Lung function impairment and metabolic syndrome: the critical role of abdominal obesity.

RATIONALE: Increased risk for cardiovascular morbidity and mortality has been related to both lung function impairment and metabolic syndrome. Data on the relationship between lung function and metabolic syndrome are sparse. OBJECTIVES: To investigate risk for lung function impairment according to metabolic syndrome traits. METHODS: This cross-sectional population-based study included 121,965 men and women examined at the Paris Investigations Préventives et Cliniques Center between 1999 and 2006. The lower limit of normal was used to define lung function impairment (FEV(1) or FVC < lower limit of normal). Metabolic syndrome was assessed according to the American Heart Association/National Heart, Lung, and Blood Institute statement. MEASUREMENTS AND MAIN RESULTS: We used a logistic regression model and principal component analysis to investigate the differential associations between lung function impairment and specific components of metabolic syndrome. Lung function impairment was associated with metabolic syndrome (prevalence = 15.0%) independently of age, sex, smoking status, alcohol consumption, educational level, body mass index, leisure-time physical activity, and cardiovascular disease history (odds ratio [OR] [95% confidence interval], 1.28 [1.20-1.37] and OR, 1.41 [1.31-1.51] for FEV(1) and FVC, respectively). Three factors were identified from factor analysis: "lipids" (low high-density lipoprotein cholesterol, high triglycerides), "glucose-blood pressure" (high fasting glycemia, high blood pressure), and "abdominal obesity" (large waist circumference). All factors were inversely related to lung function, but abdominal obesity was the strongest predictor of lung function impairment (OR, 1.94 [1.80-2.09] and OR, 2.11 [1.95-2.29], for FEV(1) and FVC, respectively). Similar results were obtained for women and men. CONCLUSIONS: We found a positive independent relationship between lung function impairment and metabolic syndrome in both sexes, predominantly due to abdominal obesity. Further studies are required to clarify the underlying mechanisms.

Six-year survival study after myocardial infarction: The EOLE prospective cohort study. Long-term survival after MI.

BACKGROUND: Studies of survival after myocardial infarction (MI) are often based on intention to treat analyses of controlled trials. OBJECTIVES: Describe long-term survival after MI in France. METHODS: Six-year cohort study of patients recruited within 3 months after MI. Primary outcome was all-cause death. Vital status was verified in the national death registry. Analysis used Cox models with time-dependent variables and propensity scores. RESULTS: Five thousand five hundred and twenty-seven (5527) subjects were included, 62.1±13 years old, 77.6% male, 9.6% smokers, 16.7% diabetic, 13.3% with previous MI. Up to 99% of patients were initially prescribed secondary prevention drugs (aspirin and/or other antiplatelet agents, beta-blockers, statins or other lipid-lowering agents, angiotensin converting enzyme inhibitors or angiotensin receptor blockers); 73% had all four classes. Overall 6-year mortality was 13.1% [95% confidence interval 12.3 to 14.0%], 2.34 per hundred patient-years (% PY); 49% returned all or all but one of the possible questionnaires (compliant [C]), 50.8% did not (non-compliant [NC]). The main predictors for death were non-compliance with study protocol (death rates NC 2.98% PY, C 1.69%PY, hazard ratio (HR) 3.13 [2.63-3.57]); increasing age at inclusion (HR up to 15.7 [10.7-23.2] for age ≥80); diabetes (1.39 [1.17-1.65]); smoking at inclusion (1.76 [1.27-2.44]), previous MI (1.46 [1.22-1.75]). Beta-blockers (0.79 [0.64-0.96]), statins (0.68 [0.51-0.90]), and enrolment in physical rehabilitation programs (0.74 [0.62-0.89]) were associated with a lower death rate. CONCLUSION: Association of mortality with non-compliance to study protocol probably indicates general non-compliance with prevention. Analyses of treatment effects were hindered by paucity of events and of unexposed patients.

Absence of CTX-M enzymes but high prevalence of clones, including clone ST131, among fecal Escherichia coli isolates from healthy subjects living in the area of Paris, France.

Quinolone-resistant and CTX-M-15-producing Escherichia coli isolates belonging to clone ST131 have been reported in the community. This study was designed to identify these E. coli isolates in the stools of 332 independent healthy subjects living in the area of Paris, France. Stools were plated on media without antibiotics, in order to obtain the dominant (Dm) fecal E. coli strain, and with nalidixic acid (NAL) and cefotaxime. Quinolone susceptibility, phylogenetic groups, and molecular profiles, including multilocus sequence types (ST), were determined for all NAL-resistant (NAL-R) isolates. Groups were also determined for the Dm strains from participants with NAL-R isolates and from a subgroup without NAL-R isolates. All B2 isolates were typed; pulsed-field gel electrophoresis was performed for the ST131 isolates, and the results were compared with those for intercontinental clone ST131. Two participants (0.6%) had extended-spectrum beta-lactamase-producing (SHV-2, TEM-52) fecal E. coli isolates, and 51 (15%) had NAL-R isolates; 51% of NAL-R isolates belonged to phylogenetic group A, 31% to group D, 16% to group B2, and 2% to group B1. The Dm strain was NAL-R in 3.3% of the 332 subjects. Forty-nine percent of the NAL-R isolates belonged to clones: ST10 and ST606 for group A isolates, ST117 and ST393 for group D isolates. Of all B2 isolates studied from 100 subjects (8 NAL-R strains; 19 NAL-susceptible dominant strains), 52% belonged to three clones: ST131 (n = 7), ST95 (n = 4), and ST141 (n = 3). This is the first study to show the presence of fecal E. coli isolates of clone ST131 in 7% of independent healthy subjects not colonized by CTX-M-15-producing isolates.

The metabolic syndrome: similar deleterious impact on all-cause mortality in hypertensive and normotensive subjects.

OBJECTIVES: Few data are available on the impact of the metabolic syndrome on all-cause mortality risk according to the presence of hypertension. Our aim was to evaluate the 5-year impact of the metabolic syndrome, according to blood pressure status, on all-cause mortality risk in a large French population. METHODS: The study population included 39 998 men and 20 756 women with no personal history of cardiovascular disease, who had a health check-up at the IPC Center (Paris, France) between 1999 and 2002, and who were followed up for 4.7 +/- 1.2 years. The metabolic syndrome was defined according to the National Cholesterol Educational Program classification (2001). Cox regression models were used to evaluate risk of all-cause mortality after adjustment for age, sex, classical risk factors and socioeconomic categories. Subjects were classified according to blood pressure status: hypertensive subject (systolic blood pressure > or =140 mmHg and/or diastolic blood pressure > or =90 mmHg or treatment) and normotensive subject. RESULTS: The risk of all-cause mortality associated with the metabolic syndrome was 1.50 (1.24-1.82) [hazard ratio (HR) (95% confidence interval)]. The risk of all-cause mortality associated with the presence of hypertension was 1.60 (1.38-1.85). During the 4.7 years of follow-up, the impact of the metabolic syndrome was similar among normotensive and hypertensive subjects [HR: 1.09 (0.68-1.75) and 1.40 (1.13-1.74), respectively, P for interaction = 0.35]. CONCLUSION: The findings from this study show that, in a large middle-aged French population, the metabolic syndrome has the same deleterious impact on all-cause mortality in hypertensive subjects and normotensive subjects.

All-cause and cardiovascular mortality using the different definitions of metabolic syndrome.

The aim of the present study was to assess the risk of all-cause and cardiovascular disease (CVD) mortality in subjects identified as having metabolic syndrome (MS) using either the recent International Diabetes Federation (IDF) definition or the revised National Cholesterol Educational Program (NCEP-R) definition, but not the original NCEP (2001) definition. The study population was composed of 84,730 men and women without CVD aged > or =40 years who had a health checkup at the IPC Center. Follow-up for mortality was 4.7 +/-1.7 years. Prevalences of MS were 9.6%, 21.6%, and 16.5% according to the NCEP, IDF, and NCEP-R definitions, respectively. Compared with subjects without MS, risks of all-cause mortality associated with MS were 1.63 (95% confidence interval [CI] 1.38 to 1.93) with the NCEP, 1.25 (95% CI 1.09 to 1.45) with the IDF, and 1.32 (95% CI 1.13 to 1.53) with the NCEP-R, and risks of CVD mortality were 2.05 (95% CI 1.28 to 3.28), 1.77 (95% CI 1.18 to 2.64), and 1.64 (95% CI 1.08 to 2.50), respectively. In subjects with MS detected using the IDF and NCEP-R definitions, but not the NCEP definition, risks of all-cause mortality were 1.07 (95% CI 0.89 to 1.28) and 0.92 (95% CI 0.73 to 1.18) and 1.42 (95% CI 0.86 to 2.34) and 1.07 (95% CI 0.55 to 2.09) for CVD mortality, respectively. In conclusion, in a large French population, the recent definitions of MS almost double the prevalence compared with the original definition. Subjects identified as having MS using only the recent definitions and not the original definition did not have higher rates of all-cause and CVD mortality compared with subjects without MS during follow-up.

[Diabetes and socio-economic deprivation. A study in a large French population]. / Diabète et précarité. Etude d'une vaste population française.

Socio-economically deprived subjects are reported to have an increased risk of diabetes and related complications. The aim of this study was to confirm this relation in a large French population. The study subjects consisted of 32,435 men and 16,378 women aged from 35 to 80 years who had a free health checkup at the IPC Center (Investigations Preventives et Cliniques, Paris-Ile de France) between January 2003 and December 2006. Socio-economic deprivation was evaluated by using the EPICES approach (Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examens de Santé de France). Socio-economically deprived subjects were defined as those with scores in the 5th quintile. The prevalence of diabetes among deprived men and women was respectively 6% and 7% at age 35-59 years, and 18% and 15% at age 60-80 years. The prevalence of diabetes increased with level of deprivation. Compared to the 1st quintile of the EPICES score distribution, diabetes was three to eight times more frequent in the 5th quintile. After taking into account age, the body mass index, waist circumference, and anxiety and depression, the risk that deprived subjects would be diabetic (odds ratio) was respectively 4.2 and 5.2 for men and women aged 35-39 years, and 3.5 and 2.2 for those aged 60-80 years. The following cardiovascular risk markers were significantly higher or more frequent among deprived subjects: body mass, abdominal obesity, high blood pressure and the metabolic syndrome in women; and lower HDL cholesterol, higher triglyceride levels, proteinuria, a higher heart rate and additional ECG abnormalities in both men and women. Other indicators of poor health were also more frequent among deprived subjects, including anxiety and depression, smoking (among men), elevated gamma-GT and alkaline phosphatase levels, lung vital capacity, visual disorders, and dental plaque. Finally, deprived subjects also had more limited access to health care. Thus, socio-economic status markedly influences the risk of diabetes, independently of confounding factors. Several markers of cardiovascular risk and poor health were significantly more frequent among socio-economically deprived subjects, who also had more limited access to health care.

Ejection fraction and blood pressure are important and interactive predictors of 4-week mortality in severe acute heart failure.

BACKGROUND: In acute heart failure syndromes (AHFS), the prognostic value of left ventricular ejection fraction (LVEF), although widely accepted, has been recently challenged. In contrast, blood pressure is increasingly gaining ground over LVEF as predictor of mortality. Therefore, it is not clear whether both LVEF and mean arterial pressure (MAP) are independent risk factors in patients with AHFS. METHODS AND RESULTS: The EFICA study enrolled 581 AHFS patients admitted to 60 CCU/ICUs. Survival at 4 weeks was analyzed for all cases with echocardiographic LVEF available on admission (n=355). Four-week mortality was 23%. Multivariable analysis identified lower LVEF, lower MAP and serum creatinine >1.5 mg/dl as independent correlates of mortality (respectively, OR: 1.27 per 10% decrease, CI: 1.05-1.53, p=0.012; OR: 1.30 per 10 mmHg decrease, CI: 1.15-1.48, p<0.0001; OR: 2.84, CI: 1.64-4.93, p=0.0002). LVEF interacted significantly with MAP (p<0.0001) and the subgroup analysis showed that reduced LVEF was a strong risk factor in patients with MAP 90 mmHg. CONCLUSIONS: Both LVEF and MAP are important predictors of death in severe AHFS. LVEF can provide additional prognostic information on top of MAP but mainly in patients with low MAP (

[Atrial fibrillation: prevalence, risk factors and mortality in a large French population with 15 years of follow-up]. / Fibrillation atriale: prévalence, facteurs de risque et mortalité dans une vaste population française suivie 15 ans.

We examined the prevalence of atrial fibrillation (AF) in a large French population according to age, risk factors, all-cause mortality, and cardiovascular and cerebrovascular mortality. The study population was composed of 98,961 men and 55,109 women over 30 years of age who had a free medical checkup at the IPC Center (Centre d'Investigations Préventives et Cliniques). Routine electrocardiograms revealed the presence of AF in 235 men (mean age 60.2 +/- 10.3 years) and 63 women (mean age 62.5 +/- 9.1 years). Mean follow-up was 15.2 years. The relative risk of death [Hazard Ratio (95% CI)] was determined with a Cox regression model. The prevalence of AF increased strongly with age in both genders and was higher among men. Before 50 years of age, AF was present in 0.05% of men and 0.01% of women, compared to 6.5% and 5.2%, respectively, in over-80s. After adjustment for age, factors significantly associated with AF were cardiopathy [Odds Ratio (OR) = 3.2 (2.3-4.5) among men and 4.9 (2.5-9.5) among women], hypertension [OR = 1.4 (1.1-1.9) in men and 2.2 (1.2-3.9) in women], overweight [OR = 2.2 (1.4-3.2) in men and 2.3 (1.0-5. 1) in women], ventilatory failure [OR = 1.4 (0.9-2.2) in men and 4.9 (2.4-10) in women], diabetes [OR = 1.7 (1.1-2.5) in men] and alcohol consumption [OR = 1.7 (1.2-2.4) in men]. The relative risk of death was then adjusted for age, cardiopathy, left venticular hypertrophy, blood pressure, cholesterol, glycemia, body mass index, smoking, alcohol, and vital capacity. The HR of all-cause mortality was 1.5 (1.0-2.0) in men and 1.8 (1.0-3.3) in women. The HR of cardiovascular mortality was 2.2 (1.2-3.1) in men and 3.4 (1.5-7. 7) in women, while for stroke-related mortality it was 2.0 (0.7-4.3) in men and 4.5 (1.3-16) in women. No association was found between AF and non-cardiovascular mortality in either men or women. The risk of death among men without cardiopathy or hypertension, after adjustment for the other risk factors, was not significantly increased (overall mortality 1.1 (0.5-2.0), cardiovascular mortality 1.4 (0.6-2.9)). In contrast, men with cardiopathy or hypertension had an adjusted HR of 1.7 (1.1-2.8) for overall mortality and 2.6 (1.3-5.3) for cardiovascular mortality. In conclusion, after adjustment for all risk factors, the AF-related relative risk of overall mortality and of cardiovascular mortality was higher among women than among men, especially for cerebrovascular mortality. AF was not an independent risk factor for death among men free of cardiopathy and hypertension.

Relation of depressive mood to plasminogen activator inhibitor, tissue plasminogen activator, and fibrinogen levels in patients with versus without coronary heart disease.

The increased risk of coronary heart disease (CHD) associated with depression is well documented. We hypothesized that impaired fibrinolysis is involved in this link. To explore the association of depressive mood and/or vital exhaustion with various measurements of fibrinolysis activity, 231 men (40 to 65 years old; 123 without CHD and taking no medication and 108 with documented CHD), completed the Center of Epidemiologic Studies Depression Scale and the Maastricht Questionnaire for vital exhaustion. Using classic cut-off points (Center of Epidemiologic Studies Depression Scale score >or=17, Maastricht Questionnaire score >or=8), 6.5% and 9.8% of subjects without CHD and 38% and 48.1% of those with CHD were classified as depressed and exhausted, respectively. Patients with CHD were older, had a higher body mass index, and higher levels of total cholesterol, glucose, plasminogen activator inhibitor 1 (PAI-1), tissue plasminogen activator (t-PA) antigen, and fibrinogen; 47% were treated for hypertension. Depressed subjects had higher levels of PAI-1 activity (p = 0.006) and exhausted patients had higher levels of PAI-1 activity (p = 0.011) and fibrinogen (p = 0.009). After adjusting for clinical condition (with or without CHD), smoking, hypertension, triglyceride concentration, and body mass index, PAI-1 activity remained higher in depressed subjects (p = 0.03). This association persisted after further adjustment for vital exhaustion or for t-PA antigen and fibrinogen levels. t-PA antigen and fibrinogen levels were not associated with depressive mood in multivariate analyses. No fibrinolytic variable was associated with vital exhaustion in multivariate analyses. In conclusion, depressive mood, but not vital exhaustion, is associated with higher levels of PAI-1 activity, suggesting a possible impairment of fibrinolysis and indicating a potential additional mechanism by which depressive mood may act as a cardiovascular risk factor.

Clinical profile, contemporary management and one-year mortality in patients with severe acute heart failure syndromes: The EFICA study.

BACKGROUND: Little is known about the epidemiology of acute decompensated heart failure (ADHF) in patients admitted to intensive and coronary care units (ICU/CCU). Observational data may improve disease management and guide the design of clinical trials. AIMS: EFICA is an observational study of the clinical profile, management and survival of ADHF patients admitted to ICU/CCU. METHODS: The study included 599 patients admitted to 60 ICU/CCUs across France. Relevant data was recorded during hospitalisation. Survival was assessed at 4 weeks and 1 year. RESULTS: The main cause of ADHF was ischaemic heart disease (61%); 29% of patients had cardiogenic shock. Mortality was 27.4% at 4 weeks and 46.5% at 1 year, increasing to 43.2% and 62.5%, respectively, when including pre-admission deaths. Shock patients had the highest [57.8% vs. 15.2% without shock (p < 0.001)] and patients with hypertension and pulmonary oedema had the lowest 4-week mortality: (7%). Pre-admission NYHA class III-IV heart failure, not initial clinical presentation, influenced 1-year mortality. CONCLUSION: ADHF is a heterogeneous syndrome. Based on initial clinical presentation, three entities with distinct features and outcome may be described: cardiogenic shock, pulmonary oedema with hypertension, and 'decompensated' chronic heart failure. This should be taken into account in future observational studies, guidelines and clinical trials.

[Heart rate, a major prognostic factor of cardiovascular risk]. / La fréquence cardiaque, facteur pronostique majeur du risque cardiovasculaire.

The prognostic value of heart rate (HR) was analysed based on the reports from the literature in the general population and in patients with coronary artery disease (CAD). Multivariate analyses showed that elevated resting HR was found to be an independent predictor of total and cardiovascular mortality. The behaviour of HR during exercise testing was predictive of sudden death. The beneficial effects of betablockers in post-infarction patients are well established. Calcium channel blockers that increase resting HR are associated with a deleterious effect on mortality. Therefore, resting HR should not be overlooked in risk stratification of CAD patients. Reduction of resting HR should be viewed as an attractive therapeutic target in CAD patients.

[Metabolic syndrome: prevalence, risk factors and mortality in a French population of 62 000 subjects]. / Syndrome métabolique: prévalence, marqueurs de risque associés et mortalité dans une population française de 62 000 sujets.

We evaluated the prevalence, risk factors and impact on all-cause mortality of the metabolic syndrome (MetS) and its components in a large French population. The study population consisted of subjects aged 40 years or more who volunteered for a free health check-up at the IPC Center (Investigations Préventives et Cliniques, Paris) between 1999 and 2002. There were 40 977 men (53.2 +/- 9.1 years) and 21 277 women (55.9 +/- 10.3 years). The cutoff date for mortality data was March 2004. The mean follow-up period was 3.57 +/- 1.12 years. During this period, 271 men and 87 women died. MetS was defined according to NCEP-ATP III criteria. Cox regression models were used to evaluate the risk of death [hazards ratio (95% CI)]. MetS was present at baseline in 11.8% of men and 7.6% of women. The prevalence of MetS increased from 9% in men aged 40 to 49 years to 12.5% in men aged 70 years. In women, the prevalence rose from 4.9% to 11.3%, respectively. From 1999 to 2002, the prevalence of MetS increased from 11.0% to 12.8% in men and from 7.2% to 8.8% in women. The following clinical and biological parameters were significantly associated with MetS in men and women, after adjustment for age: lower physical activity, lower vital capacity ratio, higher pulse pressure and heart rate, higher gamma-glutamyl transpeptidase, ASA and ALA transaminase and alkaline phosphatase levels, higher uricemia, leukocyte and globulin levels, dental and gingival inflammation, and higher stress and depression scores. After adjustment for age, the excess risk of all-cause mortality in subjects with MetS compared to subjects without MetS was 1.82 (1.35-2.43) in men and 1.80 (1.01-3.19) in women. After adjustment for age, gender, smoking, cholesterol, physical activity, socioeconomic status and prior cardiovascular disease, the risk of all-cause mortality was 1.69 (1.28-2.22) in the entire population. In order to evaluate the impact of each Mets component, and combinations of three MetS components, on all-cause mortality, a control group of subjects with no MetS components was used. After adjustment for age and gender, the risk of death associated with each MetS component was 2.36 (1.65-3.37) for high waist circumference, 2.08 (1.44-3.01) for elevated triglyceride levels, 1.71 (1.07-2.72) for low HDL-cholesterol levels, 1.75 (1.29-2.38) for elevated arterial pressure, and 2.93 (2.04-4.22) for elevated glucose levels. Waist circumference + elevated triglycerides + elevated glucose was the three-component combination with the strongest impact [HR = 4.95 (2.92-8.37)]. In this large French population, in which MetS was moderate, MetS was associated with other hemodynamic, hepatic, inflammatory and psychological risk factors, and with a 70% increase in all-cause mortality. The three-component combination most strongly associated with mortality was high waist circumference + elevated glucose + elevated triglycerides.

[Cardiac arrhythmias in the elderly]. / Les troubles du rythme cardiaque du sujet agé.

In the elderly, cardiac arrhythmias and conduction disturbances are characterized by their high frequency, diagnostic difficulties, low tolerance, and delicate treatment. Atrial fibrillation, the prevalence of which exceeds 10% after 80 years, is usually related to hypertensive or ischemic heart disease, and is the cause or the consequence of heart failure. It is first and foremost a cause of thromboembolic events, and especially cerebrovascular embolism. In elderly patients, sinus node dysfunction and AV block are often induced or aggravated by drugs. The iatrogenic risk associated with antiarrhythmic drugs (especially class I) and antithrombotic drugs is elevated in the elderly, and these agents must thus be used with great care. Ventricular rate control is often a safer option than sinus rhythm control for atrial fibrillation. Ablative methods and cardiac pacing techniques are other therapeutic options.

Determinants of accelerated progression of arterial stiffness in normotensive subjects and in treated hypertensive subjects over a 6-year period.

BACKGROUND: Elastic artery stiffness, a result of arterial aging, is an independent indicator of cardiovascular risk. The aim of the present longitudinal study was to compare the progression of aortic stiffness over a 6-year period in treated hypertensive subjects and normotensive subjects, and to evaluate the determinants of this progression. METHODS AND RESULTS: Data for the present analysis were gathered from 483 subjects who had 2 health checkups at the Centre d'Investigations Préventives et Cliniques, the first one in 1992--1993 and the second one in 1998--1999. Carotid-femoral pulse wave velocity (PWV) was used to evaluate aortic stiffness in 187 hypertensive subjects who were under treatment at the time of the first visit and throughout the follow-up period, and in 296 subjects who were classified as normotensive during the first visit and who remained treatment-free throughout the follow-up period. In both populations, PWV progression was higher in older subjects. Annual rates of progression in PWV in treated hypertensives were significantly higher than in normotensives. Only treated hypertensives with well-controlled blood pressure levels at the time of both visits had a PWV progression similar to that of normotensives. In treated hypertensives, high heart rate and high creatinine during the first visit were associated with an accelerated progression in PWV. CONCLUSIONS: The presence of high blood pressure, high heart rate, and high serum creatinine were the major determinants of accelerated progression of aortic stiffness in treated hypertensives. This is the first longitudinal study to evaluate the determinants of arterial aging over an extended period of time.

Role of modifiable risk factors in life expectancy in the elderly.

OBJECTIVE: The aim of the present study was to evaluate the role of 'modifiable' risk factors, assessed between the ages of 60 and 70 years, in late survival. DESIGN: The study population included subjects aged 60-70 years, who had a standard health examination at the IPC Center, and who could potentially reach the age of 80 years for men and 85 years for women at the end of the follow-up period. METHODS: The role of 'modifiable' risk factors was assessed by comparing subjects who died before the age of 80 years for men (n=1333) and before 85 years for women (n=543) to subjects who survived beyond these ages (3681 men, 1910 women). Multivariate analyses were conducted to determine which parameters were independently associated with survival to an advanced age. RESULTS: The multivariate analysis showed a decreased probability of late survival with higher pulse pressure (P<0.0001), higher heart rate (P<0.002), higher glycemia (P<0.0034), and an increased probability with regular physical activity (P<0.0001). A significant interaction between heart rate and gender (P<0.01) was observed, indicating that heart rate was a predictor of late survival in men but not in women. Body mass index, cholesterol and triglyceride levels, and diastolic blood pressure and tobacco smoking were not associated with late survival in this population. CONCLUSIONS: A systematic search for certain risk factors in an elderly patient can have a significant impact on late survival and can lead to the establishment of priority goals, such as increasing physical activity and reducing blood pressure, heart rate and glycemia.

Prognostic value of systolic and diastolic blood pressure in treated hypertensive men.

BACKGROUND: The aim of this study was to assess the cardiovascular risk in hypertensive subjects according to systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels. METHODS: The study sample consisted of 4714 hypertensive men, treated by their physician, who had a standard health checkup at the d'Investigations Préventives et Cliniques Center, Paris, France, between 1972 and 1988. Cardiovascular disease (CVD) and coronary heart disease (CHD) mortality were assessed for a mean period of 14 years. RESULTS: Among treated subjects, 85.5% presented uncontrolled values for SBP (> or = 40 mm Hg) and/or DBP (> or = 90 mm Hg). After adjustment for age and associated risk factors, these subjects presented an increased risk for CVD mortality (risk ratio [RR], 1.66; 95% confidence interval [CI], 1.04-2.64) and for CHD mortality (RR, 2.35; 95% CI, 1.03-5.35) compared with controlled subjects. After adjustment for age, associated risk factors, and DBP, and compared with subjects with SBP under 140 mm Hg, the RR for CVD mortality was 1.81 (95% CI, 1.04-3.13) in subjects with SBP between 140 and 160 mm Hg and 1.94 (95% CI, 1.10-3.43) in subjects with SBP over 160 mm Hg. By contrast, after adjustment for SBP levels, CVD risk was not associated with DBP. Compared with subjects with DBP under 90 mm Hg, RR for CVD mortality was 1.17 (95% CI, 0.80-1.70) in subjects with DBP between 90 and 99 mm Hg and 1.03 (95% CI, 0.67-1.56) in subjects with DBP over 100 mm Hg. Similar results were observed for CHD mortality. CONCLUSIONS: In hypertensive men treated in clinical practice, SBP is a good predictor of CVD and CHD risk. Diastolic blood pressure, which remains the main criterion used by most physicians to determine drug efficacy, appears to be of little value in determining cardiovascular risk. Evaluation of risk in treated individuals should take SBP rather than DBP values into account.

[Prognosis at six months for primary care patients: prognostics factors analysis]. / Pronostic a six mois des patients coronariens suivis en médecine de ville: etude des facteurs influençant le devenir.

UNLABELLED: AIM OF THE SURVEY: The aim of the PREVENIR III study was to assess, in secondary prevention, the risk of subsequent coronary and cerebrovascular events at six months in a population of patients in private practice. METHODS: This was a prospective observational survey (6-month follow-up), including patients diagnosed with previous myocardial infarction, unstable angina or ischemic stroke, carried out by French general practitioners and cardiologists in private practice. RESULTS: 8288 patients were selected by 3746 physicians (2961 general practitioners and 785 cardiologists) representative of French metropolitan physicians in private practice. In this analysis the medical records of 6859 coronary patients were analyzed. After a 6-month follow-up, 84 patients had been hospitalized for a subsequent coronary or cerebrovascular event (1.2%) i.e. cumulative incidence 3.1 event per 100 person-years (95% CI 2.4-3.8). In the coronary population 77.4% of the subsequent vascular events were coronary events and 22.6% were cerebrovascular events. The event rate of coronary events was 0.9% and the cumulative incidence 2.3 event per 100 person-years (95% CI 1.8-2.8), the risk of secondary ischemic stroke was 0.3% and the cumulative incidence 0.7 event per 100 person-years (95% CI 0.4-1.0), and the all-cause mortality rate was 1.0% and the cumulative incidence 2.5 event per 100 person-years (95% CI 1.9-3.1). 61.0% of total death was cardiovascular deaths. Multivariate analysis showed that older age, recent index event, three vessel disease were more likely to undergo recurrent events. CONCLUSION: Our survey enabled a better understanding of the prognosis at six months for a large sample of coronary patients recruited in private practice medicine. For coronary patients treated in private practice the risk of subsequent events and total mortality is far from insignificant.

[Prognosis at six months for coronary patients: impact of antiplatelet agents and statins]. / Pronostic a six mois des patients coronariens: impact de l'association antiagrégants plaquettaires-statines.

PURPOSE: The aim of the PREVENIR III study was to assess, in secondary prevention, the risk after six months of subsequent coronary and cerebrovascular events. METHODS: A prospective observational survey, including patients diagnosed with previous myocardial infarction, unstable angina or ischemic stroke, was carried out by French general practitioners and cardiologists. RESULTS: 9556 patients were selected by 3746 physicians representative of French physicians. The medical records of 6859 patients with previous unstable angina or myocardial infarction were analyzed. After a 6-month follow-up, 84 patients (1.2%) had been hospitalized for coronary or cerebrovascular event i.e. cumulative incidence 3.1 per 100 person-years (95% CI 2.4-3.8) and 67 patients died (1.0%) i.e. 2.5 per 100 person-years (95% CI 1.9-3.1). Patients treated with statins and antiplatelet agents were less likely to undergo subsequent vascular events (relative risk: 0.35; 95% CI 0.20-0.61) than patients not receiving statins or antiplatelet agents. All-cause mortality rate decreased dramatically (relative risk: 0.32; 95% CI 0.16-0.65) in patients treated with a combination of statins and antiplatelet agents when compared to patients treated with neither statins nor antiplatelet agents. CONCLUSION: This work enabled a better understanding of the prognosis at six months in a large sample of coronary patients. We observed the beneficial impact of the combination of statins and antiplatelet agents in secondary prevention.

Cost of care distribution in atrial fibrillation patients: the COCAF study.

BACKGROUND: Atrial fibrillation (AF) currently represents a major economic burden for society. Very few studies have been performed to evaluate the cost of care for AF patients. This study is a large prospective survey designed to analyze the different cost drivers in the treatment of these patients. This survey, named Cost of Care in Atrial Fibrillation (COCAF), evaluated the cost of care for patients with AF treated by cardiologists in general office practice. METHODS: A group of 671 patients was recruited by 82 cardiologists distributed in all regions of France. The mean age of the patients was 69 years, and 64% were male. The mean follow-up was 329 +/- 120 days. The costs of care were analyzed from the health care payer and the societal perspectives. RESULTS: During the follow-up period, 21 patients (3.13%) died and 210 (31.3%) patients were hospitalized. The number of hospitalizations and deaths was significantly higher in the group of persistent or permanent AF (PEAF) patients, as compared to paroxysmal AF (PAAF) patients. Hospitalizations were much more frequent in the PEAF group (127) than in the PAAF group (83, P <.05). Deaths were also much more frequent in the PEAF group (17) as compared to the PAAF group (4, P <.001). From the societal perspective, the first cost driver was hospitalizations (52%), followed by drugs (23%), consultations (9%), further investigations (8%), loss of work (6%), and paramedical procedures (2%). In multivariate analysis the following parameters were significantly associated with higher costs: heart failure (P <.04), coronary artery disease (P <.001), use of class III antiarrhythmic drugs (P <.002), hypertension (P <.002) and metabolic disease (P <.001). CONCLUSIONS: This prospective survey shows that hospitalizations represent the major cost driver in the treatment of AF patients. Outpatient care programs must be proposed to AF patients in order to avoid readmissions and to reduce the cost of treatment.

Why cardiovascular mortality is higher in treated hypertensives versus subjects of the same age, in the general population.

OBJECTIVE: The aim of the present study was to assess whether increased cardiovascular mortality in treated hypertensives could be explained by high blood pressure levels, or by the presence of associated risk factors and/or associated diseases. DESIGN: The study sample consisted of 8893 treated hypertensive men and women from the Investigations Préventives et Cliniques cohort, and 25880 gender-matched and age-matched untreated subjects from the same cohort. Vital status was obtained for an 8-12 year period. RESULTS: Treated hypertensive subjects had higher systolic blood pressure (SBP) (+ 15 mmHg) and higher diastolic blood pressure (+ 9 mmHg), and a higher prevalence of associated risk factors and diseases. Treated hypertensives compared with untreated subjects presented a two-fold increase in the risk ratio (RR) for cardiovascular mortality [RR, 1.96; 95% confidence interval (CI), 1.74-2.22] and coronary mortality (RR, 1.99; 95% CI, 1.63-2.44). Adjustment for unmodifiable risk factors decreased the excess cardiovascular risk observed in treated subjects only slightly: RR, 1.77; 95% CI, 1.56-2.00 for cardiovascular mortality; and RR, 1.76; 95% CI, 1.44-2.16 for coronary mortality. After additional adjustment for modifiable associated risk factors, the increased mortality in treated subjects persisted: RR, 1.52; 95% CI, 1.33-1.74 for cardiovascular mortality; and RR, 1.49; 95% CI, 1.19-1.86 for coronary mortality. Only after additional adjustment for SBP were cardiovascular mortality and coronary mortality similar in the two groups of subjects: RR, 1.06; 95% CI, 0.92-1.23; and RR, 1.06; 95% CI, 0.85-1.35, respectively. CONCLUSIONS: The increased cardiovascular mortality in treated hypertensive subjects as compared with untreated subjects is mainly due to high SBP levels under treatment. This result suggests that the excess risk found in treated hypertensives may be drastically reduced if SBP were brought under control.