The Association of Body Mass Index and 20-Year All-Cause Mortality Among Patients With Stable Coronary Artery Disease.

BACKGROUND: Limited data exist regarding the long-term association of body mass index (BMI) and all-cause mortality among patients with stable coronary artery disease (CAD). Accordingly, the aim of this study is to explore the association between BMI and long-term all-cause mortality among patients with stable CAD. METHODS: Our study included 15,357 patients with stable CAD who were enrolled in the Bezafibrate Infarction Prevention (BIP) registry between February, 1990 and October1992, and subsequently followed-up through December 2014. RESULTS: 5,051 (33%) patients were classified as normal weight (BMI 18.5-24.99kg/m2), while 7,841 (51%) patients were classified as overweight (BMI 25-29.99kg/m2), and 2,465 (16%) as obese (BMI≥30). Kaplan-Meier survival analysis showed that at 20 years of follow-up the rate of all-cause mortality was significantly higher among obese patients (67%) compared to overweight (61%) and normal weight (61%); log rank p-value for the overall difference <0.001. Multivariable analysis showed that obese patients had an independently 12% greater mortality risk compared to normal weight patients (HR=1.12; 95% CI 1.02-1.23; p=0.02), whereas, overweight patients experienced a similar mortality risk as normal weight patients (HR=0.99; 95% CI 0.92-1.06; p=0.76). The mortality risk associated with obesity was pronounced among patients younger than 65 years (p-value for interaction<0.05). CONCLUSIONS: Our findings indicate that obesity is independently associated with increased risk for long-term mortality among patients with stable coronary artery disease, whereas overweight does not appear to confer an additional risk in this population.

Participation in an Exercise-Based Cardiac Rehabilitation Program and Functional Improvement of Heart Failure Patients with Preserved Versus Reduced Left Ventricular Systolic Function.

BACKGROUND: About half of all patients with heart failure are diagnosed with heart failure preserved ejection fraction (HFpEF). Until now, studies have failed to show that medical treatment improves the prognosis of patients with HFpEF. OBJECTIVES: To evaluate changes in exercise capacity of patients with HFpEF compared to those with heart failure with reduced ejection fraction (HFrEF) following an exercise training program. METHODS: Patient data was retrieved from a multi-center registry of patients with heart failure who participated in a cardiac rehabilitation program. Patients underwent exercise testing and an echocardiogram prior to entering the program and were retested6  months later. RESULTS: Of 216 heart failure patients enrolled in the program, 170 were diagnosed with HFrEF and 46 (21%) with HFpEF. Patients with HFpEF had lower baseline exercise capacity compared to those with HFrEF. Participating in a 6 month exercise program resulted in significant and similar improvement in exercise performance of both HFpEF and HFrEF patients: an absolute metabolic equivalent (MET) change (1.45 METs in HFrEF patients vs. 1.1 in the HFpEF group, P = 0.3). CONCLUSIONS: An exercise training program resulted in similar improvement of exercise capacity in both HFpEF and HFrEF patients. An individualized, yet similarly structured, cardiac rehabilitation program may serve both heart failure groups, providing safety and efficacy.

The prognostic significance of improvement in exercise capacity in heart failure patients who participate in cardiac rehabilitation programme.

Introduction There are limited contemporary data regarding the association between improvement in cardiovascular fitness in heart failure patients who participate in a cardiac rehabilitation programme and the risk of subsequent hospitalisations. Methods The study population comprised 421 patients with heart failure who participated in our cardiac rehabilitation programme between the years 2009 and 2016. All were evaluated by a standard exercise stress test before initiation, and underwent a second exercise stress test on completion of 3 ± 1 months of training. Participants were dichotomised by fitness level at baseline, according to the percentage of predicted age and sex norms achieved. Each group was further divided according to its degree of functional improvement, between the baseline and the follow-up exercise stress test. Major improvement was defined as improvement above the median value in each group. The combined primary endpoint was cardiac hospitalisation or all-cause mortality. Results A total of 211 (50%) patients had low baseline fitness (<73% (median)) for age and sex-predicted metabolic equivalents of task value. Compared to patients with higher fitness, those with a low baseline fitness were more commonly smokers, had diabetes and were obese ( P < 0.05 for all). Multivariable Cox proportional hazard regression analysis showed that, independent of baseline capacity, an improvement of 5% of predicted fitness was associated with a corresponding 10% reduced risk of cardiac hospitalisation or all-cause mortality ( P < 0.001). Conclusion In heart failure patients participating in a cardiac rehabilitation programme, improved cardiovascular fitness is associated with reduced mortality or cardiac hospitalisation risk during long-term follow-up, independent of baseline fitness.

Impaired Fasting Glucose Is the Major Determinant of the 20-Year Mortality Risk Associated With Metabolic Syndrome in Nondiabetic Patients With Stable Coronary Artery Disease.

BACKGROUND: We wanted to explore the association of metabolic syndrome (MetS) versus its individual components with 20-year all-cause mortality among patients with stable coronary artery disease. METHODS AND RESULTS: The cohort comprised 12 403 nondiabetic patients with stable coronary artery disease who were enrolled in the Bezafibrate Infarction Prevention Registry between February 1990 and October 1992 and followed up through December 2014. The study cohort was divided into 4 groups: patients without MetS or impaired fasting glucose (IFG), patients with IFG but without MetS, patients with MetS but without IFG, and patients with both MetS and IFG. Kaplan-Meier survival analysis showed that at 20 years of follow-up, the rates of all-cause mortality were the highest among patients with both MetS and IFG (66%). Patients with IFG without MetS experienced a significantly higher mortality rate compared with those with MetS without IFG (61% versus 56%; log-rank P<0.001). Multivariable Cox proportional hazard analysis showed that the final Cox model demonstrated that the additive effect of MetS (hazard ratio, 1.13; 95% confidence interval, 1.1-1.16; P=0.02) and IFG (hazard ratio, 1.54; 95% confidence interval, 1.46-1.62; P<0.001) on 20 years mortality was nonsignificant (hazard ratio, 1.01; 95% confidence interval, 0.93-1.11; P=0.69). IFG was associated with the most pronounced increase in mortality risk among the individual components (hazard ratio, 1.22; 95% confidence interval, 1.14-1.3; P<0.001). CONCLUSIONS: Our findings suggest that IFG alone is a major independent predictor of long-term mortality among patients with stable coronary artery disease versus other components of the MetS.

Elevated Admission Potassium Levels and 1-Year and 10-Year Mortality Among Patients With Heart Failure.

BACKGROUND: Limited, contradictory data exist regarding the effect of hyperkalemia on both short- and long-term all-cause mortality among hospitalized patients with heart failure (HF). METHODS: We analyzed 4,031 patients who were enrolled in the Heart Failure Survey in Israel. The study patients were grouped into 3 different potassium (K) categories. Multivariate analysis was used to determine the association of potassium levels as well as 1- and 10-year all-cause mortality. RESULTS: A total of 3,349 patients (83%) had K < 5mEq/L, whereas 461 patients (11%) had serum K ≥ 5mEq/L but≤ 5.5mEq/L and 221 patients (6%) had K > 5.5mEq/L. Survival analysis showed that 1-year mortality rates were significantly higher among patients with K > 5.5mEq/L (40%) and those with serum K ≥ 5mEq/L but ≤ 5.5mEq/L (34%) compared to those with K < 5mEq/L (27%); (all log rank P < 0.01). Similarly, 10-year mortality rates among those with K > 5.5mEq/L were 92%, whereas among those with serum K ≥ 5mEq/L but ≤ 5.5mEq/L rates were 88%, and in those with K < 5mEq/L rates were 82%; (all log rank P < 0.001). Consistently, multivariate analysis showed that compared to patients with K < 5mEq/L, patients with K > 5.5mEq/L had an independently 51% and 31% higher mortality risk at 1 year and 10 years, respectively (1-year hazard ratio = 1.51, 95% CI: 1.04-2.2; 10-years hazard ratio = 1.31, 95% CI: 1.035-1.66), whereas patients with serum K ≥ 5mEq/L but ≤ 5.5mEq/L had comparable adjusted mortality risk to patients with K < 5mEq/L at 1 and 10 years. CONCLUSIONS: Among hospitalized patients with HF, admission K > 5.5mEq/L was independently associated with increased short- and long-term mortality, whereas serum K ≥ 5mEq/L but ≤ 5.5mEq/L was not independently associated with worse outcomes.

Cardiac rehabilitation following an acute coronary syndrome: Trends in referral, predictors and mortality outcome in a multicenter national registry between years 2006-2013: Report from the Working Group on Cardiac Rehabilitation, the Israeli Heart Society.

Background Utilization of cardiac rehabilitation is suboptimal. The aim of the study was to assess referral trends over the past decade, to identify predictors for referral to a cardiac rehabilitation program, and to evaluate the association with one-year mortality in a large national registry of acute coronary syndrome patients. Design and methods Data were extracted from the Acute Coronary Syndrome Israeli Survey national surveys between 2006-2013. A total of 6551 patients discharged with a diagnosis of acute coronary syndrome were included. Results Referral to cardiac rehabilitation following an acute coronary syndrome increased from 38% in 2006 to 57% in 2013 ( p for trend < 0.001). Multivariate modeling identified the following independent predictors for non-referral: 2006 survey, older age, female sex, past stroke, heart or renal failure, prior myocardial infarction, minority group, and lack of in-hospital cardiac rehabilitation center (all p < 0.01). Kaplan-Meier survival analyses showed one-year survival rates of 97% vs 92% in patients referred for cardiac rehabilitation as compared to those not referred (log-rank p < 0.01). Multivariate analysis showed that referral for cardiac rehabilitation was associated with a 27% mortality risk reduction at one-year follow-up ( p = 0.03). Consistently, a 32% lower one-year mortality risk was evident in a propensity score matched group of 3340 patients (95% confidence interval 0.48-0.95, p = 0.02). Conclusions Over the past decade there was a significant increase in cardiac rehabilitation referral following an acute coronary syndrome. However, cardiac rehabilitation is still under-utilized in important high-risk subsets of this population. Patients referred to cardiac rehabilitation have a lower adjusted mortality risk.

Metabolic syndrome is independently associated with increased 20-year mortality in patients with stable coronary artery disease.

BACKGROUND: Data regarding long-term association of metabolic syndrome (MetS) with adverse outcomes are conflicting. We aim to determine the independent association of MetS (based on its different definitions) with 20 year all-cause mortality among patients with stable coronary artery disease (CAD). METHODS: Our study comprised 15,524 patients who were enrolled in the Bezafibrate Infarction Prevention registry between February 1, 1990, and October 31, 1992, and subsequently followed-up for the long-term mortality through December 31, 2014. MetS was defined according to two definitions: The International Diabetes Federation (IDF); and the National Cholesterol Education Program-Third Adult Treatment Panel (NCEP). RESULTS: According to the IDF criteria 2122 (14%) patients had MetS, whereas according to the NCEP definition 7446 (48%) patients had MetS. Kaplan-Meier survival analysis showed that all-cause mortality was significantly higher among patients with MetS defined by both the IDF (67 vs. 61%; log rank-p < 0.001) as well as NCEP (67 vs. 54%; log rank-p < 0.001) criteria. Multivariate adjusted mortality risk was 17% greater [Hazard Ratio (HR) 1.17; 95% Confidence Interval (CI) 1.07-1.28] in patients with MetS according to IDF and 21% (HR 1.21; 95% CI 1.13-1.29) using the NCEP definition. Subgroup analysis demonstrated that long-term increased mortality risk associated with MetS was consistent among most clinical subgroups excepted patients with renal failure (p value for interaction < 0.05). CONCLUSIONS: Metabolic syndrome is independently associated with an increased 20-year all-cause mortality risk among patients with stable CAD. This association was consistent when either the IDF or NCEP definitions were used. Trial registration retrospective registered.

Vitamin D inflammatory cytokines and coronary events: a comprehensive review.

Myocardial infarction (MI) is the most common cause of cardiac injury in the Western world. Cardiac injury activates innate immune mechanisms initiating an inflammatory reaction. Inflammatory cytokines and vascular cell adhesion molecules (VCAM) promote adhesive interactions between leukocytes and endothelial cells, resulting in the transmigration of inflammatory cells into the site of injury. Low vitamin D levels are associated with higher prevalence of cardiovascular risk factors and a higher risk of MI. In this paper, we examine the effects of short-term vitamin D supplementation on inflammatory cytokine levels after an acute coronary syndrome. We recruited patients arriving to the hospital with an acute MI. All patients received optimal medical therapy and underwent a coronary catheterization. Half of the patients were randomly selected and treated with a daily supplement of vitamin D (4,000 IU) for 5 days. A short course of treatment with vitamin D effectively attenuated the increase in circulating levels of inflammatory cytokines after an acute coronary event. Control group patients had increased cytokine and cellular adhesion molecules serum concentrations after 5 days, while the vitamin D-treated group had an attenuated elevation or a reduction of these parameters. There were significant differences in VCAM-1 levels, C-reactive protein, and interleukin-6. There were trends toward significance in interleukin-8 levels. There were no significant differences in circulating levels of intercellular adhesion molecule 1, E-selectin, vascular endothelial growth factor, and tumor necrosis factor-α. These findings provide information on the anti-inflammatory effects of vitamin D on the vascular system and suggest mechanisms that mediate some of its cardioprotective properties. There is place for further studies involving prolonged vitamin D treatment in patients suffering from ischemic heart disease.

SOA does not Reveal the Absolute Time Course of Cognitive Processing in Fast Priming Experiments.

Applying Bloch's law to visual word recognition research, both exposure duration of the prime and its luminance determine the prime's overall energy, and consequently determine the size of the priming effect. Nevertheless, experimenters using fast-priming paradigms traditionally focus only on the SOA between prime and target to reflect the absolute speed of cognitive processes under investigation. Some of the discrepancies in results regarding the time course of orthographic and phonological activation in word recognition research may be due to this factor. This hypothesis was examined by manipulating parametrically the luminance of the prime and its exposure duration, measuring their joint impact on masked repetition priming. The results show that small and non-significant priming effects can be more than tripled as a result of simply increasing luminance, when SOA is kept constant. Moreover, increased luminance may compensate for briefer exposure duration and vice versa.