Safety and effectiveness of primary prevention cardioverter defibrillators in octogenarians.

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) reduce the rate of sudden cardiac death (SCD) in patients with cardiomyopathy and reduced left ventricular systolic function. It is unclear if this benefit extends to the very elderly patient population. METHODS: Patients who underwent initial ICD implantation at age 80 or older between January 1995 and April 2010 for primary SCD prevention were identified. Clinical data were collected from the medical record, including periprocedural complications, device type, and therapies delivered. RESULTS: Three-hundred eighty patients were identified; 84 patients met eligibility criteria. The mean age was 82.68 years; mean follow-up was 34 months. Mean left ventricular ejection fraction was 28.1%. Mortality during follow-up was 17.9%. One- and 5-year survival estimates were 100% and 60%, respectively. Periprocedural complications occurred in 9.4% of patients; serious complications occurred in 4.8% with no periprocedural deaths. Device therapies occurred in 11.9% (n = 10) of patients (9.5% appropriate, n = 8; 2.4% inappropriate, n = 2). Cardiac resynchronization therapy-defibrillator (CRT-D) implantation was associated with prolonged median survival and decreased risk of death (hazard ratio 0.212; 95% confidence interval 0.048-.942, P = 0.042) compared to ICD alone. CONCLUSIONS: Implantation of primary prevention ICDs in patients 80 years of age or older was associated with a low risk of serious complications and a 5-year survival estimate of 60%. Inappropriate therapies after implantation were uncommon. CRT-D implantation was associated with a decreased risk of death compared to ICD alone. These data suggest that, in selected patients in this age group, ICD implantation is safe and effective.

The confounded relation of coffee drinking to coronary artery disease.

After decades of conflicting studies, the relation of coffee drinking to coronary artery disease (CAD) risk remains unresolved. Using Cox proportional-hazards models with 5 covariates, 127,212 subjects who supplied baseline data at voluntary health examinations from 1978 to 1985 were studied. Subsequently, 8,357 subjects were hospitalized for CAD. Coffee drinking was unrelated to CAD risk in 58,888 never smokers, but in ex-smokers and current baseline smokers, daily coffee intake was associated with higher CAD risk. This disparity was generally consistent in stratified subgroups. In conclusion, this relation of coffee consumption to increased CAD risk only in smokers could be explained by incomplete control for smoking, by other traits of smokers, or by an adverse biologic interaction of a coffee ingredient with smoking effect on CAD.

Sequelae of systemic hypertension in alcohol abstainers, light drinkers, and heavy drinkers.

A link exists between alcohol intake and increased blood pressure (BP), with many studies showing increased hypertension prevalence in heavy drinkers. The harmful and beneficial effects of alcohol can confound the study of the long-term risks of alcohol-related hypertension. We therefore studied cardiovascular sequelae separately in heavy drinkers, light drinkers, and abstainers among 127,212 subjects with BP and alcohol intake ascertained at 1978 to 1985 health examinations. Subsequent cardiovascular end points included mortality risk, hospitalization risk, and outpatient diagnosis of hypertension. Analyses were performed for all subjects and stratified by 5 alcohol-drinking categories (from never drinkers to >or=3 drinks/day). With <120/80 mm Hg as the referent, Cox proportional hazards models were used to estimate relative risks and 95% confidence intervals for 3 higher BP categories (120 to 129/80 to 84, 130 to 139/85 to 89, and >or=140/90 mm Hg). The covariates were age, gender, race, body mass index, education, and smoking. The risk of all outcomes was progressively higher for increasing BP categories, with a similarly increased risk for abstainers, light drinkers, and heavy drinkers. The interaction tests for alcohol and BP were not statistically significant for the mortality and hospitalization outcomes. Interpretation was limited by an inability to separate subjects with increased BP from alcohol consumption from those with other etiologies. In conclusion, the data indicate that the risks of hypertension are similar regardless of the amount of alcohol consumption.

Coronary calcifications and plaque characteristics in patients with end-stage renal disease: a computed tomographic study.

BACKGROUND: We examined the association between coronary artery calcifications, atherosclerotic burden, and plaque morphology in end-stage renal disease (ESRD) and non-ESRD patients undergoing 64-slice multidetector coronary computed tomographic angiography. METHODS: The prevalence, extent, and severity of coronary atherosclerosis, calcium burden, and plaque morphology were determined in ESRD patients (n=48), and calcium score-matched (n=39) and unmatched non-ESRD controls (n=29) undergoing computed tomographic angiography using dedicated plaque imaging software. RESULTS: ESRD was associated with a higher prevalence of calcified plaques (55.9% vs. 38.3 and 26.9% in the non-ESRD groups, P=0.005) and higher plaque calcium content (43.7 vs. 34.5% and 33.9%; P=0.003). Nonetheless, the calcium score correlated well with plaque burden (r=0.403 in ESRD vs. r=0.433 in non-ESRD, P<0.001 for both), and the diagnostic association between the calcium score and atherosclerotic lesions was good irrespective of ESRD (area under the curve 0.771 vs. 0.804; P=0.574). CONCLUSION: ESRD is associated with diffuse atherosclerosis and calcific plaque morphology. Nonetheless, the association between the calcium score and atherosclerotic burden is not affected by the presence of ESRD.

Diagnostic performance of computed tomographic coronary angiography in patients with end-stage renal disease.

BACKGROUND: End-stage renal disease (ESRD) is characterized by a very high rate of cardiovascular events that warrants thorough screening for coronary atherosclerosis, especially in patients undergoing a kidney transplant. Therefore, we assessed the diagnostic performance of 64-slice multidetector coronary computed tomographic angiography (CCTA) in patients with ESRD. METHODS: We included patients who had been referred for a CCTA and an invasive coronary angiography (diagnostic standard) within 6 months, either as part of clinical work-up in two urban medical centers or as part of the multicenter ACCURACY trial. RESULTS: Thirty-one ESRD patients were included and compared with 588 non-ESRD patients undergoing CCTA and invasive coronary angiography. On a patient-based model, the sensitivity, specificity, and positive and negative predictive values to detect at least 50% and at least 70% stenosis were 100, 78, 92, and 100% and 100, 91, 95, and 100%, respectively, for ESRD patients and 97, 83, 87, and 96% and 94, 87, 85, and 95%, respectively, for non-ESRD controls. There were no statistically significant differences between ESRD and non-ESRD participants in diagnostic performance measures. CONCLUSION: Results show 64-row multidetector CCTA is highly sensitive and specific in the detection of coronary artery stenosis irrespective of ESRD. Our findings suggest that CCTA is a promising diagnostic tool for the timely detection and/or exclusion of coronary atherosclerosis in patients undergoing pretransplant cardiovascular surveillance.