Impact of Cardiovascular Risk Factors on Long-Term Mortality After Liver Transplantation.

Immunosuppression with calcineurin inhibitors has contributed to an increased prevalence of hypertension, diabetes, and hypercholesterolemia in patients receiving liver transplantation. This study evaluated the prevalence of cardiovascular risk factors, their management, and long-term mortality after liver transplantation. Medical records were reviewed in 333 adult patients who underwent orthotopic liver transplantation. Data were collected on medical diagnoses before and after transplantation, medication use, and on long-term mortality. The 333 patients in the study included 223 men and 110 women, mean age 59 ± 10 years. The mean follow-up was 50 ± 28 months. After transplantation, there was a high prevalence of hypertension (67%), hypercholesterolemia (46%), diabetes mellitus (42%), and chronic kidney disease (45%). Out of 333 patients in the study, 96 patients (29%) died during follow-up. Stepwise logistic regression was performed to identify the risk factors that might influence long-term mortality outcomes. Based on pretransplant characteristics, positive independent risk factors that increased mortality were age at transplant and hepatitis C. After transplantation, positive predictive factors were diabetes mellitus and cancer. A negative predictive risk factor for mortality was hypercholesterolemia. Analysis of medication after transplantation showed that positive predictive factors were the use of insulin, steroids, and antibiotics. Negative predictors for mortality were tacrolimus and mycophenolate. Our data suggest that diabetes mellitus and hepatitis C play an important role in worsening posttransplant mortality.

Effect of cardiovascular drugs on cardiovascular events in 1599 patients followed in an academic outpatient cardiology practice.

This study investigated the effects of medical therapy on incidences of myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABG) in an academic outpatient cardiology practice. Chart reviews were performed in 1599 treated patients (1138 men and 461 women), mean age 72 years. Medications investigated included the use of statins, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and aspirin. The mean follow-up was 63 months during 1977-2009. Of 1599 patients, MI occurred in 100 patients (6%), PCI occurred in 296 patients (19%), and CABG occurred in 235 patients (15%). Stepwise logistic regression analysis showed that significant independent risk factors for MI were statins [odds ratio = 0.07; 95% confidence interval (CI), 0.05-0.11, P < 0.001], beta blockers (odds ratio = 0.15, 95% CI, 0.10-0.23, P < 0.001), ACE inhibitors (odds ratio = 0.27, 95% CI, 0.16-0.45, P < 0.001), ARBs (odds ratio = 0.09, 95% CI, 0.04-0.20, P < 0.001), and aspirin (odds ratio = 0.18, 95% CI, 0.12-0.29, P < 0.001). Significant independent risk factors for PCI were statins (odds ratio = 0.15, 95% CI, 0.11-0.20, P < 0.001), beta blockers (odds ratio = 0.26, 95% CI, 0.20-0.35, P < 0.001), ACE inhibitors (odds ratio = 0.25, 95% CI, 0.18-0.34, P < 0.001), and ARBs (odds ratio = 0.18, 95% CI, 0.11-0.28, P < 0.001). Significant independent risk factors for CABG were statins (odds ratio = 0.16, 95% CI, 0.12-0.22, P < 0.001), beta blockers (odds ratio = 0.43, 95% CI, 0.32-0.58, P < 0.001), ACE inhibitors (odds ratio = 0.38, 95% CI, 0.27-0.53, P < 0.001), ARBs (odds ratio = 0.19, 95% CI, 0.11-0.31, P < 0.001), and aspirin (odds ratio = 0.45, 95% CI, 0.33-0.61, P < 0.001).

Risk factors for hemodialysis and mortality in patients with contrast-induced nephropathy.

The purpose of this study was to identify risk factors for renal failure requiring hemodialysis and mortality in patients who developed contrast-induced nephropathy (CIN) after cardiac catheterization. Out of 13,742 patients who received cardiac catheterization at Westchester Medical Center/New York Medical College from 2005 to 2008, 268 patients (2%) with a discharge diagnosis of renal failure were screened for CIN. CIN was defined as either a >25% increase of the serum creatinine or an absolute increase in serum creatinine of 0.5 mg/dL within the first 48 hours of the procedure. Chart reviews were performed on 80 patients (1%) who met the criteria for CIN. The 80 patients in the study included 46 men and 34 women, mean age 69 ± 14 years. Of the 80 patients, 18 patients (23%) died, and 22 patients (28%) developed renal failure requiring hemodialysis. Stepwise logistic regression analysis showed that independent risk factors for mortality were the use of calcium channel blockers [odds ratio = 0.0025, 95% confidence interval (CI), 0.0001-0.1210, P < 0.01], catecholamine use (odds ratio = 71.2177, 95% CI, 4.2153-1203, P < 0.01), circulatory failure with lactic acidosis (odds ratio = 32.1405, 95% CI, 2.6331-392, P < 0.01), and renal failure requiring hemodialysis (odds ratio = 17.0376, 95% CI, 1.2344-235, P < 0.05). Significant independent risk factors for renal failure requiring hemodialysis were smoking (odds ratio = 0.06, 95% CI, 0.0045-0.8080, P < 0.05), N-acetylcysteine use (odds ratio = 0.08, 95% CI, 0.0148-0.4179, P < 0.01), anemia (odds ratio = 11.32, 95% CI, 2.57-50, P < 0.01), and circulatory failure with lactic acidosis (odds ratio = 9.76, 95% CI, 2.37-40, P < 0.01). Our data showed that risk factors for mortality in patients with CIN were catecholamine use, circulatory failure with lactic acidosis, and renal failure requiring hemodialysis. Risk factor for reducing mortality in patients with CIN was calcium channel blocker use. Significant risk factors for renal failure requiring hemodialysis were anemia, and circulatory failure with lactic acidosis. Risk factors for reducing renal failure requiring hemodialysis were N-acetylcysteine use and smoking.

The impact of statin therapy on long-term cardiovascular outcomes in an outpatient cardiology practice.

BACKGROUND: Statins reduce coronary events in patients with coronary artery disease. MATERIAL/METHODS: Chart reviews were performed in 305 patients (217 men and 88 women, mean age 74 years) not treated with statins during the first year of being seen in an outpatient cardiology practice but subsequently treated with statins. Based on the starting date of statins use, the long-term outcomes of myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABGS) before and after statin use were compared. RESULTS: Mean follow-up was 65 months before statins use and 66 months after statins use. MI occurred in 31 of 305 patients (10%) before statins, and in 13 of 305 patients (4%) after statins (p < 0.01). PCI had been performed in 66 of 305 patients (22%) before statins and was performed in 41 of 305 patients (13%) after statins (p < 0.01). CABGS had been performed in 56 of 305 patients (18%) before statins and was performed in 20 of 305 patients (7%) after statins (p < 0.001). Stepwise logistic regression showed statins use was an independent risk factor for MI (odds ratio = 0.0207, 95% CI, 0.0082-0.0522, p < 0.0001), PCI (odds ratio = 0.0109, 95% CI, 0.0038-0.0315, p < 0.0001), and CABGS (odds ratio = 0.0177, 95% CI = 0.0072-0.0431, p<0.0001.) CONCLUSIONS: Statins use in an outpatient cardiology practice reduces the incidence of MI, PCI, and CABGS.

Prevalence of complications during implantation and during 38-month follow-up of 1060 consecutive patients with implantable cardioverter-defibrillators.

During implantation and during 38-month follow-up of 1060 consecutive patients who had implantable cardioverter-defibrillators, complications occurred in 60 (5.7%) of 1060 patients. These complications consisted of fractured leads requiring lead revision in 36 (3.4%) patients, lead infection requiring antibiotics in 5 (0.5%) patients, device replacement because of malfunction in 5 (0.5%) patients, repositioning of leads in 3 (0.3%) patients, a hematoma at the time of implantation in 3 (0.3%) patients, pneumothorax at the time of implantation in 2 (0.2%) patients, repair of a defective generator in 1 (0.1%) patient, replacement of the device because of atrophy of the skin over the device in 1 (0.1%) patient, a transient ischemic attack because of atrial fibrillation developing during implantation in 1 (0.1%) patient, device replacement because of a recall from Guidant in 1 (0.1%) patient, pocket revision because of pain when lying on the side of the pacemaker in 1 (0.1%) patient, and pacemaker infection in 1 (0.1%) patient.

Patients with ischemic stroke have a higher prevalence of a planar QRS-T angle >90° than patients with transient ischemic attack.

BACKGROUND: The aim of the study was to investigate the prevalence of a planar QRS-T angle >90° in patients with ischemic stroke versus transient ischemic attack (TIA). MATERIAL/METHODS: In a prospective study of 279 consecutive patients who had ischemic stroke (197 patients) or TIA (82 patients), the planar QRS-T angle was measured from a 12-lead electrocardiogram taken at the time of the stroke or TIA. All QRS-T angle measurements were made by 3 authors who agreed on the measurements and who were blinded to the clinical findings. A QRS-T angle >90° was considered abnormal. RESULTS: The mean age was 66±6 years in patients with ischemic stroke versus 62±6 years in patients with TIA (p=0.04). The mean body mass index and the prevalence of gender, smoking, hypertension, diabetes mellitus, dyslipidemia, and coronary artery disease were not significantly different between patients with ischemic stroke versus TIA. A QRS-T angle >90° was present in 55 of 197 patients (28%) with ischemic stroke and in 10 of 82 patients (12%) with TIA (p=0.004). CONCLUSIONS: The prevalence of a planar QRS-T angle >90° was higher in patients with ischemic stroke than in patients with TIA (p=0.004).

Prevalence of use of anticoagulants in 502 elderly hospitalized patients at increased risk for systemic embolism or venous thromboembolism without contraindications to anticoagulants in a university hospital.

We investigated, in a university hospital, the prevalence of use of anticoagulants in 502 elderly hospitalized patients at increased risk for systemic embolism or venous thromboembolism without contraindications to anticoagulants. The 502 patients included 291 men and 211 women with a mean age of 77 +/- 7 years (range, 65-98 years). Anticoagulants were used to treat 479 of 502 hospitalized patients (95%) at increased risk for systemic embolism or venous thromboembolism. Of the 479 patients treated with anticoagulants, 317 (66%) were treated with unfractionated heparin, 203 (42%) with warfarin, 81 (17%) with low-molecular-weight heparin, two (<1%) with fondaparinux, and two (<1%) with argatroban.

Prevalence of appropriate cardioverter-defibrillator shocks in 1038 consecutive patients with implantable cardioverter-defibrillators.

During a 33-month follow-up of 1038 consecutive patients who had implantable cardioverter-defibrillators, appropriate shocks occurred in 329 of 1038 patients (32%). Appropriate shocks occurred in 101 of 380 patients (27%) treated with beta-adrenergic blockers alone; in 31 of 95 patients (33%) treated with amiodarone alone; in 39 of 149 patients (26%) treated with beta-blockers plus amiodarone; in 11 of 28 patients (39%) treated with sotalol alone; and in 147 of 386 patients (38%) treated with no beta-blockers, amiodarone, or sotalol (P < 0.001 comparing patients treated with beta-adrenergic blockers alone with patients treated with no beta-blockers, amiodarone, or sotalol; and P < 0.01 comparing patients treated with beta-blockers plus amiodarone with patients treated with no beta-blockers, amiodarone, or sotalol). In conclusion, patients having implantable cardioverter-defibrillators should also be treated with beta-adrenergic blockers to reduce the frequency of appropriate shocks.

Statins reduce appropriate cardioverter-defibrillator shocks and mortality in patients with heart failure and combined cardiac resynchronization and implantable cardioverter-defibrillator therapy.

Of 209 patients with heart failure treated with combined cardiac resynchronization therapy and implantable cardioverter-defibrillator therapy, appropriate cardioverter-defibrillator shocks occurred at 34-month follow-up in 22 of 121 patients (18%) on statins and in 30 of 88 patients (34%) not on statins (P = .009). Deaths occurred in 3 of 121 patients (2%) on statins and in 9 of 88 patients (10%) not on statins (P = .017). Stepwise Cox regression analysis showed that significant independent prognostic factors for appropriate shocks were use of statins (risk ratio = 0.46), smoking (risk ratio = 3.5), and diabetes (risk ratio = 0.34). Significant independent prognostic factors for the time to mortality were use of statins (risk ratio = 0.05), use of digoxin (risk ratio = 4.2), systemic hypertension (risk ratio = 14.2), diabetes (risk ratio = 4.3), and left ventricular ejection fraction (risk ratio = 1.1).

Effect of beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins on mortality in patients with implantable cardioverter-defibrillators.

Nine hundred sixty-five patients (mean age 70 years) with implantable cardioverter-defibrillator were followed for 32 +/- 33 months for all-cause mortality. Death occurred in 73 of 515 patients (13%) treated with beta blockers (group 1), in 84 of 494 patients (17%) treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (group 2), in 56 of 402 patients (14%) treated with statins (group 3), in 40 of 227 patients (18%) treated with amiodarone (group 4), in 5 of 26 patients (19%) treated with sotalol (group 5), and in 64 of 265 patients (24%) treated with no beta blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, statin, amiodarone, or sotalol (group 6) (p <0.001 for group 1 vs group 6 and group 3 vs group 6, p <0.02 for group 2 vs group 6). In conclusion, patients with implantable cardioverter-defibrillators should be treated with beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins to reduce mortality.

Comparison of sensitivity, specificity, positive predictive value, and negative predictive value of stress testing versus 64-multislice coronary computed tomography angiography in predicting obstructive coronary artery disease diagnosed by coronary angiography.

Sixty-four-multislice coronary computed tomographic angiography (CTA) and coronary angiography were performed in 145 patients (mean age 67 +/- 10 years), and stress testing was performed in 47 of these patients to determine the sensitivity, specificity, positive predictive value, and negative predictive value of coronary CTA and of stress testing in diagnosing obstructive coronary artery disease (CAD) in patients with suspected CAD. In 145 patients, coronary CTA had 98% sensitivity, 74% specificity, 90% positive predictive value, and 94% negative predictive value in diagnosing obstructive CAD. In 47 patients, stress testing had 69% sensitivity, 36% specificity, 78% positive predictive value, and 27% negative predictive value for diagnosing obstructive CAD, whereas coronary CTA had 100% sensitivity, 73% specificity, 92% positive predictive value, and 100% negative predictive value for diagnosing obstructive CAD. In conclusion, coronary CTA has better sensitivity, specificity, positive predictive value, and negative predictive value than stress testing in diagnosing obstructive CAD.

Prevalence of an increased ascending thoracic aorta diameter diagnosed by two-dimensional echocardiography versus 64-multislice cardiac computed tomography.

The prevalence of an enlarged ascending thoracic aortic diameter (AAD) diagnosed by 2-dimensional echocardiography compared with 64-slice cardiac computed tomography (MSCT) was investigated in 97 women and 117 men (mean age 65 +/- 12 years). Enlarged AADs were diagnosed in 42 of 214 patients (20%) by echocardiography and in 45 of 214 patients (21%) by MSCT (p = NS). The sensitivity, specificity, positive predictive value, and negative predictive value of echocardiography in diagnosing an enlarged AAD using MSCT were 69%, 93%, 74%, and 92%, respectively. A Bland-Altman plot showed that the agreement for AAD measured by echocardiography and MSCT was 95% inside the 2-SD limits. In conclusion, the sensitivity, specificity, positive predictive value, and negative predictive value of 2-dimensional echocardiography in diagnosing enlarged AAD using MSCT were 69%, 93%, 74%, and 92%, respectively.

Prevalence of influenza vaccination and pneumococcal vaccination in elderly and high-risk patients seen in a university general medicine clinic.

Charts of 240 unselected patients (149 women and 91 men), mean age 74 +/- 7 years (range, 64-95 years), seen in a university general medicine clinic at Westchester Medical Center/New York Medical College between April 2004 and April 2007 were reviewed for the use of influenza vaccination and pneumococcal vaccination. Of the 240 patients, 108 (45%) had cardiovascular disease, 183 (76%) had hypertension, 70 (29%) had diabetes mellitus, 32 (13%) had chronic pulmonary disease, 30 (13%) had cancer, 26 (11%) had chronic renal disease, and 19 (8%) had no chronic illness. Of the 240 patients, 24 (10%) refused influenza vaccination and two (1%) had a hypersensitivity to eggs. Of 240 patients, 18 (8%) refused pneumococcal vaccination. Of 94 patients who did not refuse influenza vaccination or were allergic to eggs during the winter season of October 2004 through January 2005, 58 (62%) had influenza vaccination. Ninety-two of 172 patients (54%) had influenza vaccination during October 2005 through January 2006. Ninety-seven of 136 patients (71%) had influenza vaccination during October 2006 through January 2007. Of 222 patients, 111 (50%) had pneumococcal vaccination during 2004 through 2007.

Prevalence of an increased ascending and descending thoracic aorta diameter diagnosed by multislice cardiac computed tomography in men versus women and in persons aged 23 to 50 years, 51 to 65 years, 66 to 80 years, and 81 to 88 years.

The prevalence of increased ascending thoracic aortic diameter (AAD) and increased descending thoracic aortic diameter (DAD) diagnosed using multislice cardiac computed tomography was investigated in 624 consecutive patients at an academic cardiology practice in 2006. Increased AAD (>3.7 cm) was present in 71 of 361 men (20%) and in 23 of 263 women (9%) (p <0.001). Increased DAD (>3.0 cm) was present in 26 of 339 men (8%) and in 8 of 258 women (3%) (p <0.02). Increased AAD was present in (1) 7 of 96 patients (7%) aged 23 to 50 years, (2) 22 of 234 patients (9%) aged 51 to 65 years, (3) 53 of 263 patients (20%) aged 66 to 80 years, and (4) 12 of 31 patients (39%) aged 81 to 88 years (p <0.005 comparing groups 3 and 1; p <0.001 comparing groups 4 and 1, groups 4 and 2, and groups 3 and 2; p <0.02 comparing groups 4 and 3). Increased DAD was present in (1) 0 of 96 patients (0%) aged 23 to 50 years, (2) 5 of 227 patients (2%) aged 51 to 65 years, (3) 21 of 244 patients (9%) aged 66 to 80 years, and (4) 8 of 30 patients (27%) aged 81 to 88 years (p <0.005 comparing groups 3 and 1, groups 3 and 2, and groups 4 and 3; p <0.001 comparing groups 4 and 1 and groups 4 and 2). In conclusion, men have a higher prevalence of increased AAD and DAD than women, and increasing age increases the prevalence of increased AAD and DAD.

Association of coronary artery calcium with severity of myocardial ischemia in left anterior descending, left circumflex, and right coronary artery territories.

BACKGROUND: An increasing coronary artery calcium score is associated with a higher likelihood of myocardial ischemia. HYPOTHESIS: The association of the coronary calcium score with myocardial ischemia in different coronary arteries needed to be investigated. METHODS: We correlated the coronary artery calcium (CAC) score with the severity of myocardial ischemia diagnosed by myocardial perfusion imaging in the left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA) territories in 206 patients, mean age 66 years, without cardiac stents or coronary artery surgery. RESULTS: The mean CAC score in the LAD coronary artery was 160 ± 218 in patients with no or mild ischemia and 336 ± 379 in patients with moderate or severe ischemia (P = 0.039). The mean CAC score in the LCX coronary artery was 57 ± 117 in patients with no or mild ischemia and 161 ± 191 in patients with moderate or severe ischemia (P = 0.018). The mean CAC score in the RCA was 114 ± 237 in patients with no or mild ischemia and 261 ± 321 in patients with moderate or severe ischemia (P = 0.045). Stepwise linear regression analysis showed that male gender (P < 0.0001), age (P < 0.0001), and moderate or severe ischemia (P = 0.023) were significantly associated with high LAD coronary artery CAC scores. Male gender (P < 0.0001), age (P = 0.0002), and moderate or severe ischemia (P = 0.006) were significantly associated with high LCX coronary artery CAC scores. Male gender (P < 0.0001) and age (P < 0.0001) were significantly associated with high RCA CAC scores. CONCLUSIONS: Higher CAC scores are significantly associated with moderate or severe ischemia in the LAD and LCX coronary arteries.

Risk factor reduction in progression of angiographic coronary artery disease.

INTRODUCTION: To investigate differences between outpatients with progressive and nonprogressive coronary artery disease (CAD) measured by coronary angiography. MATERIAL AND METHODS: Chart reviews were performed in patients in an outpatient cardiology practice having ≥ 2 coronary angiographies ≥ 1 year apart. Progressive CAD was defined as 1) new non-obstructive or obstructive CAD in a previously disease-free vessel; or 2) new obstruction in a previously non-obstructive vessel. Coronary risk factors, comorbidities, cardiovascular events, medication use, serum low-density lipoprotein cholesterol (LDL-C), and blood pressure were used for analysis. RESULTS: The study included 183 patients, mean age 71 years. Mean follow-up duration was 11 years. Mean follow-up between coronary angiographies was 58 months. Of 183 patients, 108 (59%) had progressive CAD, and 75 (41%) had nonprogressive CAD. The use of statins, ß-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and aspirin was not significantly different in patient with progressive CAD or nonprogressive CAD Mean arterial pressure was higher in patients with progressive CAD than in patients with nonprogressive CAD (97±13 mm Hg vs. 92±12 mm Hg) (p<0.05). Serum LDL-C was insignificantly higher in patients with progressive CAD (94±40 mg/dl) than in patients with nonprogressive CAD (81±34 mg/dl) (p=0.09). CONCLUSIONS: Our data suggest that in addition to using appropriate medical therapy, control of blood pressure and serum LDL-C level may reduce progression of CAD.

The impact of statin therapy on long-term cardiovascular outcomes in an outpatient cardiology practice.

INTRODUCTION: Statins reduce coronary events in patients with coronary artery disease. MATERIAL AND METHODS: Chart reviews were performed in 305 patients (217 men and 88 women, mean age 74 years) not treated with statins during the first year of being seen in an outpatient cardiology practice but subsequently treated with statins. Based on the starting date of statins use, the long-term outcomes of myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABGs) before and after statin use were compared. RESULTS: Mean follow-up was 65 months before statins use and 66 months after statins use. Myocardial infarction occurred in 31 of 305 patients (10%) before statins, and in 13 of 305 patients (4%) after statins (p < 0.01). Percutaneous coronary intervention had been performed in 66 of 305 patients (22%) before statins and was performed in 41 of 305 patients (13%) after statins (p < 0.01). Coronary artery bypass graft surgery had been performed in 56 of 305 patients (18%) before statins and in 20 of 305 patients (7%) after statins (p < 0.001). Stepwise logistic regression showed statins use was an independent risk factor for MI (odds ratio = 0.0207, 95% CI, 0.0082-0.0522, p < 0.0001), PCI (odds ratio = 0.0109, 95% CI, 0.0038-0.0315, p < 0.0001) and CABGs (odds ratio = 0.0177, 95% CI = 0.0072-0.0431, p < 0.0001) CONCLUSIONS: Statins use in an outpatient cardiology practice reduces the incidence of MI, PCI, and CABGs.

Reduction in atherosclerotic events: a retrospective study in an outpatient cardiology practice.

INTRODUCTION: Although atherosclerotic disease cannot be cured, risk of recurrent events can be reduced by application of evidence-based treatment protocols involving aspirin, beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statin medications. We studied atherosclerotic event rates in a patient population treated before and after the development of aggressive risk factor reduction treatment protocols. MATERIAL AND METHODS: We performed a retrospective chart review of patients presenting for follow-up treatment of coronary artery disease in a community cardiology practice, comparing atherosclerotic event rates and medication usage in a 2-year treatment period prior to 2002 and a 2-year period in 2005-2008. Care was provided in both the early and later eras by 7 board-certified cardiologists in a suburban cardiology practice. Medication usage was compared in both treatment eras. The primary outcome was a composite event rate of myocardial infarction, cerebrovascular events, and coronary interventions. RESULTS: Three hundred and fifty-seven patients were studied, with a follow-up duration of 12.1 (±3.5) years. There were 132 composite events in 104 patients (29.1%) in the early era compared to 40 events in 33 patients (9.2%) in the later era (p < 0.0001). From the early to the later eras, there was an increase in use of ß-blockers (66% to 83%, p < 0.0001), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (34% to 80%, p < 0.0001), and statins (40% to 90%, p < 0.0001). CONCLUSIONS: Application of aggressive evidence-based medication protocols for treatment of atherosclerosis is associated with a significant decrease in atherosclerotic events or need for coronary intervention.

Incidence of appropriate cardioverter-defibrillator shocks and mortality in patients with implantable cardioverter-defibrillators with ischemic cardiomyopathy versus nonischemic cardiomyopathy at 33-month follow-up.

INTRODUCTION: The aim of the study was to investigate at long-term follow-up the incidence of appropriate implantable cardioverter-defibrillator (ICD) shocks and of all-cause mortality in patients with ICDs with ischemic cardiomyopathy versus nonischemic cardiomyopathy. MATERIAL AND METHODS: ICDs were implanted in 485 patients with ischemic cardiomyopathy and in 299 patients with nonischemic cardiomyopathy, all of whom had coronary angiography. Baseline characteristics were not significantly different between the 2 groups. Follow-up was 965 days in patients with ischemic cardiomyopathy versus 1039 days in patients with nonischemic cardiomyopathy (p not significant). The ICDs were interrogated every 3 months to see if shocks occurred. RESULTS: Appropriate ICD shocks occurred in 179 of 485 patients (37%) with ischemic cardiomyopathy and in 93 of 299 patients (31%) with nonischemic cardiomyopathy (p not significant). All-cause mortality occurred in 162 of 485 patients (33%) with ischemic cardiomyopathy and in 70 of 299 patients (23%) with nonischemic cardiomyopathy (p = 0.002). CONCLUSIONS: The incidence of appropriate ICD shocks was not significantly different at 33-month follow-up in patients with ischemic cardiomyopathy versus nonischemic cardiomyopathy. However, patients with ischemic cardiomyopathy had a significantly higher incidence of all-cause mortality than patients with nonischemic cardiomyopathy (p = 0.002).

Cardiovascular manifestations in patients with thrombotic thrombocytopenic purpura: a single-center experience.

BACKGROUND: Cardiovascular manifestation in patients with thrombotic thrombocytopenic purpura. HYPOTHESIS: The aim of this study was to investigate the incidence of acute myocardial infarction (AMI), arrhythmias, congestive heart failure, and mortality in patients hospitalized for thrombotic thrombocytopenic purpura (TTP). METHODS: Thirty-eight patients (27 women and 11 men), mean age 44 years, were hospitalized with the diagnosis of TTP confirmed by a hematologist. We investigated the incidence of AMI which developed during hospitalization for TTP. AMI was diagnosed by new electrocardiographic changes, increased serum cardiac troponin I levels, and clinical symptomatology. The patients with AMI were also monitored for development of arrhythmias during hospitalization. RESULTS: Of the 38 patients, 8 (21%) developed new Q-wave AMI. There was no significant difference in baseline characteristics between patients who developed AMI and those who did not develop AMI. Of the 8 patients with AMI, 2 (25%) developed atrial fibrillation, 1 (13%) developed atrial flutter, 1 (13%) developed supraventricular tachycardia, and 2 (25%) developed congestive heart failure. Death occurred in 3 of 8 patients (38%) with AMI and in 1 of 30 patients (3%) without AMI (P < 0.01). CONCLUSIONS: New Q-wave AMI developed in 21% of 38 patients hospitalized with TTP. Supraventricular tachyarrhythmias developed in 50% of 8 patients with TTP who developed AMI. Patients hospitalized for TTP should be monitored for adverse cardiac events due to the high incidence of new AMI, supraventricular tachyarrhythmias, and mortality.