Physiologic risk stratification is important to long-term mortality, complications, and readmission in thoracic endovascular aortic repair.

Use of the American Society of Anesthesiologists (ASA) physical status classification is important for periprocedural risk stratification. However, the collective effect after adjustment for the Society for Vascular Surgery (SVS) medical comorbidity grading system on long-term all-cause mortality, complications, and discharge disposition is unknown. We examined these associations in patients after thoracic endograft placement. Data from three thoracic endovascular aortic repair (TEVAR) trials through 5 years of follow-up were included. Patients with acute complicated type B dissection (n = 50), traumatic transection (n = 101), or descending thoracic aneurysm (n = 66) were analyzed. The patients were stratified into three groups according to the ASA class: I-II, III, and IV. Multivariable proportional hazards regression models were used to examine the effect of ASA class on 5-year mortality, complications, and rehospitalizations after adjustment for SVS risk score and potential confounders. The largest proportion of patients treated by TEVAR across the ASA groups (n = 217) was ASA IV (n = 97; 44.7%; P < .001), followed by ASA III (n = 83; 38.2%) and ASA I-II (n = 37; 17.1%). Among the ASA groups, the ASA I-II patients were, on average, 6 years younger than those with ASA III and 3 years older than those with ASA IV (ASA I-II: age, 54.3 ± 22.0 years; ASA III: age, 60.0 ± 19.7 years; ASA IV: age, 51.0 ± 18.4 years; P = .009). Multivariable adjusted 5-year outcome models showed that ASA class IV, independent of the SVS score, conferred an increased risk of mortality (hazard ratio [HR], 3.83; 95% confidence interval [CI], 1.19-12.25; P = .0239) and complications (HR, 4.53; 95% CI, 1.69-12.13; P = .0027) but not rehospitalization (HR, 1.84; 95% CI, 0.93-3.68; P = .0817) compared with ASA class I-II. Procedural ASA class is associated with long-term outcomes among post-TEVAR patients, independent of the SVS score. The ASA class and SVS score remain important to patient counseling and postoperative outcomes beyond the index operation.

Using liver elastography to diagnose sinusoidal obstruction syndrome in pediatric patients undergoing hematopoetic stem cell transplant.

Sinusoidal obstruction syndrome (SOS) is a potentially fatal complication of hematopoietic stem cell transplantation (HSCT). Traditional ultrasound (US) has poor sensitivity and specificity. US shear wave elastography (SWE) is a newer technology that measures liver stiffness. This is a single-institution, prospective cohort study evaluating SWE in patients younger than 21 years who received HSCT from December 2015 through June 2017. SOS was defined using the modified Seattle criteria. Subjects had US with SWE at three scheduled time points. t-tests were used to assess for difference between the groups and ROC curves were generated. Twenty-five patients were included. Five subjects developed SOS. At day +5 HSCT, SOS patients had SWE velocities that increased by 0.25 ± 0.21 m/s compared to 0.02 ± 0.18 in patients without SOS (p = 0.020). At day +14, SOS patients had SWE velocities that significantly increased by 0.91 m/s ± 1.14 m/s compared to 0.03 m/s ± 0.23 m/s in patients without SOS (p = 0.010). SWE SOS diagnosis occurred on average 9 and 11 days before clinical and conventional US diagnosis, respectively. Patients who develop SOS have increased liver stiffness compared to patients who do not develop SOS. SWE changes occur before other imaging and clinical findings of SOS.

Expression of HBME-1 and CD56 in follicular variant of papillary carcinoma in children: An immunohistochemical study and their diagnostic utility.

Papillary thyroid carcinoma (PTC) is the most common differentiated thyroid cancer in children; and the follicular variant is the second most common variant after the classic subtype. The histological appearance of follicular variant of papillary thyroid cancer (FVPTC), can be mimicked by benign follicular nodules. Pediatric pathologists encountering such lesions with FVPTC-like appearance may err on diagnosing the benign lesions as malignant. In adult patients, several immunohistochemical markers have emerged recently as a useful adjunct to distinguish differentiated thyroid carcinomas from benign follicular lesions. We undertook an inter-institutional retrospective study to establish the diagnostic utility of immunohistochemical staining for HBME-1, Galectin-3 and CD56 in differentiating FVPTC from its benign mimics, follicular adenoma and adenomatoid nodules, in children. Our specific aim of the project was to define the sensitivity and specificity of the three antibodies in FVPTC. Based on institutional diagnoses, a total of 66 cases were obtained: 32 FVPTC and 34 benign follicular nodules that comprised of 23 follicular adenoma and 11 adenomatoid nodules. Five investigators, who were blinded to the original diagnoses, independently reviewed the slides following pre-determined criteria and semi-quantitatively scoring the immunohistochemical staining. The immunohistochemical staining revealed that a combination of positive HBME-1 and negative CD56 result gave 100% specificity and positive predictive value in distinguishing FVPTC from benign follicular nodules. However, the antibody combination suffered from a lower sensitivity (50%). We used a cutoff of 25% positivity of tumor cells in determining positivity of tumor cells to an antibody. In conclusion, our study found a very high specificity and strong positive predictive value for the combination of HBME-1 and CD56 immunohistochemical stains in distinguishing FVPTC from benign follicular lesions.

Interstage Outcomes in Infants With Single Ventricle Heart Disease Comparing Home Monitoring Technology to Three-Ring Binder Documentation: A Randomized Crossover Study.

BACKGROUND: Interstage outcomes for infants with single ventricle remain suboptimal. We have previously described a tablet PC-based platform Cardiac High Acuity Monitoring Program (CHAMP) for remote monitoring which provides immediate access to data, videos, and instant alerts to our single ventricle care team. METHODS: This study compares traditional three-ring binder monitoring (Binder) to CHAMP using a randomized crossover design to evaluate mortality, resource utilization, and caregiver experience. At discharge, all single ventricle infants were monitored using Binder and randomized to receive CHAMP at either one or two months postdischarge. One month after randomization, caregivers could choose either Binder or CHAMP for the remainder of the interstage period. Caregivers experience was recorded using surveys. RESULTS: Enrollment included 31 single ventricle infants from May 2014 to June 2015. There was no interstage mortality over 4,911 total interstage days (median: 144/patient). Of 73 readmissions, 45 were unplanned. Of the initial 23 unplanned readmissions, 13 were found to have been based on data obtained exclusively through CHAMP (as instant alerts or based on data review) rather than caregiver concerns. Due to concerns regarding patient safety, additional enrollment was stopped. The CHAMP use was associated with significantly fewer unplanned intensive care unit days/100 interstage days, shorter delays in care, lower resource utilization at readmissions, and lower incidence of interstage growth failure and was preferred by a majority of caregivers. CONCLUSIONS: These findings suggest that CHAMP may offer benefits over Binder (improved interstage outcomes, delays in care, and caregiver experience). These findings should be tested across multiple centers in larger populations.

Post-ligation cardiac syndrome is associated with increased morbidity in preterm infants.

OBJECTIVE: The influence of post-ligation cardiac syndrome (PLCS), a complication of patent ductus arteriosus (PDA) ligations, on neonatal outcomes is unknown. The purpose of this study was to determine the risks of PLCS on severe pulmonary morbidity and severe retinopathy of prematurity (ROP). STUDY DESIGN: Retrospective cohort study of infants who underwent a PDA ligation between 2006 and 2015. Data were collected on patients with and without PLCS. The primary outcome was the difference in severe bronchopulmonary dysplasia (BPD) between groups. Secondary outcomes included discharge with home oxygen and severe ROP. RESULT: A total of 100 infants that underwent PDA ligation during the study period were included in the study; 31 (31%) neonates developed PLCS. In adjusted analysis, PLCS was associated with increased risk for severe BPD (RR 1.67, 95% CI: 1.15-2.42) and home oxygen therapy (RR: 1.47, 95% CI: 1.09-1.99) only. No association with severe ROP was seen (RR: 1.48; 95% CI: 0.87-2.52). CONCLUSION: PLCS is associated with severe neonatal pulmonary morbidity, but not with severe ROP. Further investigation is warranted to validate these results.

Prevalence of traditional cardiac risk factors and secondary prevention among patients hospitalized for acute myocardial infarction (AMI): variation by age, sex, and race.

BACKGROUND: Modification of traditional cardiac risk factors is an important goal for patients after an acute myocardial infarction (AMI). Risk factor prevalence and secondary prevention efforts at discharge are well characterized among older patients; however, research is limited for younger and minority AMI populations, particularly among women. METHODS: Among 2369 AMI patients enrolled in a 19-center prospective study, we compared the prevalence and cumulative number of five cardiac risk factors (hypertension, hypercholesterolemia, current smoking, diabetes, obesity) by age, sex, and race. We also compared secondary prevention strategies at discharge for these risk factors, including prescription of antihypertensive or lipid-lowering medications and counseling on preventive behaviors (smoking cessation, diabetes management, diet/weight management). RESULTS: Approximately 93% of patients had ≥1 risk factor, 72% had ≥2 factors, and 40% had ≥3 factors. The prevalence of multiple risk factors was markedly higher for blacks than for whites within each age-sex group; black women had the greatest risk factor burden of any subgroup (60% of older black women and 54% of younger black women had ≥3 risk factors). Secondary prevention efforts for smoking cessation were less common for black compared with white patients, and younger black patients were less often prescribed antihypertensive and lipid-lowering medications compared with younger white patients. CONCLUSIONS: Multiple cardiac risk factors are highly prevalent in AMI patients, particularly among black women. Secondary prevention efforts, however, are less common for blacks compared to whites, especially among younger patients. Our findings highlight the need for improved risk factor modification efforts in these high-risk subgroups.

Body mass index and mortality in acute myocardial infarction patients.

BACKGROUND: Previous studies have described an "obesity paradox" with heart failure, whereby higher body mass index (BMI) is associated with lower mortality. However, little is known about the impact of obesity on survival after acute myocardial infarction. METHODS: Data from 2 registries of patients hospitalized in the US with acute myocardial infarction between 2003-2004 (PREMIER) and 2005-2008 (TRIUMPH) were used to examine the association of BMI with mortality. Patients (n=6359) were categorized into BMI groups (kg/m(2)) using baseline measurements. Two sets of analyses were performed using Cox proportional hazards regression with fractional polynomials to model BMI as categorical and continuous variables. To assess the independent association of BMI with mortality, analyses were repeated, adjusting for 7 domains of patient and clinical characteristics. RESULTS: Median BMI was 28.6. BMI was inversely associated with crude 1-year mortality (normal, 9.2%; overweight, 6.1%; obese, 4.7%; morbidly obese; 4.6%; P <.001), which persisted after multivariable adjustment. When BMI was examined as a continuous variable, the hazards curve declined with increasing BMI and then increased above a BMI of 40. Compared with patients with a BMI of 18.5, patients with higher BMIs had a 20% to 68% lower mortality at 1 year. No interactions between age (P=.37), sex (P=.87), or diabetes mellitus (P=.55) were observed. CONCLUSIONS: There appears to be an "obesity paradox" among patients after acute myocardial infarction such that higher BMI is associated with lower mortality, an effect that was not modified by patient characteristics and was comparable across age, sex, and diabetes subgroups.

Hospital-acquired anemia and in-hospital mortality in patients with acute myocardial infarction.

BACKGROUND: Hospital-acquired anemia (HAA) is common during acute myocardial infarction (AMI) and associated with higher long-term mortality. The relationship between HAA and adverse in-hospital outcomes may be particularly relevant to hospitals' efforts to implement prevention programs, but the association between HAA and in-hospital mortality is unclear. METHODS: We studied 17,676 patients with AMI with normal admission hemoglobin level who did not undergo bypass surgery. Hospital-acquired anemia was defined as development of new anemia during hospitalization (based on nadir hemoglobin) using age-, gender-, and race-specific criteria. In-hospital mortality of patients with mild (hemoglobin level less than HAA threshold but >11 g/dL), moderate (hemoglobin level 9-11 g/dL), and severe HAA (hemoglobin level, < 9 g/dL) was compared with those without HAA using hierarchical logistic regression, adjusting for site and potential confounders. RESULTS: Hospital-acquired anemia developed in 10,166 patients (57.5%); 6,615 (37.4%) had mild; 2,740 (15.5%), moderate; and 811 (4.6%), severe HAA. In-hospital mortality was higher in patients with HAA and increased with HAA severity (no HAA 266 [3.5%], mild HAA 260 [3.9%], moderate HAA 222 [8.1%], and severe HAA 148 [18.3%], P < .001). The adjusted odds of in-hospital death were greater in patients with moderate (odds ratio 1.38, 95% CI 1.10-1.73) and severe HAA (3.39, 95% CI 2.59-4.44) versus no HAA. CONCLUSIONS: Moderate and severe HAAs are independently associated with higher in-hospital mortality during AMI. Studies are needed to determine whether HAA is preventable and if preventing HAA improves outcomes.

Cardiovascular screening with electrocardiography and echocardiography in collegiate athletes.

BACKGROUND: Current guidelines for preparticipation screening of competitive athletes in the US include a comprehensive history and physical examination. The objective of this study was to determine the incremental value of electrocardiography and echocardiography added to a screening program consisting of history and physical examination in college athletes. METHODS: Competitive collegiate athletes at a single university underwent prospective collection of medical history, physical examination, 12-lead electrocardiography, and 2-dimensional echocardiography. Electrocardiograms (ECGs) were classified as normal, mildly abnormal, or distinctly abnormal according to previously published criteria. Eligibility for competition was determined using criteria from the 36(th) Bethesda Conference on Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities. RESULTS: In 964 consecutive athletes, ECGs were classified as abnormal in 334 (35%), of which 95 (10%) were distinctly abnormal. Distinct ECG abnormalities were more common in men than women (15% vs 6%, P<.001) as well as black compared with white athletes (18% vs 8%, P<.001). Echocardiographic and electrocardiographic findings initially resulted in exclusion of 9 athletes from competition, including 1 for long QT syndrome and 1 for aortic root dilatation; 7 athletes with Wolff-Parkinson-White patterns were ultimately cleared for participation. (Four received further evaluation and treatment, and 3 were determined to not need treatment.) After multivariable adjustment, black race was a statistically significant predictor of distinctly abnormal ECGs (relative risk 1.82, 95% confidence interval, 1.22-2.73; P=.01). CONCLUSIONS: Distinctly abnormal ECGs were found in 10% of athletes and were most common in black men. Noninvasive screening using both electrocardiography and echocardiography resulted in identification of 9 athletes with important cardiovascular conditions, 2 of whom were excluded from competition. These findings offer a framework for performing preparticipation screening for competitive collegiate athletes.

Risk factor management after myocardial infarction: reported adherence and outcomes.

BACKGROUND: Providing patients with documented discharge instructions is a performance measure of health care quality. It is not well known how often cardiac patients comply with the list of instructions or what their association is with health status outcomes after an acute myocardial infarction. METHODS: Acute myocardial infarction patients (N = 2,498) were prospectively enrolled into a 19-center study and asked, at 1 month, if they had recalled receiving instructions at discharge on any of the 13 secondary prevention behaviors (eg, exercise, medications, diet, and smoking). Adherence, defined as the percentage of relevant activities patients reported adhering to at 1 month, was grouped into 4 categories: poor (0%-49%), partial (50%-74%), careful (75%-99%), and very careful (100%). RESULTS: A total of 2,046 patients completed 1-month interviews and received instruction on at least 1 risk factor management (RFM) behavior. Very careful adherence at 1-month was reported most frequently with "taking medications as prescribed" (94%). In multivariable-adjusted models, patients who reported being poorly adherent were 58% more likely to report angina at 1 year as compared with those who very carefully followed RFM (relative risk 1.58, 95% CI 1.05-2.37). There was no independent association between RFM behavior and quality of life, physical functioning, rehospitalization, or mortality. CONCLUSIONS: There is substantial variation in the types of RFM to which acute myocardial infarction patients adhere. In aggregate, stronger adherence was associated with less angina at 1 year. More research is needed to understand adherence patterns and its association with outcomes.

Predictors of smoking cessation after a myocardial infarction: the role of institutional smoking cessation programs in improving success.

BACKGROUND: Smoking cessation after myocardial infarction (MI) is an important goal for secondary prevention of mortality. Whether new initiatives to promote cessation improve patients' quit rates after MI is unknown. METHODS: The Prospective Registry Evaluating Outcomes After Myocardial Infarction Events and Recovery (PREMIER) enrolled 2498 patients with MI from 19 US centers between January 2003 and June 2004. Smoking behavior was assessed by self-report during hospitalization and 6 months after an MI. Extensive sociodemographic, comorbidity, psychosocial, disease severity, and treatment data were collected by interview and medical record abstraction. Hierarchical multivariable logistic regression models with random site effects were constructed to predict smoking cessation 6 months after admission, with a focus on the presence of an inpatient smoking cessation program as a hospital-level covariate. RESULTS: Among 834 patients who smoked at the time of MI hospitalization, 639 were interviewed and reported their smoking habits 6 months post-MI (77%). Of these, 297 were not smoking at 6 months (46%). The odds of smoking cessation were greater among those receiving discharge recommendations for cardiac rehabilitation (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.17-2.75) and being treated at a facility that offered an inpatient smoking cessation program (OR, 1.71; 95% CI, 1.03-2.83). However, medical chart-based individual smoking cessation counseling did not predict smoking cessation rates (OR, 0.80; 95% CI, 0.51-1.25). Patients with depressive symptoms during the MI hospitalization were less likely to quit smoking (OR, 0.57; 95% CI, 0.36-0.90). CONCLUSIONS: While individual smoking cessation counseling was not associated with smoking cessation post-MI, hospital-based smoking cessation programs, as well as referral to cardiac rehabilitation, were strongly associated with increased smoking cessation rates. Such programs appear to be underutilized in current clinical practice and may be a valuable structural measure of health care quality. Moreover, smoking cessation programs should likely incorporate screening for and treating depressive disorders.

Acute coronary syndrome patients with depression have low blood cell membrane omega-3 fatty acid levels.

OBJECTIVE: To determine the extent to which levels of membrane eicosapentaenoic (EPA)+docosahexaenoic acids (DHA) (the omega-3 index) were associated with depression in patients with acute coronary syndrome (ACS). Depression is associated with worse cardiovascular (CV) outcomes in patients with ACS. Reduced levels of blood cell membrane omega-3 (n-3) fatty acids (FAs), an emerging risk factor for both CV disease and depression, may help to explain the link between depression and adverse CV outcomes. METHODS: We measured membrane FA composition in 759 patients with confirmed ACS. The analysis included not only EPA and DHA but also the n-6 FAs linoleic and arachidonic acids (LA and AA). Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ). Multivariable linear regression was used to adjust for demographic and clinical characteristics. RESULTS: There was a significant inverse relationship between the n-3 index and depressive symptoms (PHQ) in the fully adjusted model (p = .034). For every 4.54% point rise in the n-3 index, there was a 1-point decline in depressive symptoms. In contrast to the n-3 FAs, membrane levels of the n-6 FAs LA and AA were not different between depressed and nondepressed ACS patients. CONCLUSION: We found an inverse relationship between the n-3 index and the prevalence of depressive symptoms in patients with ACS. Therefore, this study supports the hypothesis that reduced n-3 FA tissue levels are a common and potentially modifiable link between depression and adverse CV outcomes.

Dissociation between hospital performance of the smoking cessation counseling quality metric and cessation outcomes after myocardial infarction.

BACKGROUND: Recognizing the importance of smoking cessation after acute myocardial infarction (AMI), the Centers for Medicare & Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations currently uses documentation of smoking cessation counseling (SCC) as a metric of hospitals' quality of AMI care. Yet, the association between hospitals' performance of this quality measure and subsequent tobacco cessation rates has not been established. METHODS: We analyzed 889 consecutive smokers treated for AMI at 19 hospitals in PREMIER (Prospective Registry Evaluating Myocardial Infarction: Events and Recovery) between January 1, 2003, and June 28, 2004. Patients were followed up for 1 year after hospitalization. Multivariate regression modeling was performed to determine the association between hospital-level documented SCC rates and tobacco cessation rates after discharge. RESULTS: On a hospital level, the median medical record-documented SCC rate was 72.0% (interquartile range, 59.6%-90.1%). At 1 year, the median smoking cessation rate was 55.6% (interquartile range, 37.5%-61.9%). Although patients with documented SCC were more likely to recall receiving SCC at 1 month (86.1% vs 70.8%, P < .001), their rate of quitting at 1 year was lower than that of patients without documented SCC (50.1% vs 60.7%, P = .02; relative risk, 0.76; 95% confidence interval, 0.61-0.94). At the hospital level, there was no correlation between SCC documentation and successful quitting at 6 months (r = -0.19, P = .11) or 1 year (r = -0.13, P = .45). CONCLUSIONS: The performance metric for SCC, as it is currently structured, does not correlate with actual smoking cessation at 6 months or 1 year. Revision of this performance measure should be considered to more effectively reflect the goal of promoting smoking cessation.

Angina at 1 year after myocardial infarction: prevalence and associated findings.

BACKGROUND: Eradication of angina is a primary goal of care after myocardial infarction (MI). However, the prevalence of angina 1 year after MI and factors associated with it are unknown. METHODS: From January 1, 2003, through June 28, 2004, 2498 patients with acute MI were recruited from 19 hospitals in the United States. Among this multicenter cohort of patients, angina was measured by the Seattle Angina Questionnaire 1 year after hospitalization for MI. Multivariate regression modeling identified the sociodemographic factors, clinical history, MI presentation, inpatient treatments, and outpatient treatments associated with 1-year angina, adjusted for site. RESULTS: Of 1957 patients in the cohort, 389 (19.9%) reported angina 1 year after MI. After multivariate analysis, patients with 1-year angina were more likely to be younger (relative risk [RR] per 10-year decrease, 1.19; 95% confidence interval [CI], 1.09-1.30), to be nonwhite males (RR, 1.50; 95% CI, 1.16-1.96), to have had prior angina (RR, 1.78; 95% CI, 1.54-2.06), to have undergone prior coronary artery bypass graft surgery (RR, 1.92; 95% CI, 1.51-2.44), and to experience recurrent rest angina during their hospitalization (RR, 1.54; 95% CI, 1.22-1.93). Among the outpatient variables, patients with 1-year angina were more likely to continue smoking (RR, 1.23; 95% CI, 1.02-1.48), to undergo revascularization after index hospitalization (percutaneous coronary intervention or coronary artery bypass graft) (RR, 1.37; 95% CI, 1.09-1.73), and to have significant new (RR, 1.96; 95% CI, 1.34-2.87), persistent (RR, 1.88; 95% CI, 1.29-2.75), or transient (RR, 1.77; 95% CI, 1.49-2.11) depressive symptoms. CONCLUSIONS: Angina occurs in nearly 1 of 5 patients 1 year after MI. It is associated with several modifiable factors, including persistent smoking and depressive symptoms.

EPA and DHA in blood cell membranes from acute coronary syndrome patients and controls.

BACKGROUND: Increased blood levels of the omega-3 fatty acids (FA) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have been inversely associated with risk for sudden cardiac death, but their relationship with acute coronary syndromes (ACS) is unclear. OBJECTIVE: We hypothesized that the EPA+DHA content of blood cell membranes, as a percent of total FAs, is reduced in ACS patients relative to matched controls. METHODS: We measured the content of EPA+DHA in 768 ACS patients and 768 age-, sex- and race-matched controls. The association with ACS case status of blood cell EPA+DHA [both by a 1 unit change and by category (low, <4%; intermediate 4.1-7.9%; and high, > or =8%)] was assessed using multivariate conditional logistic regression models adjusting for matching variables and smoking status, alcohol use, diabetes, body mass index, serum lipids, education, family history of coronary artery disease, personal histories of myocardial infarction and hypertension, and statin, aspirin, and other antiplatelet drug use. RESULTS: The combined groups had a mean age of 61+/-12 years, 66% were male, and 92% were Caucasian. The EPA+DHA content was 20% lower in cases than controls (3.4+/-1.6 vs. 4.25+/-2.0%, p<0.001). The multivariable-adjusted odds for case status was 0.77 (95% CI 0.70 to 0.85, p<0.001) for a 1 unit increase in EPA+DHA content. Compared with the lowest EPA+DHA group, the odds ratio for an ACS event was 0.58 (95% CI 0.42-0.80), in the intermediate EPA+DHA group and was 0.31 (95% CI 0.14-0.67; p for trend <0.0001) in the highest EPA+DHA group. CONCLUSIONS: Odds for ACS case status increased incrementally as the EPA+DHA content decreased suggesting that low EPA+DHA may be associated with increased risk for ACS.

Predictors of weight change in overweight patients with myocardial infarction.

BACKGROUND: Weight loss is recommended among overweight survivors of myocardial infarction (MI). This study describes patterns of weight change among overweight patients with MI and identifies factors associated with weight change. METHODS: A prospective cohort of 1253 overweight or heavier (body mass index [BMI] > or = 25 kg/m2) post-MI patients were enrolled in the 19-center PREMIER study and followed up for 1 year to determine changes in weight. Patients were categorized at 1 month as overweight (BMI = 25-29.9 kg/m2), obese (BMI = 30-39.9 kg/m2), or morbidly obese (BMI > or = 40 kg/m2). Unadjusted percent weight change was assessed at 1 year, and multivariable linear regression was used to identify independent correlates of change. RESULTS: Mean weight change was -0.2% and varied by the severity of baseline obesity (+0.4% for overweight patients, -0.5% for obese patients, and -3.7% for morbidly obese patients [P < .001]). Multivariable analyses revealed the following to be significantly associated with weight change: depression 1 month post-MI (+2.7%, P = .001), lack of health insurance (+2%, P = .01), smoking cessation 1 month post-MI (+2.7% vs current smokers, P < .001), morbid obesity (+4.7% vs overweight patients, P < .0001), and increasing age (-0.8% per decade, P = .001). An interaction between smoking cessation and weight class was detected in that overweight patients who quit had a mean increase of 5.3% (95% CI 3.1%-7.4%), whereas no significant change was observed among obese and morbidly obese patients who quit. CONCLUSIONS: Although post-MI patients had negligible weight loss over 1 year, several sociodemographic, clinical, and lifestyle characteristics were associated with weight change. New, targeted interventions will likely be needed to improve weight management after an MI.

Blood omega-3 and trans fatty acids in middle-aged acute coronary syndrome patients.

We tested the hypothesis that lower blood omega-3 (omega-3) fatty acids (FAs) and/or higher trans FAs are associated with the risk of an acute coronary syndrome (ACS). Higher levels of omega-3 FA have been associated with decreased risk of sudden cardiac death. However, their association with ACS risk is unclear. Although higher self-reported intakes of trans FAs have been linked to increased coronary risk, the association between blood levels of trans FA and ACS risk is also unknown. We analyzed the FA composition of whole blood from 94 subjects with ACS and 94 age-, gender-, and race-matched controls. Omega-3 and trans FA associations with ACS were assessed using multivariable models after adjusting for smoking status, alcohol use, diabetes, body mass index, serum lipids, and history of myocardial infarction or revascularization. Subjects' mean age was 47 years, 54% were men, and 80% were Caucasian. Whole blood long-chain omega-3 FA (eicosapentaenoic acid [EPA] plus docosahexaenoic acid [DHA]) content was 29% lower in patients than in controls (1.7 +/- 0.9% vs 2.4 +/- 1.4%, p <0.001), whereas trans FA content was not different (2.1 +/- 0.7% vs 2.0 +/- 0.9%, p = NS). The multivariable-adjusted odds for case status was 0.67 (95% confidence interval 0.46 to 0.98) for a 1 SD increase in blood EPA + DHA. The inclusion of trans FAs in the EPA + DHA model did not alter this association. In conclusion, low blood EPA + DHA content is an independent predictor of increased risk for ACS, but higher blood trans FA content is not. Blood EPA + DHA may serve as a new, modifiable risk factor for ACS.

Immature platelet fraction as a predictor of platelet recovery following hematopoietic progenitor cell transplantation.

The immature platelet fraction (IPF) as determined by the Sysmex XE-2100 is a rapid automated measure of the least mature component of the platelet population and is thought to correlate with thrombopoietic activity of the marrow. We investigated the ability of IPF to predict platelet recovery following hematopoietic progenitor cell (HPC) transplantation. IPF was compared to standard parameters of hematopoietic recovery, including the immature reticulocyte fraction (IRF), an early predictor of recovery. Fifty patients undergoing peripheral blood HPC transplantation (38 autologous and 12 allogeneic) were followed daily for 11 to 28 days after transplantation with measurement of IPF, IRF, absolute neutrophil counts (ANC) and platelet counts. Mean days to recovery for IPF was 3.1 days less than for platelet count (P <.0001), 3.8 days less than for ANC (P <.0001), and 0.6 days less than for IRF (P = .0477). IPF recovered at least 1 day prior to platelet count in 79% (38 of 48) of patients, and was followed by platelet count recovery within 1 to 12 days (mean, 4.1 days). When autologous and allogeneic patient groups were analyzed separately, IPF recovered significantly earlier than platelet count and ANC in both groups (P <.0001). Thrombopoietin (TPO) levels in 5 patients receiving transplants correlated with IPF; however, this appeared to be secondary to an inverse correlation of both TPO and IPF with platelet count. IPF is comparable to IRF as one of the earliest predictors of hematopoietic recovery following peripheral blood HPC transplantation. IPF could potentially be useful as a predictor of platelet recovery in other bone marrow failure syndromes.

Prevalence and predictors of angina pectoris one month after myocardial infarction.

Angina pectoris (AP) is a treatable symptom that is associated with mortality and decreased quality of life. The prevalence and predictors of AP 1 month after a myocardial infarction (MI), a time when additional treatments might be offered, have not been described. We prospectively enrolled 2,094 patients with MI from 19 centers in the United States and evaluated angina symptoms 1 month after discharge with the Seattle Angina Questionnaire. Multivariable logistic regression analysis was performed to identify patient and treatment characteristics associated with 1-month AP. At 1 month, 571 patients (27.3%) had AP. Women (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.09 to 1.74), younger patients (OR 1.33 per 10-year increment, 95% CI 1.20 to 1.47), those with previous coronary artery bypass (OR 1.47, 95% CI 1.05 to 2.05), smokers (OR 1.35, 95% CI 1.09 to 1.77), and those who developed postinfarct AP during the index hospitalization (OR 1.85, 95% CI 1.20 to 2.65) were more likely to have AP at follow-up. In contrast, patients who were treated with coronary artery bypass surgery during their index admission were less likely to have AP at 1 month (OR 0.5, 95% CI 0.33 to 0.77). The strongest correlate was the frequency of AP before patients' MI. Compared with those without AP before MI, those with AP < 1 time per week (OR 1.86, 95% CI 1.45 to 2.41), weekly (OR 4.24, 95% CI 3.09 to 5.82), and daily (OR 6.12, 95% CI 3.62 to 10.3) were more likely to have AP 1 month later. In conclusion, > 1 in 4 patients reported AP 1 month after an MI.

The impact of age, body mass index, and fish intake on the EPA and DHA content of human erythrocytes.

n-3 FA are beneficial for cardiovascular health, reducing platelet aggregation, TG levels, and the risk of sudden death from myocardial infarction. The percentage of EPA + DHA in red blood cells (RBC), also known as the Omega-3 Index, has recently been proposed as a risk marker for death from coronary heart disease (CHD). The purpose of this study was to begin to explore the factors that can influence RBC EPA + DHA. We collected information on the number of servings of tuna or nonfried fish consumed per month, as well as on age, gender, ethnicity, smoking status, the presence of diabetes, and body mass index (BMI) in 163 adults in Kansas City who were not taking fish oil supplements. The average RBC EPA + DHA in this population was 4.9 +/- 2.1%. On a multivariate analysis, four factors significantly and independently influenced the Omega-3 Index: fish servings, age, BMI, and diabetes. The Index increased by 0.24 units with each additional monthly serving of tuna or nonfried fish (P < 0.0001), and by 0.5 units for each additional decade in age (P < 0.0001). The Index was 1.13% units lower in subjects with diabetes (P = 0.015) and decreased by 0.3% units with each 3-unit increase in BMI (P = 0.001). Gender or smoking status had no effect, and the univariate relationship with ethnicity vanished after controlling for fish intake. Given the importance of n-3 FA in influencing risk for death from CHD, further studies are warranted to delineate the nondietary factors that influence RBC EPA + DHA content.