Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data.

BACKGROUND: Numerous randomised trials have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for patients with coronary artery disease. However, no studies have been powered to detect a difference in mortality between the revascularisation strategies. METHODS: We did a systematic review up to July 19, 2017, to identify randomised clinical trials comparing CABG with PCI using stents. Eligible studies included patients with multivessel or left main coronary artery disease who did not present with acute myocardial infarction, did PCI with stents (bare-metal or drug-eluting), and had more than 1 year of follow-up for all-cause mortality. In a collaborative, pooled analysis of individual patient data from the identified trials, we estimated all-cause mortality up to 5 years using Kaplan-Meier analyses and compared PCI with CABG using a random-effects Cox proportional-hazards model stratified by trial. Consistency of treatment effect was explored in subgroup analyses, with subgroups defined according to baseline clinical and anatomical characteristics. FINDINGS: We included 11 randomised trials involving 11 518 patients selected by heart teams who were assigned to PCI (n=5753) or to CABG (n=5765). 976 patients died over a mean follow-up of 3·8 years (SD 1·4). Mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score was 26·0 (SD 9·5), with 1798 (22·1%) of 8138 patients having a SYNTAX score of 33 or higher. 5 year all-cause mortality was 11·2% after PCI and 9·2% after CABG (hazard ratio [HR] 1·20, 95% CI 1·06-1·37; p=0·0038). 5 year all-cause mortality was significantly different between the interventions in patients with multivessel disease (11·5% after PCI vs 8·9% after CABG; HR 1·28, 95% CI 1·09-1·49; p=0·0019), including in those with diabetes (15·5% vs 10·0%; 1·48, 1·19-1·84; p=0·0004), but not in those without diabetes (8·7% vs 8·0%; 1·08, 0·86-1·36; p=0·49). SYNTAX score had a significant effect on the difference between the interventions in multivessel disease. 5 year all-cause mortality was similar between the interventions in patients with left main disease (10·7% after PCI vs 10·5% after CABG; 1·07, 0·87-1·33; p=0·52), regardless of diabetes status and SYNTAX score. INTERPRETATION: CABG had a mortality benefit over PCI in patients with multivessel disease, particularly those with diabetes and higher coronary complexity. No benefit for CABG over PCI was seen in patients with left main disease. Longer follow-up is needed to better define mortality differences between the revascularisation strategies. FUNDING: None.

Effect of carvedilol vs metoprolol succinate on mortality in heart failure with reduced ejection fraction.

BACKGROUND: Beta blocker therapy is indicated in all patients with heart failure with reduced ejection fraction (HFrEF) as per current guidelines. The relative benefit of carvedilol to metoprolol succinate remains unknown. This study aimed to compare survival benefit of carvedilol to metoprolol succinate. METHODS: The VA's databases were queried to identify 114,745 patients diagnosed with HFrEF from 2007 to 2015 who were prescribed carvedilol and metoprolol succinate. The study estimated the survival probability and hazard ratio by comparing the carvedilol and metoprolol patients using propensity score matching with replacement techniques on observed covariates. Sub-group analyses were performed separately for men, women, elderly, duration of therapy of more than 3 months, and diabetic patients. RESULTS: A total of 43,941 metoprolol patients were matched with as many carvedilol patients. The adjusted hazard ratio of mortality for metoprolol succinate compared to carvedilol was 1.069 (95% CI: 1.046-1.092, P value: < .001). At six years, the survival probability was higher in the carvedilol group compared to the metoprolol succinate group (55.6% vs 49.2%, P value < .001). The sub-group analyses show that the results hold true separately for male, over or under 65 years old, therapy duration more than three months and non-diabetic patients. CONCLUSION: Patients with HFrEF taking carvedilol had improved survival as compared to metoprolol succinate. The data supports the need for furthering testing to determine optimal choice of beta blockers in patients with heart failure with reduced ejection fraction.

Residential distance to major roadways and cardiac structure in African Americans: cross-sectional results from the Jackson Heart Study.

BACKGROUND: Heart failure (HF) is a significant source of morbidity and mortality among African Americans. Ambient air pollution, including from traffic, is associated with HF, but the mechanisms remain unknown. The objectives of this study were to estimate the cross-sectional associations between residential distance to major roadways with markers of cardiac structure: left ventricular (LV) mass index, LV end-diastolic diameter, LV end-systolic diameter, and LV hypertrophy among African Americans. METHODS: We studied baseline participants of the Jackson Heart Study (recruited 2000-2004), a prospective cohort of cardiovascular disease (CVD) among African Americans living in Jackson, Mississippi, USA. All cardiac measures were assessed from echocardiograms. We assessed the associations between residential distance to roads and cardiac structure indicators using multivariable linear regression or multivariable logistic regression, adjusting for potential confounders. RESULTS: Among 4826 participants, residential distance to road was <150 m for 103 participants, 150-299 m for 158, 300-999 for 1156, and ≥1000 m for 3409. Those who lived <150 m from a major road had mean 1.2 mm (95% CI 0.2, 2.1) greater LV diameter at end-systole compared to those who lived ≥1000 m. We did not observe statistically significant associations between distance to roads and LV mass index, LV end-diastolic diameter, or LV hypertrophy. Results did not materially change after additional adjustment for hypertension and diabetes or exclusion of those with CVD at baseline; results strengthened when modeling distance to A1 roads (such as interstate highways) as the exposure of interest. CONCLUSIONS: We found that residential distance to roads may be associated with LV end-systolic diameter, a marker of systolic dysfunction, in this cohort of African Americans, suggesting a potential mechanism by which exposure to traffic pollution increases the risk of HF.

Prognosis for patients with heart failure and reduced ejection fraction with and without diabetes: A 7 year nationwide veteran administration analysis.

OBJECTIVE: Evidence suggests diabetes mellitus is an independent risk factor for adverse cardiovascular events in patients with heart failure. As a result, we sought to compare mortality in patients with heart failure with reduced ejection fraction (HFrEF) with and without diabetes. RESEARCH DESIGN AND METHODS: The Veteran Affairs Hospitals' databases were queried to identify all veterans diagnosed with HFrEF from 2007 to 2015. From the overall sample of 165,159 veterans, 41,120 patients with diabetes were matched by their propensity scores (without replacement) 1:1 to non-diabetic patients. To estimate the association between diabetes (Type 1 and 2) and overall mortality of HFrEF patients, a Cox proportional hazard model was used on the matched sample and controlled for patient characteristics for a mean follow up of 3.6 years (standard deviation ±2.3). RESULTS: In a matched sample of 41,120 veterans with HFrEF with and without diabetes, those with diabetes and HFrEF were more often on guideline-directed medical therapy than those without diabetes. In the matched cohort, the mortality risk for patients with concurrent HFrEF and diabetes was 17.7% at 1 year and 74.3% at 5 years, whereas the mortality risk for those without diabetes was 15.3% at 1 year and 69.2% at 5 years. After controlling for patient characteristics such as age, sex, body mass index, heart rate, medical therapies, comorbidities, medications, low-density lipoproteins, high-density lipoproteins, we found that patients with diabetes compared to those without had a significantly increased risk of mortality (HR: 1.85, 95% CI: 1.77-1.92, p < 0.001). CONCLUSIONS: Diabetic HFrEF patients have a higher risk of mortality than non-diabetic HFrEF patients despite controlling for medical therapies and comorbidities.

Effect of improvement in left ventricular ejection fraction on long-term survival in revascularized patients with ischaemic left ventricular systolic dysfunction.

AIMS: The importance of improvement in the ejection fraction to the prognosis of revascularized patients with ischaemic left ventricular (LV) dysfunction is uncertain. METHODS AND RESULTS: Eighty-seven patients with ischaemic LV dysfunction (mean ejection fraction 29 ± 8% by biplane Simpson's) had dobutamine echocardiography before revascularization (coronary bypass graft surgery-81, percutaneous intervention-6). Follow-up echocardiograms were performed a mean of 4.8 ± 6.2 months after revascularization. An 8% increase in the ejection fraction was considered significant (two times the inter-observer difference of 3.7%). Patients were followed for cardiac death. During a mean follow-up of 5.2 ± 3.9 years, there were 20 (23%) cardiac deaths. Class 3/4 heart failure, increasing low-dose wall motion score, increasing % non-viable myocardium, and digoxin use in follow-up were univariate predictors of death. Beta-blocker use, ejection fraction improvement, angina, aspirin use, and increasing fractional shortening were univariate predictors of survival. Ejection fraction improvement [P= 0.02, hazard ratio (HR) = 0.26], digoxin use in follow-up (P= 0.006, HR = 5.85), and low-dose wall motion score (P= 0.017, HR = 4.78) were independent predictors of outcome. In step-wise analysis, low-dose wall motion score added incremental prognostic value to ejection fraction improvement (P= 0.003), and digoxin use in follow-up (P= 0.003) added incremental value to a low-dose score and ejection fraction improvement. CONCLUSION: Ejection fraction improvement is an independent predictor of long-term outcome in revascularized patients but viability (low-dose wall motion score) and digoxin use in follow-up are also independent predictors and add incremental prognostic value to ejection fraction improvement.

Incremental prognostic value of echocardiography in patients with prior mitral valve surgery.

BACKGROUND AND AIM OF THE STUDY: Patients with prior mitral valve surgery are at increased risk for events late after surgery. The study aim was to investigate the value of assessing clinical variables, and left and right heart anatomy and function, to predict outcome in these patients. METHODS: Two-dimensional echocardiography, Doppler echocardiography and tissue Doppler imaging (TDI) were performed in 84 patients at a mean of 7.3 +/- 7.1 years after mitral valve surgery. The left ventricular ejection fraction (LVEF) was 50 +/- 15%, and 30% of patients were in NYHA class III/IV (congestive heart failure; CHF). Follow up was obtained for events that included repeat mitral or tricuspid valve surgery, and death. RESULTS: During a follow up period of 4.3 +/- 2.0 years, 28 patients suffered events, the univariate clinical predictors of which were NYHA class, calcium antagonist therapy, hyperlipidemia, and tobacco smoking. Left heart predictors included the mean mitral valve gradient (MMVG), left atrial volume index, and lateral wall TDI systolic velocity. Right heart predictors were atrial and right ventricular (RV) dimensions, RV systolic pressure, tricuspid regurgitation (TR) severity, RV free wall TDI E-velocity and E/e' ratio. Multivariate analysis showed that NYHA class (p = 0.02; RR 1.8 (1.1-2.9)), MMVG (p < 0.001; RR 1.16 (1.08-1.24)) and RV dimensions (p = 0.001; RR = 3.2 (1.7-6.2)) were independent predictors of events. A step-wise analysis of independent predictors showed that MMVG added an incremental value to NYHA class (p = 0.003), while RV size added additional value (p = 0.007) to the combination of NYHA class and MMVG. CONCLUSION: Echocardiographic assessments of the left and right heart can add significant prognostic value to the clinical assessment of patients after mitral valve surgery.

Lower Post Myocardial Infarction Mortality Among Women Treated at Veterans Affairs Hospitals Compared to Men.

BACKGROUND: There is conflicting evidence about whether mortality after myocardial infarction is higher among women than among men. This study aimed to compare sex differences in post myocardial infarction mortality in the Veterans Affairs system, a setting where the predominant subjects are men. MATERIALS AND METHODS: The Veterans Affairs Corporate Data Warehouse inpatient and laboratory chemistry databases were used to identify patients diagnosed with acute myocardial infarction from inpatient records from January 1st, 2005 to April 25th, 2015. Mortality data was obtained through the Veterans Affairs death registry. RESULTS: A total of 130,241 patients were identified; 127,711 men (98%) and 2,530 women (2%). Men typically had more comorbidities including congestive heart failure (54% vs. 46%, P value < 0.001), diabetes mellitus (54% vs. 48%, P value < 0.001), and chronic kidney disease (39% vs. 28%, P value < 0.001). The peak troponin-I was significantly higher among men (16.0 vs. 10.7 ng/mL, P value = 0.03). The mean follow-up time was 1490.67 ± 8 days. After adjusting for differences in demographics and comorbidities, women had a significantly lower risk of mortality (hazard ration [HR]: 0.747, P value < 0.0001) as compared to men. CONCLUSIONS: In a health care system where the predominant subjects are men, women had better short- and long-term survival than men after an acute myocardial infarction. Further investigation is warranted to determine the reasons behind the improved outcomes in women post myocardial infarction in the veteran population.

One-year mortality after implantable cardioverter-defibrillator placement within the Veterans Affairs Health System.

AIMS: Implantable cardioverter-defibrillator (ICD) therapy reduces mortality in patients with heart failure and current guidelines advise implantation of ICDs in patients with a life expectancy of >1 year. We examined trends in all-cause mortality in patients who underwent primary or secondary prevention ICD placement in the Veterans Affairs (VA) Health System. METHODS AND RESULTS: US veterans receiving a new ICD placement for primary or secondary prevention of sudden cardiac death between January 2007 and January 2015, who had heart failure with reduced ejection fraction (HFrEF) were included in the analysis. We assessed all-cause mortality 1 year post-ICD implantation. ICD implantation and HFrEF diagnosis were established with associated ICD-9 codes. The VA death registry was utilized to identify mortality rates following ICD placement. Results were subsequently age-stratified. There were 17 901 veterans with HFrEF with ICD placement nationwide. There was no statistically significant difference in 1-year mortality from 2007 (13.1%) to 2014 (13.4%, P > 0.05). There was a significant increase in 1-year mortality in patients in the oldest age quartile (81.6 years, 32.3% mortality) compared to the youngest quartile (55.5 years, 7% mortality). The finding of diverging clinical outcomes extended to the 30-day but also 8-year mark. CONCLUSIONS: Our data suggest there is a high 1-year mortality in aging HFrEF patients undergoing primary and secondary prevention ICD placement. This highlights the importance of developing better predictive models for mortality in our ICD eligible patient population.

Heart failure due to systolic dysfunction and mortality in diabetes: pooled analysis of 39,505 subjects.

BACKGROUND: Despite recent successes in improving mortality from congestive heart failure (CHF) with drugs and devices, several reports suggest increased mortality among CHF subjects with diabetes. Our objective was to conduct a meta-analysis to determine aggregate risk of mortality and hospitalization in CHF from systolic dysfunction and diabetes. METHODS AND RESULTS: Observational and randomized trials reporting on CHF and mortality in diabetes since 2001 were identified through MEDLINE and Cochrane database searches and hand searching of cross-references. Minimum follow-up of the study cohort should have been at least 6 months. Studies with very small sample size (n < 200) were excluded. Major outcome measure of mortality and secondary outcome measure of CHF hospitalization were extracted from published results. Analysis was done for composite mortality and hospitalization risk, heterogeneity, robustness, and publication bias. A total of 17 trials (n = 39,505 subjects) were eligible. There were a total of 10,068 deaths, with 3615 among diabetics, from available data. The relative risk was significantly higher for diabetics by 28% (95% CI 1.22-1.34, P < .0001). Similarly pooled relative risk for hospitalization was significantly higher for diabetics by 36% (95% CI 1.26-1.48, P < .0001). Heterogeneity was present (P < .01) and accounted for by observational studies. There was no significant publication bias and lack of robustness was not obvious. CONCLUSIONS: Aggregate mortality and recurrent hospitalization risk for diabetic subjects with CHF is 28% and 36% higher than for nondiabetic subjects. Future trials should specifically focus on improving survival in these subjects.

Effect of time to titration to maximum dose of statins on cardiovascular outcomes: a retrospective analysis in high-risk patients.

BACKGROUND: Recent trials have shown that high-dose HMG-CoA reductase inhibitor (statin) therapy reduces cardiovascular events in high-risk subjects within weeks of initiating therapy. We investigated the effect of time to titration to maximum dose of statin therapy on cardiovascular events. METHODS: From a list of all patients actively taking simvastatin 80 mg/day as of April 2003 at our hospital, two clinical pharmacists reviewed 213 electronic medical records including pharmacy records from November 1992 to April 2003. Data on cardiovascular risk factors, laboratory results, titration schedules, and outcomes were extracted from the electronic database. RESULTS: Titration period time frames were compared between patient groups using a Student t-test and multiple-variable logistic regression to account for other risk factors. Titration schedules and time frames to attain a regimen of simvastatin 80 mg/day were available for 154 (73%) subjects. Titrations ranged from 1 to 8 and averaged 2.3 +/- 1.3 titrations per patient (median titrations = 2) over 1 month to 8.4 years. On follow-up, 47 patients experienced 80 cardiovascular-related outcomes. The average time to titration to maximum dose of statin therapy was longer for patients who experienced a cardiac event than for those who did not (3.5 +/- 2.2 vs 2.1 +/- 1.8 years; p = 0.0004). After accounting for other risk factors, the titration period was still significantly related to the presence of a cardiac event (p = 0.0060, odds ratio per month increase in the titration period 1.3, 95% CI 1.08, 1.58). CONCLUSIONS: Despite potential limitations, the results of our study show that an excessive delay in titrating statin therapy to the optimal dose may lead to an increased risk of atherosclerosis-related events in high-risk patients.

Do cardioselective beta-adrenoceptor antagonists reduce mortality in diabetic patients with congestive heart failure?

BACKGROUND: The relative benefits of cardioselective beta-adrenoceptor antagonists (CSB) among patients with congestive heart failure (CHF) and diabetes mellitus are not firmly established. OBJECTIVE: To determine whether diabetic patients with CHF accrue the same mortality benefit from CSB therapy as non-diabetic patients. METHOD: Between October 1999 and November 2000 consecutive patients with CHF at the Veteran's Affairs Medical Center in Indianapolis, IN, USA, were enrolled in a randomized controlled trial and prospectively followed for 5 years. Disease severity and CHF-specific functional status were obtained from patients at baseline. Medical records were accessed for data regarding co-morbidities, medications, and mortality. Propensity-score analysis was used to balance co-variates because of the observational nature of CSB use, given this was a post hoc analysis. A multivariate Cox proportional hazards model was used to compare survival between diabetic and non-diabetic patients stratified by whether they were or were not receiving CSB therapy. RESULTS: Of the 412 evaluable patients, 222 (54%) had diabetes and 212 (51%) were taking a CSB. At 5-year follow-up, 186 (45%) patients had died. In the multivariate analysis, using propensity scores to balance co-variates, CSB therapy was an independent predictor of survival in patients without diabetes (hazard ratio 0.60; p = 0.054) only. CONCLUSIONS: These results extend prior observations that patients with diabetes and CHF may not accrue the same mortality benefit from CSB therapy as patients without diabetes, and warrant further prospective investigation.

Does diabetes accelerate progression of calcific aortic stenosis?

AIMS: Calcific aortic valve stenosis (CAS) is an active disease like atherosclerosis. Effect of diabetes (D) on severity of CAS is not well documented. METHODS AND RESULTS: We retrospectively analysed 166 consecutive patients with CAS and multiple echocardiograms from January 1997 to March 2005. Aortic valve area (AVA) was measured using the continuity equation. CAS severity was categorized using AVA. D and non-D patients were compared for differences in sex, hypertension, smoking, statin use using chi(2) tests. Comparisons between D and non-D for changes in AVA per year were performed using ANOVA. Study cohort included 166 males with age 70 +/- 9 years, of which 72 (43%) had D. Baseline CAS was mild in 66 subjects, moderate in 75, and severe in 25. D subjects smoked less (P = 0.02), but all other variables were similar (P > 0.05). The interaction between D and baseline CAS severity was significant (P = 0.0191), indicating comparisons should be viewed by baseline CAS severity. D had significantly larger change in AVA than non-D (P = 0.0016) for those with moderate CAS at baseline only. Adjusting for statin use did not alter the results. CONCLUSION: CAS severity progresses faster in D than in non-D in subjects with moderate CAS at baseline. Statins do not affect progression of CAS.

Long term postischemic stroke mortality in diabetes: a veteran cohort analysis.

BACKGROUND AND PURPOSE: Recent data on stroke mortality in diabetics in the United States is lacking. We investigated trends in diabetes prevalence and stroke morality among diabetics in a large veteran cohort. METHODS: The Patient Treatment File was used to identify all patients discharged from any Veterans hospital between October 1990 and September 1997 with a diagnosis of ischemic stroke (ICD-9-CM codes 434, 436) listed as primary diagnosis. Demographic, morbidity, and mortality data were recorded. Chi-square tests were used to examine differences between diabetics and nondiabetics, and t tests were used for continuous variables. Cox proportional hazards regression was used to examine the effects of diabetes (DM) on the survival times controlling for multiple covariates. RESULTS: Of 48 733 ischemic stroke patients identified, 98% were male and 13 925 (25%) had DM. Mean age was similar between DM and non-DM (67.2 versus 67.5, P=NS). Prevalence of DM among stroke subjects increased from 25% to 31%. Charlson index >2 was much higher in DM (68.2% versus 47.9%, P<0.001). Mortality at 60 days and 1 year was similar in both groups (2.9 versus 2.7%, P=NS; 12.6 versus 13.1, P=NS). Kaplan-Meier survival plot showed that DM had shorter long term survival time (log-rank, P<0.001). Multivariate Cox proportional hazards regression showed a higher risk of death for diabetics (HR=1.15, 95% CI 1.11 to 1.19, P<0.001). CONCLUSIONS: Despite greater comorbidity, postacute ischemic stroke mortality at 60 days and 1 year is not different between subjects with and without DM. Long term mortality after stroke is much lower among DM than that reported in older studies.

Effect on Mortality of Higher Versus Lower ß-Blocker (Metoprolol Succinate or Carvedilol) Dose in Patients With Heart Failure.

This study aimed to compare the effect of ß-blocker dose and heart rate (HR) on mortality in patients with heart failure with reduced ejection fraction (HFrEF). The Veteran Affairs databases were queried to identify all patients diagnosed with HFrEF based on International Classification of Diseases Ninth Revision codes from 2007 to 2015 and ß-blocker (carvedilol or metoprolol succinate) use. 36,168 patients on low dose ß blocker were then matched with 36,168 patients on high dose ß-blocker using propensity score matching. The impact of ß-blocker dose and HR was assessed on overall mortality using Cox proportional hazard model. After dividing average HR into separate quartiles and adjusting for patient characteristics, high ß-blocker dose was associated with lower overall mortality as compared with a low dose of ß blocker (hazard ratio 0.75, 95% confidence interval 0.73 to 0.77, p <0.01) independent of the HR achieved. The results held for all 4 quartiles of average HR. A higher ß-blocker dose or a lower HR were independently and jointly associated with lower mortality for all quartiles of HR. In conclusion, higher dose of ß-blocker therapy and a lower achieved HR were independently associated with a reduction in mortality in HFrEF patients.

Post-Traumatic Stress Disorder and Heart Failure in Men Within the Veteran Affairs Health System.

Patients with post-traumatic stress disorder (PTSD) are at risk of multiple co-morbidities and are more likely to develop incident heart failure with reduced ejection fraction (HFrEF). The relation of PTSD with clinical outcomes in HFrEF is not established. US veterans diagnosed with HFrEF from January 2007 to January 2015 and treated nationwide in the Veterans Affairs (VA) Health System were included in the study. Patients with HFrEF were identified through International Classification of Diseases, Ninth Revision (ICD-9) codes. Mortality data were obtained from the VA's death registry. We compared characteristics of patients with HFrEF with and without PTSD. We identified 111,970 VA patients with HFrEF and 11,039 patients with concomitant PTSD (9.9%). Patients with PTSD and HFrEF tended to be younger (64 vs 69 years) and have a higher rate of coronary artery disease (73% vs 64%), chronic obstructive pulmonary disease (42% vs 31%), and hypertension (80% vs 64%, p <0.01 for all variables). Patients with PTSD and HFrEF were more commonly on a high-dose ß blocker (70% vs 68%, p <0.01) and angiotensin-converting enzyme inhibitors (96% vs 93%, p <0.01). PTSD was associated with significantly increased mortality at 7 years compared with patients with heart failure without PTSD (adjusted 1.54, 95% confidence interval 1.30 to 1.82, p <0.01). In conclusion, nearly 10% of veterans with HFrEF have PTSD. Patients with HFrEF with PTSD have a higher burden of co-morbidities, and PTSD is associated with a higher rate of all-cause death. Our findings support greater attention to the treatment of patients with PTSD and the causes associated with the poor outcomes.

Post-stroke hypertension control and receipt of health care services among veterans.

Many ischemic stroke patients do not achieve goal blood pressure (BP < 140/90 mm Hg). To identify barriers to post-stroke hypertension management, we examined healthcare utilization and BP control in the year after index ischemic stroke admission. This retrospective cohort study included patients admitted for acute ischemic stroke to a VA hospital in fiscal year 2011 and who were discharged with a BP ≥ 140/90 mm Hg. One-year post-discharge, BP trajectories, utilization of primary care, specialty and ancillary services were studied. Among 265 patients, 246 (92.8%) were seen by primary care (PC) during the 1-year post-discharge; a median time to the first PC visit was 32 days (interquartile range: 53). Among N = 245 patients with post-discharge BP data, 103 (42.0%) achieved a mean BP < 140/90 mm Hg in the year post-discharge. Provider follow-ups were: neurology (51.7%), cardiology (14.0%), nephrology (7.2%), endocrinology (3.8%), and geriatrics (2.6%) and ancillary services (BP monitor [30.6%], pharmacy [20.0%], nutrition [8.3%], and telehealth [8%]). Non-adherence to medications was documented in 21.9% of patients and was observed more commonly among patients with uncontrolled compared with controlled BP (28.7% vs 15.5%; P = .02). The recurrent stroke rate did not differ among patients with uncontrolled (4.2%) compared with controlled BP (3.8%; P = .89). Few patients achieved goal BP in the year post-stroke. Visits to primary care were not timely. Underuse of specialty as well as ancillary services and provider perception of medication non-adherence were common. Future intervention studies seeking to improve post-stroke hypertension management should address these observed gaps in care.

Stroke Rates Following Surgical Versus Percutaneous Coronary Revascularization.

BACKGROUND: Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with large numbers of patients are required to detect differences in stroke rates between CABG and PCI. OBJECTIVES: This study sought to compare rates of stroke after CABG and PCI and the impact of procedural stroke on long-term mortality. METHODS: We performed a collaborative individual patient-data pooled analysis of 11 randomized clinical trials comparing CABG with PCI using stents; ERACI II (Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease) (n = 450), ARTS (Arterial Revascularization Therapy Study) (n = 1,205), MASS II (Medicine, Angioplasty, or Surgery Study) (n = 408), SoS (Stent or Surgery) trial (n = 988), SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial (n = 1,800), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) trial (n = 600), FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900), VA CARDS (Coronary Artery Revascularization in Diabetes) (n = 198), BEST (Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease) (n = 880), NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trial (n = 1,184), and EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial (n = 1,905). The 30-day and 5-year stroke rates were compared between CABG and PCI using a random effects Cox proportional hazards model, stratified by trial. The impact of stroke on 5-year mortality was explored. RESULTS: The analysis included 11,518 patients randomly assigned to PCI (n = 5,753) or CABG (n = 5,765) with a mean follow-up of 3.8 ± 1.4 years during which a total of 293 strokes occurred. At 30 days, the rate of stroke was 0.4% after PCI and 1.1% after CABG (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.20 to 0.53; p < 0.001). At 5-year follow-up, stroke remained significantly lower after PCI than after CABG (2.6% vs. 3.2%; HR: 0.77; 95% CI: 0.61 to 0.97; p = 0.027). Rates of stroke between 31 days and 5 years were comparable: 2.2% after PCI versus 2.1% after CABG (HR: 1.05; 95% CI: 0.80 to 1.38; p = 0.72). No significant interactions between treatment and baseline clinical or angiographic variables for the 5-year rate of stroke were present, except for diabetic patients (PCI: 2.6% vs. CABG: 4.9%) and nondiabetic patients (PCI: 2.6% vs. CABG: 2.4%) (p for interaction = 0.004). Patients who experienced a stroke within 30 days of the procedure had significantly higher 5-year mortality versus those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and CABG (41.5% vs. 8.9%, p < 0.001). CONCLUSIONS: This individual patient-data pooled analysis demonstrates that 5-year stroke rates are significantly lower after PCI compared with CABG, driven by a reduced risk of stroke in the 30-day post-procedural period but a similar risk of stroke between 31 days and 5 years. The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes. Five-year mortality was markedly higher for patients experiencing a stroke within 30 days after revascularization.

Assessing prognosis in patients with diabetes mellitus--the Achilles' heel of cardiac stress imaging tests?

The prognostic utility of stress imaging studies has been validated in numerous studies and, in general, patients with a normal imaging study have annual cardiac ischemic event rates of <1%. However, this predictive value of a normal stress imaging study does not appear to be applicable to subjects with diabetes. In this editorial, we summarize the current available data on prognostic utility of stress imaging studies in subjects with diabetes and provide insights into how to interpret and integrate these data for daily clinical practice. In conclusion, currently available data suggest that the prognostic value of stress imaging studies in subjects with diabetes differs from those without diabetes and should be interpreted as such.

Heart failure in diabetes and related conditions.

BACKGROUND: Despite advances in therapy for congestive heart failure (CHF), mortality remains 40% to 80% higher for diabetics with CHF than nondiabetics. Diabetes prevalence is increasing worldwide with prevalence of diabetes among patients with CHF increasing at an even faster pace. METHODS AND RESULTS: Although multiple mechanisms are responsible for development of CHF in diabetes, ischemic heart disease plays a major role. In the foreseeable future, physicians will have to deal with increasing numbers of subjects with diabetes, coronary disease, and heart failure. Several recent developments in the field of heart failure have revolutionized the way patients are treated for CHF with improvements in quality of life and mortality. Although long-term prospective studies specifically addressing heart failure in diabetes are lacking, extrapolation of data from recent large trials has shed light on management of CHF in diabetes. CONCLUSIONS: This review summarizes new developments in the field of CHF among subjects with diabetes, metabolic syndrome, and obesity.

Stroke mortality and race: does access to care influence outcomes?

BACKGROUND: Stroke is the third leading cause of death in the United States. We investigated racial differences in death after hospital discharge for ischemic stroke in a large cohort of Veterans Health Affairs (VHA) stroke patients. We hypothesized that having access to VA care would ameliorate the excess stroke mortality rates in African-Americans (AA) reported in non-VA studies. METHODS: Hospital administrative data were used to identify all patients discharged from any VA hospital between October 1990 and September 1997 with a primary discharge diagnosis of ischemic stroke (ICD-9-CM codes 434 and 436). We obtained demographic data and clinical data recorded during the index hospitalization and after discharge, including deaths, from VA clinical and administrative databases. The Charlson comorbidity index was constructed for each patient from the index admission's discharge diagnoses. Patients were followed through 1998. RESULTS: Of 55,094 VHA stroke patients discharged after ischemic strokes, 34,579 (63%) were white and 11,530 (21%) were AA. Charlson index was similar between the groups. One-year mortality rate was significantly higher for whites: Adjusting for demographic and clinical differences, being white remained predictive of higher mortality rates (multivariable hazard ratio, 1.06; 95% CI, 1.02 to 1.10). From Kaplan-Meier estimates, the probability that whites would survive for 1 year was 0.86 compared with 0.87 for AA. CONCLUSIONS: Despite having similar severity of illness and adjusting for other clinical differences, mortality rate was marginally lower in AA after being discharged from VA hospitals after ischemic strokes. This is contrary to prior reports from non-VA hospitals and suggests the possibility of access to care playing a role in stroke deaths.