Pulmonary Arteriovenous Fistula with Pulmonary Hypertension - To Close or Not to Close?

UNLABELLED: A 37-year-old female presented to our facility suffering from exertional dyspnea for 2-3 months. Her chest x-ray showed a nodular shadow in the right lower lung, and chest CT revealed a pulmonary arteriovenous fistula (PAVF). Subsequent echocardiographic examination detected no intra-cardiac shunt but did indicate pulmonary hypertension as evidenced by a tricuspid regurgitation flow velocity of 4.17 M/sec. Contrast echocardiography with antecubital vein injection of agitated normal saline demonstrated visualization of the left heart chambers compatible with PAVF. At cardiac catheterization, pulmonary arterial pressure was 59/26 mmHg, mean 34 mmHg. Because there was no intra-cardiac communication detected, primary pulmonary hypertension was tentatively diagnosed. Pulmonary angiography demonstrated a PAVF arising from the lower right pulmonary artery, forming a secular structure on its course in draining into the left atrium through a long pulmonary vein. In this particular anomaly, a concurrence of PAVF with pulmonary hypertension, we judged that the PAVF might serve as a safety valve for pulmonary hypertension and should not be closed. We therefore left the PAVF untreated and thereafter provided medical management for this patient. The concomitant presence of PAVF and pulmonary hypertension is a rare clinical condition. The ultimate treatment strategy for this uncommon condition should be carefully considered. KEY WORDS: Computed tomography; Contrast echocardiography; Pulmonary angiography; Pulmonary arteriovenous fistula; Pulmonary hypertension.

Accordion Stent Deformation upon Retrieval of a Side-Branch Protective Guidewire.

UNLABELLED: In this case we herein report a dangerous complication from primary percutaneous coronary intervention, where an unnoticed loop of the guidewire was inadvertently made around the stent during provisional stenting. Since the guidewire and the stent were entangled, efforts to retrieve the guidewire only exacerbated the problem by compressing the stent like an accordion. We review those factors that may have influenced stent compression in our case, as well as possible ways to avoid it from occurring in the future. KEY WORDS: Catheterization; Coronary stenosis; Embolism; Myocardial infarction; Percutaneous coronary intervention; Stents.

Effect of 8-Week Combination Therapy with an Extended-Release α1-Blocker (Bunazosin or Doxazosin) in Inadequate Responders to an Angiotensin II Antagonist (Valsartan) in Patients with Stage 1 or 2 Essential Hypertension.

BACKGROUND: Given the favorable impact of α1-blockers on lipid and glucose metabolism, this study was designed to compare the efficacy of two extended-release α1-blockers (bunazosin and doxazosin) as an add-on treatment in subjects with stage 1 or 2 essential hypertension which was inadequately controlled by valsartan 80 mg/day. METHODS: After a 5-week treatment of valsartan monotherapy, subjects with inadequately controlled hypertension were randomized to receive either extended-release bunazosin (n = 47) or doxazosin (n = 46) after breakfast for 8 weeks. Office sitting blood pressure (BP), 24-hour ambulatory BP, and metabolic profiles were measured at baseline, start of study drug, and study end. RESULTS: In the intention-to-treat population (n = 93), the average daily doses of bunazosin and doxazosinwere 2.8 mg and 3.6 mg, respectively. The two add-on treatments achieved significant and similar BP reductions from monotherapy (bunazosin, 13.2/9.3 mmHg; doxazosin, 9.2/8.5 mmHg, all p < 0.001). However, in patients with stage 2 hypertension, patients randomized to the bunazosin group, compared to those in the doxazosin group, achieved a significantly greater reduction in sitting systolic BP (14.4 ± 8.1 vs. 6.6 ± 13.8 mmHg, p = 0.015). In addition, patients who received bunazosin had significant changes in night-day systolic and diastolic BP ratios compared with those who received doxazosin (-0.02 vs. 0.02, p = 0.04 and 0 vs. 0.04, p = 0.04). No significant changes in metabolic profiles were observed in both add-on groups. Both drugs were well-tolerated, but adverse events related to the study drugs were marginally more frequent in the doxazosin group than in the bunazosin group (20% vs. 6%, p = 0.058). CONCLUSIONS: Both extended-release bunazosin and doxazosinwerewell-tolerated and similarly effective as add-on therapy in hypertensive patients uncontrolled by valsartan monotherapy. However, add-on treatment with bunazosin seemed to be associated with favorable night-day BP ratio and greater sitting systolic BP reductions in stage 2 hypertensive patients. KEY WORDS: Combination therapy; Hypertension; α1-blocker.

An international model to predict recurrent cardiovascular disease.

BACKGROUND: Prediction models for cardiovascular events and cardiovascular death in patients with established cardiovascular disease are not generally available. METHODS: Participants from the prospective REduction of Atherothrombosis for Continued Health (REACH) Registry provided a global outpatient population with known cardiovascular disease at entry. Cardiovascular prediction models were estimated from the 2-year follow-up data of 49,689 participants from around the world. RESULTS: A developmental prediction model was estimated from 33,419 randomly selected participants (2394 cardiovascular events with 1029 cardiovascular deaths) from the pool of 49,689. The number of vascular beds with clinical disease, diabetes, smoking, low body mass index, history of atrial fibrillation, cardiac failure, and history of cardiovascular event(s) <1 year before baseline examination increased risk of a subsequent cardiovascular event. Statin (hazard ratio 0.75; 95% confidence interval, 0.69-0.82) and acetylsalicylic acid therapy (hazard ratio 0.90; 95% confidence interval, 0.83-0.99) also were significantly associated with reduced risk of cardiovascular events. The prediction model was validated in the remaining 16,270 REACH subjects (1172 cardiovascular events, 494 cardiovascular deaths). Risk of cardiovascular death was similarly estimated with the same set of risk factors. Simple algorithms were developed for prediction of overall cardiovascular events and for cardiovascular death. CONCLUSIONS: This study establishes and validates a risk model to predict secondary cardiovascular events and cardiovascular death in outpatients with established atherothrombotic disease. Traditional risk factors, burden of disease, lack of treatment, and geographic location all are related to an increased risk of subsequent cardiovascular morbidity and cardiovascular mortality.

Age, male gender, and atrial fibrillation predict lower extremity amputation or revascularization in patients with peripheral artery diseases: a population-based investigation.

By using the National Health Insurance (NHI) claim data of Taiwan, we sought to determine the predictors for nontraumatic lower extremity amputation (LEA) or peripheral revascularization procedures (PRP) in patients with peripheral artery disease (PAD). From the NHI claim data, we identified 12,206 patients with newly diagnosed PAD between 1998 and 2008, and followed them up to 2008. We explored the age, gender, and whether the patients had concomitant comorbid conditions, such as diabetes mellitus (DM), hypertension (HTN), atrial fibrillation (AF), stroke, hospitalization for coronary artery disease (CAD), myocardial infarction (MI), or heart failure (HF), and whether they were taking cilostazol at the time of recruitment. We searched for clinical parameters that might be important determinants for LEA or PRP in the study population. Of the 12,206 patients, 150 (1.2%) were found to undergo either LEA or PRP or both (LEA 81, PRP 53, both PRP and LEA 16). Old age, male gender, and history of hospitalization for CAD or MI and AF were found to be risk predictors for both procedures. Patients with DM were at lower risk for PRP (odds ratio 0.418, p = 0.001). Patients who were taking cilostazol had higher risk for LEA or PRP. HTN was not a risk predictor for LEA or PRP. From this nationwide study, we found that among PAD patients in Taiwan, age, male gender, AF, and hospitalization for CAD or MI are risk predictors for future LEA or PRP. DM is a negative predictor for PRP while both DM and HTN are not risk predictors for LEA.

Ethnic differences in cardiovascular risks and mortality in atherothrombotic disease: insights from the Reduction of Atherothrombosis for Continued Health (REACH) registry.

OBJECTIVE: To determine whether ethnic-specific differences in the prevalence of cardiovascular risk factors and outcomes exist worldwide among individuals with stable arterial disease. PATIENTS AND METHODS: From December 1, 2003, to June 30, 2004, the prospective, observational REduction of Atherothrombosis for Continued Health (REACH) Registry enrolled 49,602 out-patients with coronary artery disease, cerebrovascular disease, and/or peripheral arterial disease from 7 predefined ethnic/racial groups: white, Hispanic, East Asian, South Asian, Other Asian, black, and Other (comprising any race distinct from those specified). The baseline demographic and risk factor profiles, medication use, and 2-year cardiovascular outcomes were assessed among these groups. RESULTS: The prevalence of traditional atherothrombotic risk factors varied significantly among the ethnic/racial groups. The use of medical therapies to reduce risk was comparable among all groups. At 2-year follow-up, the rate of cardiovascular death was significantly higher in blacks (6.1%) compared with all other ethnic/racial groups (3.9%; P=.01). Cardiovascular death rates were significantly lower in all 3 Asian ethnic/racial groups (overall, 2.1%) compared with the other groups (4.5%; P<.001). CONCLUSION: The REACH Registry, a large international study of individuals with atherothrombotic disease, documents the important ethnic-specific differences in cardiovascular risk factors and variations in cardiovascular mortality that currently exist worldwide.

Arterial function of carotid and brachial arteries in postmenopausal vegetarians.

BACKGROUND: Vegetarianism is associated with a lower risk of cardiovascular disease. However, studies of arterial function in vegetarians are limited. METHODS: This study investigated arterial function in vegetarianism by comparing 49 healthy postmenopausal vegetarians with 41 age-matched omnivores. The arterial function of the common carotid artery was assessed by carotid duplex, while the pulse dynamics method was used to measure brachial artery distensibility (BAD), compliance (BAC), and resistance (BAR). Fasting blood levels of glucose, lipids, lipoprotein (a), high-sensitivity C-reactive protein, homocysteine, and vitamin B12 were also measured. RESULTS: Vegetarians had significantly lower serum cholesterol, high-density and low-density lipoprotein, and glucose compared with omnivores. They also had lower vitamin B12 but higher homocysteine levels. Serum levels of lipoprotein (a) and high-sensitivity C-reactive protein were no different between the two groups. There were no significant differences in carotid beta stiffness index, BAC, and BAD between the two groups even after adjustment for associated covariates. However, BAR was significantly lower in vegetarians than in omnivores. Multiple linear regression analysis revealed that age and pulse pressure were two important determinants of carotid beta stiffness index and BAD. Vegetarianism is not associated with better arterial elasticity. CONCLUSION: Apparently healthy postmenopausal vegetarians are not significantly better in terms of carotid beta stiffness index, BAC, and BAD, but have significantly decreased BAR than omnivores. Prevention of vitamin B12 deficiency might be beneficial for cardiovascular health in vegetarians.

Determinants of lower extremity amputation or revascularization procedure in patients with peripheral artery diseases: a population-based investigation.

We used the National Health Insurance Claim data in Taiwan to evaluate determinants for nontraumatic lower extremity amputation (LEA) or peripheral revascularization procedures (PRP) in patients with peripheral artery diseases (PAD). We identified 14 241 patients. Sex-specific odds ratios of age, diabetes mellitus (DM), hypertension (HTN), coronary artery disease (CAD), cerebral vascular accident (CVA), or using cilostazol for LEA or PRP were explored. In patients with PAD, 14.3% of male and 7.4% of female had LEA; whereas 7.1% of male and 4.6% of female had PRP. Among male patients, HTN and CAD were significant risk factors for LEA, whereas DM and using cilostazol had protective roles. Findings in female patients were similar. For PRP, elderly patients had less such procedures. The risk/protective factors were similar. In conclusion, PAD patients having DM and using cilostazol had less LEA or PRP, whereas those having HTN and CAD had more LEA or PRP.

Data feedback reduces door-to-balloon time in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Current guidelines recommend a goal of door-to-balloon (D2B) time < 90 min for patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). We aim to prospectively determine the effect of data feedback on D2B time and its seven individual components in primary PCI. From December 7, 2007, to June 2, 2009, 116 consecutive patients with STEMI who received PCI within 12 h of symptom onset were enrolled, including 56 patients before and 60 patients after the implementation of data feedback on July 28, 2008. The proportion of patients treated within 90 min increased from 26.8 to 55.0% (p = 0.002). On multivariable analyses, data feedback (OR 5.3, p = 0.003), known coronary artery disease (OR 5.6, p = 0.043), regular hours presentation (OR 3.3, p = 0.048), and arrival by transfer (OR 14.0, p = 0.003) were independent predictors of a D2B time less than 90 min. Median D2B time decreased from 112 min before data feedback to 87 min after data feedback (p < 0.001). The most significant decrease occurred in median door-to-ECG (11 vs. 3 min, p < 0.001), consult-to-cardiologist (5 vs. 3 min, p < 0.001), and puncture-to-balloon (21 vs. 17 min, p = 0.004) time. Data feedback to the emergency department and catheterization laboratory staff decreases D2B time in primary PCI. This simple approach may be the best first step to decrease D2B time in hospitals that are still striving to achieve the goal of D2B time < 90 min.

Comparative determinants of 4-year cardiovascular event rates in stable outpatients at risk of or with atherothrombosis.

CONTEXT: Clinicians and trialists have difficulty with identifying which patients are highest risk for cardiovascular events. Prior ischemic events, polyvascular disease, and diabetes mellitus have all been identified as predictors of ischemic events, but their comparative contributions to future risk remain unclear. OBJECTIVE: To categorize the risk of cardiovascular events in stable outpatients with various initial manifestations of atherothrombosis using simple clinical descriptors. DESIGN, SETTING, AND PATIENTS: Outpatients with coronary artery disease, cerebrovascular disease, or peripheral arterial disease or with multiple risk factors for atherothrombosis were enrolled in the global Reduction of Atherothrombosis for Continued Health (REACH) Registry and were followed up for as long as 4 years. Patients from 3647 centers in 29 countries were enrolled between 2003 and 2004 and followed up until 2008. Final database lock was in April 2009. MAIN OUTCOME MEASURES: Rates of cardiovascular death, myocardial infarction, and stroke. RESULTS: A total of 45,227 patients with baseline data were included in this 4-year analysis. During the follow-up period, a total of 5481 patients experienced at least 1 event, including 2315 with cardiovascular death, 1228 with myocardial infarction, 1898 with stroke, and 40 with both a myocardial infarction and stroke on the same day. Among patients with atherothrombosis, those with a prior history of ischemic events at baseline (n = 21,890) had the highest rate of subsequent ischemic events (18.3%; 95% confidence interval [CI], 17.4%-19.1%); patients with stable coronary, cerebrovascular, or peripheral artery disease (n = 15,264) had a lower risk (12.2%; 95% CI, 11.4%-12.9%); and patients without established atherothrombosis but with risk factors only (n = 8073) had the lowest risk (9.1%; 95% CI, 8.3%-9.9%) (P < .001 for all comparisons). In addition, in multivariable modeling, the presence of diabetes (hazard ratio [HR], 1.44; 95% CI, 1.36-1.53; P < .001), an ischemic event in the previous year (HR, 1.71; 95% CI, 1.57-1.85; P < .001), and polyvascular disease (HR, 1.99; 95% CI, 1.78-2.24; P < .001) each were associated with a significantly higher risk of the primary end point. CONCLUSION: Clinical descriptors can assist clinicians in identifying high-risk patients within the broad range of risk for outpatients with atherothrombosis.

Working the night shift causes increased vascular stress and delayed recovery in young women.

Shiftwork has been associated with elevated blood pressure (BP) and decreased heart-rate variability (HRV), factors that may increase the long-term risk of cardiovascular-related mortality and morbidity. This study explored the effect of shiftwork on dynamic changes in autonomic control of HRV (cardiac stress), systolic BP and diastolic BP, i.e., SBP and DBP (vascular stress), and recovery in the same subjects working different shifts. By studying the same subjects, the authors could reduce the effect of possible contribution of between-subject variation from genetic predisposition and environmental factors. The authors recruited 16 young female nurses working rotating shifts--day (08:00-16:00 h), evening (16:00-00:00 h), and night (00:00-08:00 h)--and 6 others working the regular day shift. Each nurse received simultaneous and repeated 48-h ambulatory electrocardiography and BP monitoring during their work day and the following off-duty day. Using a linear mixed-effect model to adjust for day shift, the results of the repeated-measurements and self-comparisons found significant shift differences in vascular stress. While working the night shift, the nurses showed significant increases in vascular stress, with increased SBP of 9.7 mm Hg. The changes of SBP and DBP seemed to peak during waking time at the same time on the day off as they did on the working day. Whereas HRV profiles usually returned to baseline level after each shift, the SBP and DBP of night-shift workers did not completely return to baseline levels the following off-duty day (p < .001). The authors concluded that although the nurses may recover from cardiac stress the first day off following a night shift, they do not completely recover from increases in vascular stress on that day.

The causes and outcomes of inadequate implementation of existing guidelines for antiplatelet treatment in patients with acute coronary syndrome: the experience from Taiwan Acute Coronary Syndrome Descriptive Registry (T-ACCORD Registry).

BACKGROUND: Benefits of antiplatelet agents in preventing future cardiovascular events have been well established. However, the prescription pattern of antiplatelet usage in patients with acute coronary syndrome (ACS) is rarely investigated. Hence, Taiwan ACute CORonary Syndrome Descriptive Registry (T-ACCORD Registry) aimed to evaluate medical practices in Taiwan in managing ACS patients. HYPOTHESIS: The guidelines of antiplatelet treatment is not properly implanted in the management of ACS patients. METHODS: This prospective observational study was performed between April 2004 and December 2006 in 27 hospitals in Taiwan. A total of 1331 patients with unstable angina or non-ST-elevation myocardial infarction (NSTEMI) discharged from hospitals was analyzed. RESULTS: The patients with older age, lower hemoglobin levels, or previous cardiovascular ischemic diseases were less likely to receive aspirin at discharge, whereas patients with NSTEMI were less likely to receive clopidogrel at discharge. The prescription of dual antiplatelet agents declined rapidly from 61.8% at discharge to 12.6% at 12 months. The most common reason for clopidogrel discontinuation was recorded as physician's judgment. Dual antiplatelet treatment for 9 months or longer was associated with lower 1-year mortality. Percutaneous coronary intervention (PCI) was the only factor leading to dual antiplatelet therapy for at least 9 months. CONCLUSIONS: Our registry showed that underlying medical conditions may affect antiplatelet prescriptions at discharge. During the first year following an ACS episode, the prescription rate of dual antiplatelet therapy declined over time, mainly due to physician's judgment leading to the discontinuation of clopidogrel. Adherence to dual antiplatelet treatment was associated with lower total mortality at 1 year.

Cardiovascular risk profiles and outcomes of Chinese living inside and outside China.

AIM: To assess whether cardiovascular risk differs among the Chinese living inside and outside mainland China. METHODS AND RESULTS: Three thousand, four hundred and eighty-two East Asians were enrolled in the REduction of Atherothrombosis for Continued Health Registry in mainland China, Hong Kong/Singapore/Taiwan, Western Europe, and North America. Baseline demographics, medication use, risk factor control, and 30-month cardiovascular outcomes of the 2938 patients with atherothrombotic disease were compared. Rates of hypertension, hypercholesterolemia, diabetes, abdominal obesity, and body mass index ≥25 kg/m² were lowest in mainland China, were increased in Hong Kong/Singapore/Taiwan, and were highest in Western Europe and North America. Diabetes prevalence was 23% in mainland China, approximately two-fold lower than the other regions. Antihypertensive, antidiabetic, and antiplatelet agent use was similar in all regions. Risk factor control was significantly poorer in Western Europe and, except for glucose control, significantly better in North America. Thirty-month nonfatal stroke rates were highest in mainland China and fell in a stepwise manner in more westernized societies. Conversely, nonfatal myocardial infarction rates increased in more westernized societies. CONCLUSION: Obesity and other risk factors progressively worsen as patients move from mainland China to Hong Kong/Singapore/Taiwan and overseas. Despite similar medication use, risk factor control and cardiovascular outcomes were significantly different. The magnitude of these changes is larger than formerly estimated, suggesting population differences in cardiovascular risk and disease prevalence, likely to be more closely associated with lifestyle and cultural habits than genetic differences.

Ethnic differences in the relationships of anthropometric measures to metabolic risk factors in Asian patients at risk of atherothrombosis: results from the REduction of Atherothrombosis for Continued Health (REACH) Registry.

The aim of the study is to examine the relationships between 4 anthropometric indices and metabolic risk factors (hypertension, atherogenic dyslipidemia, and glucose intolerance) in different Asian ethnic groups of patients at risk of atherothrombosis. We analyzed the baseline data of 11 017 Asian patients with established atherothrombotic cardiovascular diseases or at least 3 atherothrombotic risk factors. In East and South Asians, the graded relationships of body mass index (BMI) with the presence of at least 2 metabolic risk factors remained significant after adjustment for waist circumference (top vs bottom quartile--East Asians: odds ratio, 2.02; 95% confidence interval, 1.67-2.45; South Asians: 3.24, 1.18-8.95), whereas the graded relationships of waist circumference decreased or became nonsignificant after adjustment for BMI (East Asians: 1.64, 1.35-1.99; South Asians: 0.68, 0.20-2.30). In Southeast Asian men, the graded relationship of waist circumference with metabolic risk factors (2.27, 1.42-3.63) was stronger than that of BMI (1.34, 0.84-2.12), whereas in Southeast Asian women, there was a trend toward a stronger association between BMI and metabolic risk factors. In East Asians and in Southeast Asian women, the waist-to-BMI ratio decreased with the number of metabolic risk factors. The optimal cutoff points for BMI and waist circumference with regard to the presence of at least 2 metabolic risk factors were lowest in East Asians (men: 24 kg/m(2) and 86 cm; women: 24 kg/m(2) and 82 cm). Our findings suggest that both BMI and waist circumference, rather than waist circumference alone, should be included in metabolic risk assessment in this high-risk multiethnic Asian population. Uniform anthropometric cutoff values for all Asian ethnic groups are not appropriate to assess obesity-related metabolic complications, even in patients with established atherothrombotic disease.

Three-year follow-up and event rates in the international REduction of Atherothrombosis for Continued Health Registry.

AIMS: To determine 3-year event rates in outpatients with vascular disease enrolled in the REduction of Atherothrombosis for Continued Health (REACH) Registry. METHODS AND RESULTS: REACH enrolled 67 888 outpatients with atherothrombosis [established coronary artery disease (CAD), cerebrovascular disease, or peripheral arterial disease (PAD)], or with at least three atherothrombotic risk factors, from 44 countries. Among the 55 499 patients at baseline with symptomatic disease, 39 675 were eligible for 3-year follow-up, and 32 247 had data available (81% retention rate). Among the symptomatic patients at 3 years, 92% were taking an antithrombotic agent, 91% an antihypertensive, and 76% were on lipid-lowering therapy. For myocardial infarction (MI)/stroke/vascular death, 1- and 3-year event rates for all patients were 4.2 and 11.0%, respectively. Event rates (MI/stroke/vascular death) were significantly higher for patients with symptomatic disease vs. those with risk factors only at 1 year (4.7 vs. 2.3%, P < 0.001) and at 3 years (12.0 vs. 6.0%, P < 0.001). One and 3-year rates of MI/stroke/vascular death/rehospitalization were 14.4 and 28.4%, respectively, for patients with symptomatic disease. Rehospitalization for a vascular event other than MI/stroke/vascular death was common at 3 years (19.0% overall; 33.6% for PAD; 23.0% for CAD). For patients with symptomatic vascular disease in one vascular bed vs. multiple vascular beds, 3-year event rates for MI/stroke/vascular death/rehospitalization were 25.5 vs. 40.5% (P < 0.001). CONCLUSION: Despite contemporary therapy, outpatients with symptomatic atherothrombotic vascular disease experience high rates of recurrent vascular events and rehospitalizations.

Cardiovascular risk factor control and outcomes in peripheral artery disease patients in the Reduction of Atherothrombosis for Continued Health (REACH) Registry.

OBJECTIVES: To examine differences in risk factor (RF) management between peripheral artery disease (PAD) and coronary artery (CAD) or cerebrovascular disease (CVD), as well as the impact of RF control on major 1-year cardiovascular (CV) event rates. METHODS: The REACH Registry recruited >68000 outpatients aged >or=45 years with established atherothrombotic disease or >or=3 RFs for atherothrombosis. The predictors of RF control that were evaluated included: (1) patient demographics, (2) mode of PAD diagnosis, and (3) concomitant CAD and/or CVD. RESULTS: RF control was less frequent in patients with PAD (n=8322), compared with those with CAD or CVD (but no PAD, n=47492) [blood pressure; glycemia; total cholesterol; smoking cessation (each P<0.001)]. Factors independently associated with optimal RF control in patients with PAD were male gender (OR=1.9); residence in North America (OR=3.5), Japan (OR=2.5) or Latin America (OR=1.5); previous coronary revascularization (OR=1.3); and statin use (OR=1.4); whereas prior leg amputation was a negative predictor (OR=0.7) (P<0.001). Optimal RF control was associated with fewer 1-year CV ischemic symptoms or events. CONCLUSIONS: Patients with PAD do not achieve RF control as frequently as individuals with CAD or CVD. Improved RF control is associated with a positive impact on 1-year CV event rates.

Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis.

BACKGROUND: Atrial fibrillation (AF) is a major risk factor (RF) for ischemic stroke. Its prevalence and prognostic impact in patients with atherothrombosis are unclear. METHODS: Risk factors, drug usage, and 1-year cardiovascular (CV) outcomes (CV death, myocardial infarction [MI], and stroke) were compared in AF and non-AF patients from the REduction of Atherothrombosis for Continued Health (REACH) Registry, an international, prospective cohort of 68,236 stable outpatients with established atherothrombosis or>or=3 atherothrombotic RFs. RESULTS: Atrial fibrillation and 1-year follow-up data are available for 63,589 patients. The prevalence of AF was, 12.5%, 13.7%, 11.5%, and 6.2% among coronary artery disease, CV disease, peripheral artery disease, and RF-only patients, respectively. Of the 6,814 patients with AF, 6.7% experienced CV death, nonfatal MI, or nonfatal stroke within a year. The annual incidence of nonfatal stroke (2.4% vs 1.6%, P<.0001) and unstable angina (6.0% vs 4.0%, P<.00001) was higher, and CV death was more than double (3.2% vs 1.4%, P<.0001), in AF versus non-AF patients. In these patients with or at high risk of atherothrombosis, most patients with AF received antiplatelet agents, but only 53.1% were treated with oral anticoagulants. Even with high CHADS2 (congestive heart failure, hypertension, aging, diabetes mellitus, and stroke) scores, anticoagulant use did not exceed (59%). The rate of bleeding requiring hospitalization was higher in AF versus non-AF patients (1.5% vs 0.8%, P<.0001), possibly related to the more frequent use of anticoagulants (53.1% vs 7.1%). CONCLUSIONS: Atrial fibrillation is common in patients with atherothrombosis, associated with more frequent fatal and nonfatal CV outcomes, and underuse of oral anticoagulants.

Modifiable risk factors control and its relationship with 1 year outcomes after coronary artery bypass surgery: insights from the REACH registry.

AIMS: To evaluate the influence of achieving secondary prevention target treatment goals for cardiovascular (CV) risk factors on clinical outcomes in patients with prior coronary artery bypass surgery (CABG). METHODS AND RESULTS: Accordingly, we analysed treatment to target goals in patients with prior CABG and atherothrombotic disease or known risk factors (diabetes, hypertension, hypercholesterolaemia, smoking, obesity) enrolled in the global REduction in Atherothrombosis for Continued Health (REACH) Registry, and their association with 1 year outcomes. A total of 13 907 of 68 236 patients (20.4%) in REACH had a history of prior CABG, and 1 year outcomes data were available for 13 207 of these. At baseline <25, 25-<50, 50-<75, and > or =75% risk factors were at goal in 3.7, 12.9, 31.7, and 51.7% of patients, respectively. One-year composite rates of CV death, non-fatal MI, non-fatal stroke were inversely related to the proportion of risk factors at goal at baseline (age, gender, and region adjusted rates 6.1, 5.6, 5.2, and 4.3% of patients with <25, 25-<50, 50-<75, and >75% risk factors at goal, respectively; P for trend 0.059). CONCLUSION: Risk-factor control varied greatly in CABG patients. Although CABG patients are frequently treated with appropriate therapies, these treatments fail to achieve an adequate level of prevention in many. This failure was associated with a trend for worse age-, gender-, and region-adjusted clinical outcomes. Thus, perhaps secondary prevention after CABG needs to focus on more comprehensive modification of risk factors to target goals in the hope of preventing subsequent CV events, and represents an opportunity to improve CV health.