproteins cholesterol are independently associated with acute coronary heart disease in patients hospitalized for chest pain.

INTRODUCTION AND OBJECTIVES: The role of high-density lipoproteins in the context of acute chest pain has not been well characterized. The objective of this study was to determine the relative contribution of lipid profile to the risk of acute coronary syndrome in patients admitted to a cardiology ward for chest pain. METHODS: We included all consecutive admissions in a single cardiology department over a period of 10 months and 1-year follow-up was performed. RESULTS: In total, 959 patients were included: 457 (47.7%) were diagnosed with non-ischemic chest pain, 355 (37%) with non-ST-elevation acute coronary syndrome, and 147 (15.3%) with ST-elevation acute coronary syndrome. Prevalence of high-density lipoproteins <40 mg/dL was 54.6%, and was higher in patients with acute coronary syndrome (69.4% vs 30.6%; P<.01). The prevalence of acute coronary syndrome increased with reductions in mean high-density lipoproteins. Age, active smoking, diabetes, fasting glucose >100 mg/dL, and high-density lipoproteins <40 mg/dL were independently associated with acute coronary syndrome, and low high-density lipoproteins was the main associated factor (odds ratio, 4.11; 95% confidence interval, 2.87-5.96). Survival analysis determined that, compared with non-ischemic chest pain, the presence of acute coronary syndrome was associated with significantly greater risk of all-cause and cardiovascular mortality. CONCLUSIONS: Low levels of high-density lipoproteins cholesterol (≤40 mg/dL) were independently associated with a diagnosis of acute coronary syndrome in patients hospitalized for chest pain, with an inverse relationship between lower levels of high-density lipoproteins and prevalence of acute coronary syndrome.

[Factors associated with uncontrolled hypertension in patients with and without cardiovascular disease]. / Factores asociados a la falta de control de la hipertensión arterial en pacientes con y sin enfermedad cardiovascular.

INTRODUCTION AND OBJECTIVES: Hypertension is one of the most prevalent and poorly controlled risk factors, especially in patients with established cardiovascular disease (CVD). The aim of this study was to describe the rate of blood pressure (BP) control and related risk factors. METHODS: Multicenter, cross-sectional and observational registry of patients with hypertension recruited from cardiology and primary care outpatient clinics. Controlled BP defined as <140/90 mmHg. RESULTS: 55.4% of the 10 743 patients included had controlled BP and these had a slightly higher mean age. Patients with uncontrolled BP were more frequently male, with a higher prevalence of active smokers, obese patients, and patients with diabetes. The rate of controlled BP was similar in patients with or without CVD. Patients with uncontrolled BP had higher levels of blood glucose, total cholesterol, low density lipoproteins and uric acid. Patients with uncontrolled BP were receiving a slightly higher mean number of antihypertensive drugs compared to patients with controlled BP. Patients with CVD were more frequently receiving a renin-angiotensin-aldosterone axis inhibitor: 83.5% vs. 73.2% (P<.01). Multivariate analysis identified obesity and current smoking as independently associated with uncontrolled BP, both in patients with or without CVD, as well as relevant differences between the two groups on other factors. CONCLUSIONS: Regardless of the presence of CVD, 55% of hypertensive patients had controlled BP. Lifestyle and diet, especially smoking and obesity, are independently associated with lack of BP control. Full English text available from: www.revespcardiol.org.

Pathological ankle-brachial index is equivalent of advanced age in acute coronary syndromes.

BACKGROUND: Age is one the factors associated with poor prognosis in acute coronary syndromes (ACS) and elderly patients are a high-risk collective with few parameters for mid-term cardiovascular stratification. We aimed to assess the predictive value of ankle-brachial index (ABI) in patients (> 75 years) for 1-year mortality after an ACS. MATERIALS AND METHODS: Prospective, observational and multicentre study of ACS patients in whom ABI was assessed during hospitalization. RESULTS: A total of 1·054 patients were included, mean age 66·6 (11·7) years from whom 26·6% were > 75 years. Elderly patients showed more history of cardiovascular disease and higher prevalence of all risk factors, except current smoking. Angiography and revascularization were performed less frequently in the elderly. Patients > 75 years showed higher presence of three vessel coronary disease and received fewer guideline-recommended treatments. Patients who died through the follow-up, mean time 387·9 ± 7·2 days, had lower ABI (0·73 ± 0·24 vs. 0·92 ± 0·22; P < 0·01), also in the elderly patients (0·73 ± 0·24 vs. 0·86 ± 0·23; P < 0·01). Cox regression analysis identified age > 75 years (HR: 2·30; IC 95% 1·26-4·18; P < 0·01) and ABI < 0·90 (HR: 3·58; IC 95% 1·80-7·15; P < 0·01) as risk factors for to 1-year mortality. Mortality was similar in elderly patients with ABI > 0·90 and young patients with ABI < 0·90; the worst prognosis was observed in elderly patients with ABI < 0·90 (HR: 10·01; 95% CI 3·74-27·15). CONCLUSIONS: Elderly patients represent a relevant collective of patients with ACS and are treated less optimally. ABI predicts 1-year mortality after an ACS in elderly patients.

Improvement in risk stratification with the combination of the tumour marker antigen carbohydrate 125 and brain natriuretic peptide in patients with acute heart failure.

AIM: Elevated brain natriuretic peptide (BNP) and tumour marker antigen carbohydrate 125 (CA125) levels have shown to be associated with higher risk for adverse outcomes in patients with acute heart failure (AHF). Nevertheless, no attempt has been made to explore the utility of combining these two biomarkers. We sought to assess whether CA125 adds prognostic value to BNP in predicting 6-month all-cause mortality in patients with AHF. METHODS AND RESULTS: We analysed 1111 consecutive patients admitted for AHF. Antigen carbohydrate 125 (U/mL) and BNP (pg/mL) were measured at a median of 72 +/- 12 h after instauration of treatment. Antigen carbohydrate 125 and BNP were dichotomized based on proposed prognostic cutpoints, and a variable with four categories was formed (BNP-CA125): C1 = BNP < 350 and CA125 < 60 (n = 394); C2 = BNP > or = 350 and CA125 < 60 (n = 165); C3 = BNP < 350 and CA125 > or = 60 (n = 331); and C4 = BNP > or = 350 and CA125 > or = 60 (n = 221). The independent association between BNP-CA125 and mortality was assessed with the Cox regression analysis, and their added predictive ability tested by the integrated discrimination improvement (IDI) index. At 6 months, 181 deaths (16.3%) were identified. The cumulative rate of mortality was lower for patients in C1 (7.8%), intermediate for C2 and C3 (17.8% and 16.9%, respectively), and higher for C4 (37.2%), and P-value for trend <0.001. After adjusting for established risk factors, the highest risk was observed when both biomarkers were elevated (C4 vs. C1: HR = 4.05, 95% CI = 2.54-6.45; P < 0.001) and intermediate when only one of them was elevated: (C2 vs. C1: HR = 1.71, 95% CI = 1.00-2.93; P = 0.050) and (C3 vs. C1: HR = 2.10, 95% CI = 1.30-3.39; P = 0.002). Moreover, when CA125 was added to the clinical model + BNP, a 10.4% (P < 0.0001) improvement in the IDI (on the relative scale) was found. CONCLUSION: In patients admitted with AHF, CA125 added prognostic value beyond the information provided by BNP, and thus, their combination enables better 6-month risk stratification.

Association between renal function and cardiovascular disease in patients with left ventricular hypertrophy. VIIDA study.

The association between renal dysfunction and cardiovascular risk in patients with hypertension and left ventricular hypertrophy (LVH) has not been specifically studied. The aim of this study was to analyze the association between renal function and the presence of cardiovascular disease in this group of patients. Hypertensive patients with electrocardiographic criteria for LVH were recruited in cardiology outpatient clinics from April 2003 until November 2004. Epidemiologic variables were determined, together with an estimation of the glomerular filtration rate by means of the Modification of Diet in Renal Disease (MDRD) and Crockoft-Gault equations. The population was classified according to the kidney disease stages of the National Kidney Foundation. A total of 3962 patients were included in the study, 47.6% of which were female, with a mean age of 67.2 years. The prevalence of established cardiovascular disease was higher in patients with a depressed glomerular filtration rate (68.3% vs 54.9%; P<.001). After adjusting for age, sex, body mass index, diabetes, smoking habits, and systolic and diastolic blood pressures, the stage of renal function was an independent predictor of the presence of cardiovascular disease (odds ratio, 1.5 [confidence interval, 1.19-2.02]; 2.1 [1.55-2.89]; and 2.6 [1.52-4.42], respectively, for stages 2, 3, 4-5, compared with stage 1). In hypertensive patients with electrocardiographic criteria for LVH, the determination of the glomerular filtration rate by the MDRD or Crockoft equations is easy and identifies a progressive and independent increase in cardiovascular risk.

[Invasive strategy in patients with advanced diabetes and non-ST-segment elevation acute coronary syndrome. Angiographic findings and clinical follow-up. PREDICAR study results]. / Estrategia invasiva en pacientes con diabetes avanzada y síndrome coronario agudo sin elevación del segmento ST. Hallazgos angiográficos y evolución clínica. Resultados del estudio PREDICAR.

INTRODUCTION AND OBJECTIVES: Advanced diabetes can be associated with diffuse coronary artery disease that is difficult to treat by revascularization. We studied angiographic findings and disease progression in patients with advanced diabetes (either insulin-dependent or taking antidiabetic drugs for >5 years) and non-ST-elevation acute coronary syndrome who were being treated using an invasive strategy. METHODS: The study included 141 patients. The extent of the coronary artery disease was quantified using a score derived from a 29-segment coronary angiogram. The composite endpoint was death, myocardial infarction, or readmission for unstable angina within one year of follow-up. RESULTS: The extent of coronary disease was associated with Killip class >1 at admission (P=.02), previous coronary surgery (P=.003), ST-segment depression (P=.01), and a poor ejection fraction (P=.0001). The more of these factors present (i.e., 0, 1, 2 or 3 factors), the greater the extent of the coronary disease (i.e., 12 [7], 15 [7], 21 [6] and 23 [7] points, respectively; P=.0001). There was a significant difference between patients with > or =2 factors and those with P=.02), even after adjustment using a revascularization propensity score (C-index 0.80). CONCLUSIONS: In patients with non-ST-elevation acute coronary syndrome and advanced diabetes being managed using an invasive strategy, a history of coronary surgery, ST-segment depression and poor left ventricular function were all associated with the presence of diffuse coronary artery disease. Clinical follow-up indicated that revascularization during hospital admission improved prognosis.