Cardiorenal metabolic syndrome and cardiometabolic risks in minority populations.

Cardiovascular disease (CVD), including heart disease and stroke, is the leading cause of death in the USA, regardless of self-determined race/ethnicity, and largely driven by cardiometabolic risk (CMR) and cardiorenal metabolic syndrome (CRS). The primary drivers of increased CMR include obesity, hypertension, insulin resistance, hyperglycemia, dyslipidemia, chronic kidney disease as well as associated adverse behaviors of physical inactivity, smoking, and unhealthy eating habits. Given the importance of CRS for public health, multiple stakeholders, including the National Minority Quality Forum (the Forum), the American Association of Clinical Endocrinologists (AACE), the American College of Cardiology (ACC), and the Association of Black Cardiologists (ABC), have developed this review to inform clinicians and other health professionals of the unique aspects of CMR in racial/ethnic minorities and of potential means to improve CMR factor control, to reduce CRS and CVD in diverse populations, and to provide more effective, coordinated care.

Hormone replacement therapy among postmenopausal women presenting with acute myocardial infarction: insights from the GUSTO-III trial.

Background: The role of hormone replacement therapy (HRT) in the prevention of cardiovascular disease has been controversial. In large observational studies, HRT appears to lower cardiovascular disease risk. However, prospective randomized trials do not substantiate this.

Association of door-to-balloon time and mortality in patients > or =65 years with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Current guidelines recommend patients with ST-elevation myocardial infarction receive primary percutaneous coronary intervention (PCI) within 90 minutes of admission, although there are conflicting data regarding the relation between time to treatment and mortality in these patients. We used logistic regression analyses employing a fractional polynomial model to evaluate the association between door-to-balloon time and 1-year mortality in patients with ST-elevation myocardial infarction > or =65 years old undergoing primary PCI from 1994 to 1996 (n = 1,932). Median door-to-balloon time was 128 minutes (interquartile range 92 to 178, 24.

Cardiovascular disease in women.

The rates of cardiovascular disease (CVD) have decreased significantly for men over the past few decades, but similar reductions have not occurred in women. Consequently, CVD remains the leading killer of women in the United States. Men usually develop heart disease earlier than women, but women develop heart disease more rapidly once menopause has occurred.

The pathophysiology of cardiovascular disease in diabetes mellitus and the future of therapy.

Diabetes mellitus is a complex disease with several metabolic abnormalities leading to varied, interconnected endothelial and vascular dysfunction and resulting in accelerated atherosclerosis. Cardiovascular disease is the main cause of mortality in patients with diabetes. Apart from traditional therapy for control of hyperglycemia and other associated comorbidities, various newer therapies are being investigated to fight atherosclerosis at a molecular level.

Special issues when caring for the older person with acute coronary syndromes.

Persons 75 years of age or older constitute 6% of the US population but account for more than one third of those with acute coronary syndromes (ACS). Unfortunately, most randomized clinical trials have enrolled few older persons, and, as a result, few data are available to guide clinical practice. As in younger patients, aspirin, beta-blockers, nitrates, clopidogrel, heparin, statins, and angiotensin-converting enzyme inhibitors are useful, beginning with lower doses and carefully observing the patient for symptoms of toxicity.

Hydroxymethylglutaryl-CoA reductase inhibitors in older persons with acute myocardial infarction: evidence for an age-statin interaction.

Objectives: To characterize the relationship between hydroxymethylglutaryl-CoA reductase inhibitors (statins) and outcomes in older persons with acute myocardial infarction (AMI).

Design: Observational study.

Setting: Acute care hospitals in the United States from April 1998 to June 2001.

Statins and mortality among elderly patients hospitalized with heart failure.

Background: Small studies suggest that statins may improve mortality in patients with heart failure (HF). Whether these results are generalizable to a broader group of patients with HF remains unclear. Our objective was to evaluate the association between statin use and survival among a national sample of elderly patients hospitalized with HF.

Systolic hypertension in older persons: complexities in clinical decision making.

While the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) challenges clinicians to aggressively manage systolic hypertension, few data are available to guide clinicians in treating older persons with this condition. In older persons, hypertension treatment decisions must often rely on extrapolations and fall into a gray area where optimal choice for an individual patient may be unclear. In these instances, patients must understand the probable outcomes of options, consider the personal value they place on benefits vs.

The complexity and cost of drug regimens of older patients hospitalized with heart failure in the United States, 1998-2001.

Background: Polypharmacy-the concurrent prescription of multiple medications-is a salient consideration in the care of older patients with heart failure. Little is known, however, about the complexity and financial burden of medical therapy in this population.

Methods: This is a study of the chronic medications prescribed at hospital discharge to patients 65 years or older hospitalized for heart failure in 2 cohorts separated by 27 months (April 1998-March 1999, n = 31 602; July 2000-June 2001, n = 30,774).

Physician specialty and mortality among elderly patients hospitalized with heart failure.

Background: Whether specialty care improves survival among patients with heart failure remains controversial.

Methods: We evaluated specialty care and outcomes in 25869 Medicare beneficiaries hospitalized with heart failure in the United States from 1998 through 1999. Patients were classified based on the specialty of their attending physician: cardiologist, internist, general physician, or family physician.

Adoption of spironolactone therapy for older patients with heart failure and left ventricular systolic dysfunction in the United States, 1998-2001.

Background: Concerns have been raised about the appropriateness of spironolactone use in some patients with heart failure. We studied the adoption of spironolactone therapy after publication of the Randomized Aldactone Evaluation Study (RALES) in national cohorts of older patients hospitalized for heart failure.

Methods And Results: This is a study of serial cross-sectional samples of Medicare beneficiaries > or =65 years old discharged after hospitalization for the primary diagnosis of heart failure and with left ventricular systolic dysfunction.

Sex, quality of care, and outcomes of elderly patients hospitalized with heart failure: findings from the National Heart Failure Project.

Background: Previous studies have demonstrated that women hospitalized for heart failure receive poorer quality of care and have worse outcomes than men. However, these studies were based upon selected patient populations and lacked quality of care measures.

Methods: We used data from the National Heart Failure Project, a national sample of fee-for-service Medicare patients hospitalized with heart failure in the United States in 1998-1999, to evaluate differences in quality of care and patient outcomes between men and women.

Systolic hypertension in older persons.

Context: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure emphasizes the importance of systolic hypertension (SH), defined as systolic blood pressure (SBP) of at least 140 mm Hg and diastolic blood pressure of less than 90 mm Hg, in older persons (> or =60 years).

Objective: To systematically review the literature on clinical management of SH in older persons.

Data Sources: We performed a MEDLINE search of English-language literature from 1966-2004 to identify reports about SH in older persons, with particular emphasis on data from randomized clinical trials.

National patterns of use and effectiveness of angiotensin-converting enzyme inhibitors in older patients with heart failure and left ventricular systolic dysfunction.

Background: Although ACE inhibitors are underprescribed for heart failure, factors associated with their use are not well described. Furthermore, the effectiveness of ACE inhibitors has been questioned in some populations, potentially contributing to underuse. Our objectives were to assess the correlates of ACE inhibitor use and the relationship between ACE inhibitor prescription and mortality in older patients with heart failure.

Predictors of cardiologist care for older patients hospitalized for heart failure.

Background: Studies have suggested that cardiologists may provide higher quality heart failure care than generalists. However, national rates of specialty care during hospitalization for heart failure and factors associated with care by a cardiologist are unknown.

Methods: We assessed specialty care in a sample of Medicare patients hospitalized nationwide with heart failure between 1998 and 1999 (n = 25,869).

Are statins indicated for the primary prevention of CAD in octogenarians? antagonist viewpoint.

Statin therapy (3-hydroxy-3methylglutaryl coenzyme A reductase inhibitor) is beneficial for primary prevention of cardiovascular events in patients younger than age 65 years with hyperlipidemia, yet there is uncertainty about using these agents for primary prevention in octogenarians. We present the case that can be made for not treating octogenarians with statins for the primary prevention of cardiovascular disease. This case is built on three points: 1) cholesterol levels are not associated with cardiovascular disease events in octogenarians without overt coronary artery disease; 2) no randomized, controlled trials have assessed the role of statins in reducing events in octogenarians without coronary artery disease; and 3) statins may increase risks of myositis, rhabdomyolysis, and cancer in the elderly.

Patterns of secondary prevention in older patients undergoing coronary artery bypass grafting during hospitalization for acute myocardial infarction.

Background: Aggressive risk factor modification decreases cardiovascular events and mortality in patients after coronary artery bypass grafting (CABG). Little is known regarding the use of secondary prevention in older patients undergoing CABG during hospitalization for acute myocardial infarction (AMI).

Methods And Results: Medical records were reviewed for a sample of 37,513 patients hospitalized with AMI in the United States between April 1998 and March 1999.

Long-term prognostic importance of total cholesterol in elderly survivors of an acute myocardial infarction: the Cooperative Cardiovascular Pilot Project.

Objectives: To determine the long-term prognostic importance of in-hospital total serum cholesterol in elderly survivors of acute myocardial infarction (AMI).

Design: Retrospective medical record review.

Setting: Acute care, nongovernmental hospitals in Alabama, Connecticut, Iowa, and Wisconsin.

National and state trends in quality of care for acute myocardial infarction between 1994-1995 and 1998-1999: the medicare health care quality improvement program.

Background: National efforts have focused attention on quality of care, but relatively little is known about whether, and to what extent, improvement has occurred during this recent period. Furthermore, the variability of the recent change over time is not known.

Methods: We sought to determine national and state trends in quality of care for Medicare patients hospitalized with acute myocardial infarction (AMI) between 1994-1995 (n = 234754 discharges) and 1998-1999 (n = 35713 discharges) as part of the Centers for Medicare & Medicaid Services (CMS) National AMI Project.

beta-Blockers in heart failure: clinical applications.

beta-Blockers reduce morbidity and mortality in heart failure patients with left ventricular systolic dysfunction and stable fluid status. The successful adoption of beta-blocker guidelines for these patients requires an understanding of the value of this therapy and effective systems to maintain safety and ensure high quality of care. This article distills scientific evidence and consensus guidelines into a series of cases and practical answers about patient selection, discussions with patients, management and monitoring, and systems improvements to optimize quality of care, safety, and benefit for all patients with heart failure.

beta-Blocker therapy in heart failure: scientific review.

Context: Care of patients with heart failure has been revolutionized throughout the past decade. A paradigm shift in the strategy for treating heart failure caused by systolic dysfunction is in progress. Despite the initial perception about beta-blockers' safety, they are now the most extensively studied class of agents in the treatment of heart failure and have emerged as an important intervention to improve the clinical outcomes of heart failure patients.

Fibrinogen: associations with cardiovascular events in an outpatient clinic.

Background: Fibrinogen, known to influence the coagulation process, is an independent risk factor for coronary artery disease (CAD). However, its association with myocardial infarction (MI) and its predictive potential for short-term mortality, in an ongoing clinical practice, has not been characterized.

Objectives: In a high-risk outpatient practice we sought to demonstrate whether baseline fibrinogen levels related to MI rather than CAD alone, and whether baseline serum fibrinogen levels predicted mortality over a short-term follow-up.