OBJECTIVE: To study general practitioners' (GP) assessment of the probability of ischaemic heart disease (IHD) and GP action in daily practice regarding chest pain patients. METHODS: All chest pain patients aged 20-79 years, attending three primary health-care centres in south-east Sweden and assessed by the GP to have high, low or very low probability of IHD, were included consecutively over a two year period. The "GP action in daily practice" was classed as "active decisions" (investigation or treatment) or "wait and see". "IHD" or "not IHD" was settled according to the results of acute hospital investigation or exercise testing/myocardial perfusion scintigraphy. RESULTS: 516 patients were included, 93 high, 145 low and 278 very low probability cases. The outcome was "IHD" in 47%, 9% and 1% respectively. The sensitivity and specificity of the "GP assessment of the probability of IHD" were 72% and 89%. The sensitivity and specificity of the "GP action in daily practice" were 88% and 72%, respectively. The negative predictive value was 98%. CONCLUSION: GP assessment, after clinical evaluation, that the probability of IHD was low did not safely rule out IHD. GP action in daily practice however, indicates that general practice is an appropriate level of care for chest pain patients.
Overall fifty one patients with chronic cardiac insufficiency (ChCI) were studied for changes in parameters characterizing hemodynamics and lipid peroxidation (LPO) under treatment with kapoten and prazosin. Kapoten was found to be capable of exerting an antioxidant effect and working in ways beneficial for the pulmonary circulation, while prazosin is generally indicated to patients with ChCI presenting with increased end diastolic pressure in the left ventricle. Prazosin activates LPO, for which reason its pro-oxidant action needs to be drug-corrected. Because of marked pharmacologic effects of both drugs in dealing with refractory circulatory insufficiency it is advisable that further studies be made in order that we might be able to determine indications for kapoten and prazosin therapy in coronary patients as well as those with arterial hypertension, cardiomyopathies, valvular defects, ChCI with complications more accurately.
It has been suggested that the myocardium is able to recruit endogenous protective mechanisms in response to repeated ischemia and reperfusion. We set out to study whether this is manifested in patients with coronary artery disease in the form of fewer signs of myocardial ischemia during the second of two successive exercise tests and whether any relations exist between ischemia adaptation and findings at cardiac catheterization. Twenty-one patients with typical angina pectoris symptoms underwent two repeated bicycle exercise tests with identical protocols, followed by cardiac catheterization and coronary angiography the next day. The first exercise test was discontinued whenever a 2 mm ST depression in the electrocardiogram (ECG) was achieved or further exercise was limited by symptoms. The second exercise test was performed after disappearance of the symptoms or ST depression or both. Kaplan-Meier survival analysis for the appearance of a 1 mm ST depression demonstrated improved ischemia tolerance during the second test, when the required time for its appearance was significantly longer (6.5 +/- 0.8 min vs 4.5 +/- 0.5 min; p = 0.005). The maximal intensity of anginal pain was lower during the second exercise (2.2 +/- 1.0 min vs 0.7 +/- 0.3 min in Borg's scale; p
To evaluate the relationship between antihypertensive (AH) drug adherence and cardiovascular (CV) outcomes among patients with a recent ischemic stroke and assess the validity of our approach.
A cohort of 14,227 patients diagnosed with an ischemic stroke was assembled from individuals 65 years and older who were treated with AH agents from 1999 to 2007 in Quebec, Canada. A nested case-control design was used to evaluate the occurrence of nonfatal major CV outcomes and mortality. Each case was matched to 15 controls by age and cohort entry time. Medication possession ratio was used for AH agent adherence level. Adjusted conditional logistic regression models were used to estimate the rate ratio of CV events. The validity of the approach was assessed by evaluating the adherence level of CV-protective and non-CV-protective drugs.
Mean age was 75 years, 54% were male, 38% had coronary artery disease, 23% had diabetes, 47% dyslipidemia, and 14% atrial fibrillation or flutter. High adherence to AH therapy was mirrored by similar adherence to statins and antiplatelet agents and was associated with a lower risk of nonfatal vascular events compared with lower adherence (rate ratio 0.77 [0.70-0.86]). We observed a paradoxic link between adherence to several drugs and all-cause mortality.
Adherence to AH agents is associated with adherence to other secondary preventive therapies and a risk reduction for nonfatal vascular events after an ischemic stroke. Overestimation of all-cause mortality reduction may be related to frailty and comorbidities, which may confound the apparent benefit of different drugs.
Adult height and risk of ischemic heart disease, atrial fibrillation, stroke, venous thromboembolism, and premature death: a population based 36-year follow-up study.
Few studies have associated height with cardiovascular diseases other than myocardial infarction. We conducted a population-based 36-year cohort study of 12,859 men born in 1955 or 1965 whose fitness for military service was assessed by Draft Boards in Northern Denmark. Hospital diagnoses for ischemic heart diseases, atrial fibrillation, stroke, and venous thromboembolism were obtained from the Danish National Patient Registry, covering all Danish hospitals since 1977. Mortality data were obtained from the Danish Civil Registration System. We began follow-up on the 22nd birthday of each subject and continued until occurrence of an outcome, emigration, death, or 31 December 2012, whichever came first. We used Cox regression to compute hazard ratios (HRs) with 95 % confidence intervals (CIs). Compared with short stature, the education-adjusted HR among tall men was 0.67 (95 % CI 0.54-0.84) for ischemic heart disease (similar for myocardial infarction, angina pectoris, and heart failure), 1.60 (95 % CI 1.11-2.33) for atrial fibrillation, 1.05 (95 % CI 0.75-1.46) for stroke, 1.04 (95 % CI 0.67-1.64) for venous thromboembolism, and 0.70 (95 % CI 0.58-0.86) for death. In conclusion, short stature was a risk factor for ischemic heart disease and premature death, but a protective factor for atrial fibrillation. Stature was not substantially associated with stroke or venous thromboembolism.
We describe the prevalence of cardiovascular risk factors at stroke onset in men and women of all ages.
A registry started in 2001, designed to register all hospitalized stroke patients in Denmark, now holds 40,102 patients with first-ever ischemic stroke. Patients underwent evaluation including stroke severity (Scandinavian Stroke Scale), CT, and cardiovascular risk factors: hypertension, atrial fibrillation, diabetes mellitus, intermittent arterial claudication, previous myocardial infarction, body mass index, smoking, and alcohol consumption. We estimated the independent effect of gender and age on prevalence of cardiovascular risk factors and calculated age and gender-specific prevalence rates for each risk factor.
The register contained 47.9% women and 52.1% men. Men had more often diabetes mellitus, previous myocardial infarction, intermittent arterial claudication, and over the limit alcohol consumption. Women had more often hypertension and obesity. Atrial fibrillation and smoking were equally frequent in both genders. Age stratification revealed that the lifestyle cardiovascular risk factors smoking, alcohol, and obesity were more common in the younger patients with stroke ( 70 to 80 years), the decrease being generally more pronounced in men than in women.
Cardiovascular risk factors were generally more prevalent in men. Lifestyle cardiovascular risk factors were more common in the young. Prevalence of hypertension, diabetes mellitus, coronary heart disease, and, in men, also atrial fibrillation go down after the age of 70 to 80 years.
Ventricular arrhythmia is a significant cause of sudden death. Implantable cardioverter-defibrillators (ICDs) offer at-risk patients a prophylactic treatment option. This prophylaxis is largely responsible for growth in utilization of ICDs. Identification of factors that may impact device-specific quality of life (QOL) is warranted. The influence of preimplant patient variables on postimplant device-specific QOL is unknown. The study aimed to determine whether preimplant psychosocial, generic health-related quality of life (HRQOL), personality disposition, or demographic factors predicted early postimplant device-specific QOL.
A prospective cohort study design was employed in 70 adults receiving an ICD for primary prevention. Preimplant, we measured generic HRQOL, personality disposition, depressive symptoms, age, and sex. The primary outcome was 3-month ICD device-specific QOL as measured by the Florida Patient Acceptance Scale (FPAS). We applied hierarchical multivariate regression analysis.
Mean age was 64.8 ± 9.4 years; 12.9% were women. Most had ischemic heart disease (77%) and a heart failure history (54.3%). Preimplant prevalence of elevated depressive symptoms was 30%. Three months post implant, the mean adjusted FPAS score was 76.8 ± 12.98. Of the variance in FPAS scores, 37% was explained by the independent variables. Younger age and poor preimplant mental HRQOL contributed most to lower FPAS scores.
Patient support and psychosocial interventions should target younger ICD candidates and those reporting poor preimplant mental HRQOL; these patients may be at risk for poor postimplant device-specific QOL.
Age dependency of acute ischaemic stroke aetiology and vascular risk factors have not been adequately evaluated in stroke patients in Norway. Aims of this study were to evaluate how stroke subtypes and vascular risk factors vary with age in a western Norway stroke population.
Patients aged 15-100 years consecutively admitted to our neurovascular centre with acute ischaemic stroke between 2006 and 2012 were included. The study population was categorized as young (15-49 years), middle-aged (50-74 years) or elderly (= 75 years). Stroke aetiology was defined by TOAST criteria. Risk factors and history of cardiovascular disease were recorded.
In total, 2484 patients with acute cerebral infarction were included: 1418 were males (57.3%). Mean age was 70.8 years (SD ± 14.9), 228 patients were young, 1126 middle-aged, and 1130 were elderly. The proportion of large-artery atherosclerosis and of small-vessel occlusion was highest among middle-aged patients. The proportion of cardioembolism was high at all ages, especially among the elderly. The proportion of stroke of other determined cause was highest among young patients. Some risk factors (diabetes mellitus, active smoking, angina pectoris, prior stroke and peripheral artery disease) decreased among the elderly. The proportions of several potential causes increased with age.
The proportion of stroke subtypes and vascular risk factors are age dependent. Age 50-74 years constitutes the period in life where cardiovascular risk factors become manifest and stroke subtypes change.
Ischemic heart disease (IHD) is the most common cause of heart failure (HF); however, the role of revascularization in these patients is still unclear. Consensus on proper use of cardiac imaging to help determine which candidates should be considered for revascularization has been hindered by the absence of clinical studies that objectively and prospectively compare the prognostic information of each test obtained using both standard and advanced imaging.
This paper describes the design and methods to be used in the Alternative Imaging Modalities in Ischemic Heart Failure (AIMI-HF) multi-center trial. The primary objective is to compare the effect of HF imaging strategies on the composite clinical endpoint of cardiac death, myocardial infarction (MI), cardiac arrest and re-hospitalization for cardiac causes.In AIMI-HF, patients with HF of ischemic etiology (n = 1,261) will follow HF imaging strategy algorithms according to the question(s) asked by the physicians (for example, Is there ischemia and/or viability?), in agreement with local practices. Patients will be randomized to either standard (SPECT, Single photon emission computed tomography) imaging modalities for ischemia and/or viability or advanced imaging modalities: cardiac magnetic resonance imaging (CMR) or positron emission tomography (PET). In addition, eligible and consenting patients who could not be randomized, but were allocated to standard or advanced imaging based on clinical decisions, will be included in a registry.
AIMI-HF will be the largest randomized trial evaluating the role of standard and advanced imaging modalities in the management of ischemic cardiomyopathy and heart failure. This trial will complement the results of the Surgical Treatment for Ischemic Heart Failure (STICH) viability substudy and the PET and Recovery Following Revascularization (PARR-2) trial. The results will provide policy makers with data to support (or not) further investment in and wider dissemination of alternative 'advanced' imaging technologies.
NCT01288560.
Notes
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