Rationale and Design of the SOTA-P-CARDIA Trial (ATRU-V): Sotagliflozin in HFpEF Patients Without Diabetes.

Heart failure with preserved ejection fraction (HFpEF) is now the most common form of heart failure (HF). This syndrome is associated with an elevated morbi-mortality, and effective therapies are urgently needed. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are the first pharmacological class that has demonstrated to reduce hospitalization and cardiovascular mortality in large clinical trials in HFpEF. Furthermore, the dual SGLT 1/2 inhibitor sotagliflozin has shown a reduction in cardiovascular outcomes in diabetic HF patients, regardless of ejection fraction Sotagliflozin on Cardiovascular Events in Patients with Type 2 Diabetes Post Worsening Heart Failure (SOLOIST-WHF) Trial, and prevents the development of HF in patients with diabetes and chronic kidney disease Sotagliflozin on Cardiovascular and Renal Events in Patients with Type 2 Diabetes and Moderate Renal Impairment Who Are at Cardiovascular Risk (SCORED) trial. The major objective of the Sotagliflozin in Heart Failure With Preserved Ejection Fraction Patients (SOTA-P-CARDIA) trial (NCT05562063) is to investigate whether the observed cardiorenal benefits of sotagliflozin in HF patients with diabetes can be extended to a non-diabetic population. The SOTA-P-CARDIA is a prospective, randomized, double-blinded, placebo-controlled study that will randomize non-diabetic patients with the universal definition of HFpEF (ejection fraction > 50% assessed the day of randomization). Qualifying patients will be randomized, in blocks of 4, to receive either sotagliflozin or placebo for a period of 6 months. The primary outcome is changes in left ventricular mass by cardiac magnetic resonance from randomization to end of the study between the groups. Secondary end points include changes in peak VO2; myocardial mechanics, interstitial myocardial fibrosis, and volume of epicardial adipose tissue; distance in the 6-min walk test; and quality of life. Finally, the authors expect that this trial will help to clarify the potential benefits of the use of sotagliflozin in non-diabetic HFpEF patients.

Rationale and Design of the EMPA-TROPISM Trial (ATRU-4): Are the "Cardiac Benefits" of Empagliflozin Independent of its Hypoglycemic Activity?

The SGLT2 inhibitor empagliflozin reduced cardiovascular mortality by 38% and heart failure (HF) hospitalizations by 35% in diabetic patients. We have recently demonstrated the efficacy of empagliflozin in ameliorating HF and improving cardiac function in a non-diabetic porcine model of HF mediated via a switch in myocardial metabolism that enhances cardiac energetics. Therefore, we hypothesized that the cardiac benefits of empagliflozin can also be extended to non-diabetic HF patients. The EMPA-TROPISM clinical trial is a randomized, double-blind, parallel group, placebo-controlled, trial comparing the efficacy of and safety of empagliflozin in non-diabetic HF patients. Eighty patients with stable HF for over 3 months, LVEF < 50%, and New York Heart Association functional class II to IV symptoms will be randomized to empagliflozin 10 mg for 6 months or placebo. All patients will undergo cardiac magnetic resonance (CMR), cardiopulmonary exercise test (CPET), 6-min walk test, and quality of life questionnaires. The primary outcome is the change in left ventricular end-diastolic volume measured by CMR. Secondary end-points include change in peak VO2 (CPET); change in LV mass, in LVEF, in myocardial mechanics (strains), in left atrium volumes, in RV function and volumes, in interstitial myocardial fibrosis, and in epicardial adipose tissue (CMR); change in the distance in the 6-min walk test; and changes in quality of life (Kansas Cardiomyopathy questionnaire [KCCQ-12] and the 36-Item Short Form Survey [SF-36]). Safety issues (e.g., hypoglycemia, urinary infections, ketoacidosis,…) will also be monitored. In summary, EMPA-TROPISM clinical trial will determine whether the SGLT2 inhibitor empagliflozin improves cardiac function and heart failure parameters in non-diabetic HF patients (EMPA-TROPISM [ATRU-4]: Are the "cardiac benefits" of Empagliflozin independent of its hypoglycemic activity; NCT 03485222).

TRANSCULTURAL DIABETES CARE IN THE UNITED STATES - A POSITION STATEMENT BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS.

The American Association of Clinical Endocrinologists (AACE) has created a transculturalized diabetes chronic disease care model that is adapted for patients across a spectrum of ethnicities and cultures. AACE has conducted several transcultural activities on global issues in clinical endocrinology and completed a 3-city series of conferences in December 2017 that focused on diabetes care for ethnic minorities in the U.S. Proceedings from the "Diabetes Care Across America" series of transcultural summits are presented here. Information from community leaders, practicing health care professionals, and other stakeholders in diabetes care is analyzed according to biological and environmental factors. Four specific U.S. ethnicities are detailed: African Americans, Latino/Hispanics, Asian Americans, and Native Americans. A core set of recommendations to culturally adapt diabetes care is presented that emphasizes culturally appropriate terminology, transculturalization of white papers, culturally adapting clinic infrastructure, flexible office hours, behavioral medicine-especially motivational interviewing and building trust-culturally competent nutritional messaging and health literacy, community partnerships for care delivery, technology innovation, clinical trial recruitment and retention of ethnic minorities, and more funding for scientific studies on epigenetic mechanisms of cultural impact on disease expression. It is hoped that through education, research, and clinical practice enhancements, diabetes care can be optimized in terms of precision and clinical outcomes for the individual and U.S. population as a whole.

A Comparison of Vasodilating and Non-vasodilating Beta-Blockers and Their Effects on Cardiometabolic Risk.

Cardiometabolic risk describes a collection of risk factors, with a likely underlying pathophysiology, resulting in accelerated atherosclerosis and the terminal cardiovascular events of myocardial infarction and stroke. Beta-blockers, which are divided as vasodilators or non-vasodilators, are used in the treatment of hypertension and other cardiovascular diseases. Vasodilators have been shown to be of particular benefit in both blood pressure control and other cardiometabolic components with limited disturbance in metabolic parameters. Nebivolol, a third-generation beta-blocker (BB), acts by increasing nitric oxide (NO) bioavailability. This property may be especially important in NO-deficient population, such as black people, in regulating both blood pressure control and glucose homeostasis.

Everolimus-eluting stents and zotarolimus-eluting stents for percutaneous coronary interventions: two-year outcomes in New York State.

OBJECTIVES: To compare 2-year outcomes (mortality, mortality/myocardial infarction (MI), target vessel PCI (TVPCI), and target lesion PCI (TLPCI)) for patients receiving EES and ZES. BACKGROUND: The utilization of drug-eluting coronary stents (DES) among patients undergoing percutaneous coronary interventions (PCI) has increased dramatically in the last decade. Everolimus-eluting stents (EES) and ENDEAVOR zotarolimus eluting stents (ZES) constitute the latest generation of approved DES in the United States, but little is known about their relative effectiveness. METHODS: New York patients undergoing EES and ZES revascularization without any other type of stent between 7/08 and 12/08 were propensity matched at the hospital level using multiple patient, operator, and hospital characteristics, and matched patients were followed through the end of 2010 to obtain comparative 2-year outcomes. RESULTS: A total of 3286 patients were propensity-matched. Patients receiving EES had a significantly lower TVPCI rate (9.0% vs. 11.9%, AHR = 1.31, 95% CI (1.04, 1.65)) and a significantly lower TLPCI rate (6.0% vs. 8.3%, AHR = 1.35, 95% CI (1.02, 1.79)). There was no significant difference between EES and ZES for mortality or MI/mortality. CONCLUSIONS: There were no significant differences in the hard endpoints of death or MI between patients who received EES versus those who received ZES (ENDEAVOR). Patients with EES experienced lower repeat revascularization rates than patients with ZES at 24 months.

Randomized Trial of Empagliflozin in Nondiabetic Patients With Heart Failure and Reduced Ejection Fraction.

BACKGROUND: Large clinical trials established the benefits of sodium-glucose cotransporter 2 inhibitors in patients with diabetes and with heart failure with reduced ejection fraction (HFrEF). The early and significant improvement in clinical outcomes is likely explained by effects beyond a reduction in hyperglycemia. OBJECTIVES: The purpose of this study was to assess the effect of empagliflozin on left ventricular (LV) function and volumes, functional capacity, and quality of life (QoL) in nondiabetic HFrEF patients. METHODS: In this double-blind, placebo-controlled trial, nondiabetic HFrEF patients (n = 84) were randomized to empagliflozin 10 mg daily or placebo for 6 months. The primary endpoint was change in LV end-diastolic and -systolic volume assessed by cardiac magnetic resonance. Secondary endpoints included changes in LV mass, LV ejection fraction, peak oxygen consumption in the cardiopulmonary exercise test, 6-min walk test, and quality of life. RESULTS: Empagliflozin was associated with a significant reduction of LV end-diastolic volume (-25.1 ± 26.0 ml vs. -1.5 ± 25.4 ml for empagliflozin vs. placebo, respectively; p < 0.001) and LV end-systolic volume (-26.6 ± 20.5 ml vs. -0.5 ± 21.9 ml for empagliflozin vs. placebo; p < 0.001). Empagliflozin was associated with reductions in LV mass (-17.8 ± 31.9 g vs. 4.1 ± 13.4 g, for empagliflozin vs. placebo, respectively; p < 0.001) and LV sphericity, and improvements in LV ejection fraction (6.0 ± 4.2 vs. -0.1 ± 3.9; p < 0.001). Patients who received empagliflozin had significant improvements in peak O2 consumption (1.1 ± 2.6 ml/min/kg vs. -0.5 ± 1.9 ml/min/kg for empagliflozin vs. placebo, respectively; p = 0.017), oxygen uptake efficiency slope (111 ± 267 vs. -145 ± 318; p < 0.001), as well as in 6-min walk test (81 ± 64 m vs. -35 ± 68 m; p < 0.001) and quality of life (Kansas City Cardiomyopathy Questionnaire-12: 21 ± 18 vs. 2 ± 15; p < 0.001). CONCLUSIONS: Empagliflozin administration to nondiabetic HFrEF patients significantly improves LV volumes, LV mass, LV systolic function, functional capacity, and quality of life when compared with placebo. Our observations strongly support a role for sodium-glucose cotransporter 2 inhibitors in the treatment of HFrEF patients independently of their glycemic status. (Are the "Cardiac Benefits" of Empagliflozin Independent of Its Hypoglycemic Activity? [ATRU-4] [EMPA-TROPISM]; NCT03485222).

Acinetobacter endocarditis presenting as a large right atrial mass: an atypical presentation.

This paper discusses a 26-year-old woman with end-stage renal disease on hemodialysis and Acinetobacter calcoaceticus-baumannii complex endocarditis. The patient had an indwelling right internal jugular catheter that was probably the nidus of infection. Transthoracic echocardiogram revealed an atypical presentation of the endocarditis as a large intracardiac mass, measuring in centimeters and occupying more than 50% of the right atrial cavity. The mass was attached to the lateral wall of the right atrium without valvular involvement. The patient was treated with prompt removal of the indwelling catheter, intravenous antibiotics, and surgical resection of the mass with an uneventful recovery. A literature search for cases of "Acinetobacter endocarditis" reveals this as the first case reported of Acinetobacter endocarditis presenting in this manner.

The Association of Black Cardiologists (ABC) Cardiovascular Implementation Study (CVIS): A Research Registry Integrating Social Determinants to Support Care for Underserved Patients.

African Americans, other minorities and underserved populations are consistently under- represented in clinical trials. Such underrepresentation results in a gap in the evidence base, and health disparities. The ABC Cardiovascular Implementation Study (CVIS) is a comprehensive prospective cohort registry that integrates social determinants of health. ABC CVIS uses real world clinical practice data to address critical gaps in care by facilitating robust participation of African Americans and other minorities in clinical trials. ABC CVIS will include diverse patients from collaborating ABC member private practices, as well as patients from academic health centers and Federally Qualified Health Centers (FQHCs). This paper describes the rationale and design of the ABC CVIS Registry. The registry will: (1) prospectively collect socio-demographic, clinical and biospecimen data from enrolled adults, adolescents and children with prioritized cardiovascular diseases; (2) Evaluate the safety and clinical outcomes of new therapeutic agents, including post marketing surveillance and pharmacovigilance; (3) Support National Institutes of Health (NIH) and industry sponsored research; (4) Support Quality Measures standards from the Center for Medicare and Medicaid Services (CMS) and Commercial Health Plans. The registry will utilize novel data and technology tools to facilitate mobile health technology application programming interface (API) to health system or practice electronic health records (EHR). Long term, CVIS will become the most comprehensive patient registry for underserved diverse patients with cardiovascular disease (CVD) and co morbid conditions, providing real world data to address health disparities. At least 10,000 patients will be enrolled from 50 sites across the United States.

Symptomatic metastatic right atrial lymphoma in a patient with AIDS presenting with pulmonary embolization.

Tumors involving the heart are rare, and the majority of them are benign. Secondary lymphoma with localization to the heart is the third most common malignant heart tumor and is more common, by far, than primary cardiac lymphomas. In patients with human immunodeficiency virus, the risk of development of systemic lymphoma is 60 to 200 times higher than in the general population. Symptoms usually consist of chest pain and dyspnea. Patients can also present with obstructive symptoms, based on the location and size of the tumor, and signs such as elevated jugular venous pressure, peripheral edema, ascites, and hepatomegaly. Transthoracic echocardiography is the initial modality of choice for diagnosis of cardiac lymphomas because it is readily available and helps localize the tumor, but transesophageal echocardiography and magnetic resonance imaging remain the best tests for evaluation. Treatment consists primarily of chemotherapy, and anticoagulation can be used in certain cases where embolization of the tumor is likely. This case review describes a 37-year-old man with past medical history significant for herpes zoster and stage 1 syphilis who presented with complaints of weight loss, intermittent fevers, and vague chest pains of 1-month duration.

Inflammatory aneurysm of the thoracoabdominal aorta with associated dissection.

The inflammatory variant of aortic aneurysms has 3 unique features: marked thickening of the aneurysm wall, fibrosis of the adjacent retroperitoneum, and rigid adherence of the adjacent structures to the anterior aneurysm wall. Abdominal tenderness with or without a pulsatile abdominal mass is the most common finding, although it is present in only about 33% of patients. Systemic symptoms, such as fever, malaise, and weight loss, are reported in about 20% to 50% of patients. A contrast-enhanced computed tomography scan, magnetic resonance imaging, and a transesophageal echocardiogram are among the best modalities to evaluate for inflammatory thoracoabdominal aneurysm, but a transthoracic echocardiogram can frequently be very suggestive. Medical treatment options include corticosteroids or other anti-inflammatory and immunosuppressive therapies. Surgical intervention usually consists of a transperitoneal approach with infrarenal aortic clamping. This case review describes a 64-year-old woman with a history of hypertension and dyslipidemia who presented with anemia, lower back pain, and a recent 30-pound weight loss.

HIV related stigma, perceived social support and risk of premature atherosclerosis in South Asians.

OBJECTIVE: This study sought to determine the association between social support and stigma experienced by HIV-positive patients and presence of subclinical cardiovascular disease. METHODS: We implemented a cross sectional study in 67 HIV-positive patients and 52 controls from a community health care center in central India. The participants underwent an in-depth survey and a clinical and laboratory assessment of cardiovascular risk. Carotid-intimal thickness (CIMT) was used as a marker of subclinical cardiovascular disease. RESULTS: On comparing the HIV and age and sex-matched control population, HIV patients had lower body weight (P=<0.001), and lower systolic blood pressures (P=0.002). Despite the lack of higher cardiac risk factor prevalence and lower lipid abnormalities, HIV patients had higher right, left and average CIMT values than controls (P<0.001 for all). HIV patients also showed higher prevalence of abnormal CIMT (≥ 0.9mm) than controls (32% vs. 0%, P<0.001). HIV patients with increased CIMT (n=37) in comparison with those with normal CIMT (n=30) were more frequently males (P=0.023), had higher systolic blood pressures (P=0.002), lower CD4 counts (P=0.033) and experienced higher enacted stigma (P=0.044). On multivariable stepwise logistic regression, systolic blood pressure (odds ratio:1.06, P=0.002) and stigma score > 25th percentile value (odds ratio:3.84, P=0.037) were independent predictors of the abnormal CIMT. CONCLUSIONS: HIV-positive patients from central India have a higher prevalence of abnormal CIMT as a marker of subclinical cardiovascular disease than the general population. This predisposition to increased cardiovascular risk may be related to complex interactions between HIV disease and stigma-related healthcare inequalities.

Transthyretin Cardiac Amyloidosis in Black Americans.

Transthyretin-related cardiac amyloidosis is a progressive infiltrative cardiomyopathy that mimics hypertensive and hypertrophic heart disease and often goes undiagnosed. In the United States, the hereditary form disproportionately afflicts black Americans, who when compared with whites with wild-type transthyretin amyloidosis, a phenotypically similar condition, present with more advanced disease despite having a noninvasive method for early identification (genetic testing). Although reasons for this are unclear, this begs to consider the inadequate access to care, societal factors, or a biological basis. In an effort to improve awareness and explore unique characteristics, we review the pathophysiology, epidemiology, and therapeutic strategies for transthyretin amyloidosis and highlight diagnostic pitfalls and clinical pearls for identifying patients with amyloid heart disease.

Intracardiac leiomyomatosis: iliac vein to right-ventricular outflow tract.

BACKGROUND: A 58-year-old female with a history of hypertension and asthma presented to an internist for a routine physical examination. A grade II/VI systolic ejection murmur and electrocardiogram abnormalities were noted. She was referred to a cardiologist for further assessment. INVESTIGATIONS: Transthoracic echocardiography, transesophageal echocardiography, contrast-enhanced CT and MRI, exploratory laparotomy. DIAGNOSIS: Intracardiac leiomyomatosis. MANAGEMENT: Surgical excision.

Fluoroscopic balloon-guided transesophageal echocardiography in a patient with Zenker's diverticulum.

During the past 20 years, transesophageal echocardiography (TEE) became an important diagnostic technique. Indications for TEE include: defining the cause and severity of native valve disease, particularly mitral regurgitation; detecting vegetations and other sequelae of endocarditis; assessing prosthetic valve function; and identifying a potential cardiac source for emboli.(1) TEE is usually well tolerated and is associated with few adverse events. However, structural abnormalities of the esophagus such as diverticula, stenoses, tumors, and advanced varices are relative contraindications to TEE because of the technical difficulties associated with probe advancement and the risk of esophageal perforation.(2) This report describes the successful performance of TEE in a patient with a Zenker's diverticulum. The patient was severely symptomatic of atrial fibrillation and was a poor candidate for long-term anticoagulation. Therefore, it was necessary to rule out a thrombus before cardioversion. Because the Zenker's diverticulum was large, a novel approach was taken using a balloon to occlude the orifice allowing safe passage of the TEE probe.

2014 hypertension recommendations from the eighth joint national committee panel members raise concerns for elderly black and female populations.

A report from panel members appointed to the Eighth Joint National Committee titled "2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults" has garnered much attention due to its major change in recommendations for hypertension treatment for patients ≥60 years of age and for their treatment goal. In response, certain groups have opposed the decision to initiate pharmacologic treatment to lower blood pressure (BP) at systolic BP ≥150 mm Hg and treat to a goal systolic BP of <150 mm Hg in the general population age ≥60 years. This paper contains 3 sections-an introduction followed by the opinions of 2 writing groups-outlining objections to or support of maintaining this proposed strategy in certain at-risk populations, namely African Americans, women, and the elderly. Several authors argue for maintaining current targets, as opposed to adopting the new recommendations, to allow for optimal treatment for older women and African Americans, helping to close sex and race/ethnicity gaps in cardiovascular disease morbidity and mortality.

Community-based approaches to prevention and management of hypertension and cardiovascular disease.

Community hypertension (HTN) outreach seeks to improve public health by identifying HTN and cardiovascular disease (CVD) risks. In the 1980s, the National Heart, Lung, and Blood Institute (NHLBI) funded multiple positive community studies. Additionally, the Centers for Disease Control and Prevention's (CDC's) Racial and Ethnic Approaches to Community Health (REACH) program addresses CVD risks. In 1978, in Baltimore, MD, the Association of Black Cardiologists (ABC), organized barbershops and churches as HTN control centers, as in New Orleans, LA, since 1993, the Healthy Heart Community Prevention Project (HHCPP). Also, the NHLBI Community Health Workers and Promotores de Salud are beneficial. The American Society of Hypertension (ASH) Hypertension Community Outreach program provides free HTN and CVD screenings, digital BP monitors, multilingual and literacy-appropriate information, and videos. Contemporary major federal programs, such as the Million Hearts Initiative, are ongoing. Overall, the evidence-based Logic Model should enhance planning, implementation, and dissemination.

Appropriateness of coronary revascularization for patients without acute coronary syndromes.

OBJECTIVES: The purpose of this study was to determine appropriateness of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery performed in New York for patients without acute coronary syndrome (ACS) or previous CABG surgery. BACKGROUND: The American College of Cardiology Foundation (ACCF) and 6 other societies recently published joint appropriateness criteria for coronary revascularization. METHODS: Data from patients who underwent CABG surgery and PCI without acute coronary syndrome or previous CABG surgery in New York in 2009 and 2010 were used to assess appropriateness and to examine the variation across hospitals in inappropriateness ratings. RESULTS: Of the 8,168 patients undergoing CABG surgery in New York without ACS/prior CABG who could be rated, 90.0% were appropriate for revascularization, 1.1% were inappropriate, and 8.6% were uncertain. Of the 33,970 PCI patients eligible for rating, 28% lacked sufficient information to be rated. Of the patients who could be rated, 36.1% were appropriate, 14.3% were inappropriate, and 49.6% were uncertain. A total of 91% of the patients undergoing PCI who were classified as inappropriate had 1- or 2-vessel disease without proximal left anterior descending artery disease and had no or minimal anti-ischemic medical therapy. CONCLUSIONS: For patients without ACS/prior CABG, only 1% of patients undergoing CABG surgery who could be rated were found to be inappropriate for the procedure according to the ACCF appropriateness criteria, but 14% of the PCI patients who could be rated were found to be inappropriate, and 28% lacked enough noninvasive test information to be rated.

Comparison of outcomes for patients receiving drug-eluting versus bare metal stents for non-ST-segment elevation myocardial infarction.

The outcomes for patients undergoing percutaneous coronary interventions (PCI) with drug-eluting stents (DESs) and bare metal stents (BMSs) have been compared in many studies for patients with ST-segment elevation myocardial infarction. However, little is known about the relative outcomes for patients with non-ST-segment elevation myocardial infarction (NSTEMI). The aim of the present study was to compare the NSTEMI outcomes for PCI with DESs and BMSs. New York's PCI registry was used to propensity-match 4,776 pairs of patients with NSTEMI who had received DESs and BMSs from January 1, 2003 to December 31, 2007. These patients were followed up through December 31, 2008 to test for differences in mortality, target vessel revascularization, and total repeat revascularization. The outcomes were also compared for various patient subsets. At a median follow-up period of 3.68 years, the patients receiving DESs had significantly lower mortality (16.58% vs 14.52%, difference 2.06%, p<0.001), target vessel revascularization (13.08% vs 11.04%, p=0.009), and total repeat revascularization (22.16% vs 18.77%, p<0.001). The patients receiving paclitaxel-eluting and sirolimus-eluting stents both experienced superior outcomes compared to patients receiving BMSs. The patients receiving DESs had significantly lower mortality rates than their propensity-matched counterparts receiving BMSs when they were ≥65 years (difference 2.29%, p=0.01) and male (difference 2.77%, p=0.003). In conclusion, patients with NSTEMI undergoing PCI experienced lower 4-year mortality, target vessel revascularization, and repeat revascularization rates when they had received DESs than when they had received BMSs, and patients who were >65 years old, and men received notable benefits.

Impact of incomplete revascularization on long-term mortality after coronary stenting.

BACKGROUND: The impact of incomplete revascularization (IR) on adverse outcomes after percutaneous coronary intervention remains inconclusive, and few studies have examined mortality during follow-ups longer than 5 years. The objective of this study is to test the hypothesis that IR is associated with higher risk of long-term (8-year) mortality after stenting for multivessel coronary disease. METHODS AND RESULTS: A total of 13 016 patients with multivessel disease who had undergone stenting procedures with bare metal stents in 1999 to 2000 were identified in the New York State's Percutaneous Coronary Intervention Reporting System. A logistic regression model was fit to predict the probability of achieving complete revascularization (CR) in these patients using baseline risk factors; then, the CR patients were matched to the IR patients with similar likelihoods of achieving CR. Each patient's vital status was followed through 2007 using the National Death Index, and the difference in long-term mortality between IR and CR was compared. It was found that CR was achieved in 29.2% (3803) of the patients. For the 3803 pair-matched patients, the respective 8-year survival rates were 80.8% and 78.5% for CR and IR (P=0.04), respectively. The risk of death was marginally significantly higher for IR (hazard ratio=1.12; 95% confidence interval, 1.01-1.26, P=0.04). The 95% bootstrap confidence interval for the hazard ratio was 0.98 to 1.32. CONCLUSIONS: IR may be associated with higher risk of long-term mortality after stenting with BMS in patients with multivessel disease. More prospective studies are needed to further test this association.