Predictors, Trends, and Outcomes (Among Older Patients ≥65 Years of Age) Associated With Beta-Blocker Use in Patients With Stable Angina Undergoing Elective Percutaneous Coronary Intervention: Insights From the NCDR Registry.

OBJECTIVES: This study sought to examine predictors, trends, and outcomes associated with ß-blocker prescriptions at discharge in patients with stable angina without prior history of myocardial infarction (MI) or systolic heart failure (HF) undergoing elective percutaneous coronary intervention (PCI). BACKGROUND: The benefits of ß-blockers in patients with MI and/or systolic HF are well established. However, whether ß-blockers affect outcomes in patients with stable angina, especially after PCI, remains uncertain. METHODS: We included patients with stable angina without prior history of MI, left ventricular systolic dysfunction (left ventricular ejection fraction <40%) or systolic HF undergoing elective PCI between January 2005 and March 2013 from the hospitals enrolled in the National Cardiovascular Data Registry (NCDR) CathPCI registry. These patients were retrospectively analyzed for predictors and trends of ß-blocker prescriptions at discharge. All-cause mortality (primary endpoint), revascularization, or hospitalization related to MI, HF, or stroke at 30-day and 3-year follow-up were analyzed among patients ≥65 years of age. RESULTS: A total of 755,215 patients from 1,443 sites were studied, and 71.4% population of our cohort was discharged on ß-blockers. At 3-year follow-up among patients ≥65 years of age with CMS data linkage (16.3% of the studied population), there was no difference in adjusted mortality rate (14.0% vs. 13.3%; adjusted hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.96 to 1.03; p = 0.84), MI (4.2% vs. 3.9%; adjusted HR: 1.00; 95% CI: 0.93 to 1.07; p = 0.92), stroke (2.3% vs. 2.0%; adjusted HR: 1.08; 95% CI: 0.98 to 1.18; p = 0.14) or revascularization (18.2% vs. 17.8%; adjusted HR: 0.97; 95% CI: 0.94 to 1.01; p = 0.10) with ß-blocker prescription. However, discharge on ß-blockers was associated with more HF readmissions at 3-year follow-up (8.0% vs. 6.1%; adjusted HR: 1.18; 95% CI: 1.12 to 1.25; p < 0.001). Results at 30-day follow-up were broadly consistent as well. During the period between 2005 and 2013, there was a gradual increase in prescription of ß-blockers at the index discharge in our cohort (p < 0.001). CONCLUSIONS: Among patients ≥65 years of age with history of stable angina without prior MI, systolic HF or left ventricular ejection fraction <40% undergoing elective PCI, ß-blocker use at discharge was not associated with any reduction in cardiovascular morbidity or mortality at 30-day and at 3-year follow-up. Over time, ß-blockers use at discharge in this population has continued to increase.

Changes in myocardial infarction guideline adherence as a function of patient risk: an end to paradoxical care?

OBJECTIVES: The goals of this analysis were to determine: 1) whether guideline-based care during hospitalization for a myocardial infarction (MI) varied as a function of patients' baseline risk; and 2) whether temporal improvements in guideline adherence occurred in all risk groups. BACKGROUND: Guideline-based care of patients with MI improves outcomes, especially among those at higher risk. Previous studies suggest that this group is paradoxically less likely to receive guideline-based care (risk-treatment mismatch). METHODS: A total of 112,848 patients with MI were enrolled at 279 hospitals participating in Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) between August 2000 and December 2008. We developed and validated an in-hospital mortality model (C-statistic: 0.75) to stratify patients into risk tertiles: low (0% to 3%), intermediate (3% to 6.5%), and high (>6.5%). Use of guideline-based care and temporal trends were examined. RESULTS: High-risk patients were significantly less likely to receive aspirin, beta-blockers, angiotensin-converting inhibitors/angiotensin receptor blockers, statins, diabetic treatment, smoking cessation advice, or cardiac rehabilitation referral at discharge compared with those at lower risk (all p < 0.0001). However, use of guideline-recommended therapies increased significantly in all risk groups per year (low-risk odds ratio: 1.33 [95% confidence interval (CI): 1.22 to 1.45]; intermediate-risk odds ratio: 1.30 [95% CI: 1.21 to 1.38]; and high-risk odds ratio: 1.30 [95% confidence interval: 1.23 to 1.37]). Also, there was a narrowing in the guideline adherence gap between low- and high-risk patients over time (p = 0.0002). CONCLUSIONS: Although adherence to guideline-based care remains paradoxically lower in those MI patients at higher risk of mortality and most likely to benefit from treatment, care is improving for eligible patients within all risk categories, and the gaps between low- and high-risk groups seem to be narrowing.

The significance of transient ischemic dilation in the setting of otherwise normal SPECT radionuclide myocardial perfusion images.

BACKGROUND: Transient ischemic dilation (TID) in the setting of an abnormal SPECT radionuclide myocardial perfusion imaging (MPI) study is considered a marker of severe and extensive coronary artery disease (CAD). However, the clinical significance of TID and its association with CAD in patients with an otherwise normal MPI study is unclear. METHODS: From a database of patients who underwent MPI over a 9-year period, 96 without known cardiac history who had normal image perfusion patterns, and who underwent coronary angiography within 6 months, were identified. TID quantitative values were derived. To adjust for varying stress and image protocols, a TID index based on published threshold values was derived for each patient, with >1 considered as TID. We examined the relationship of TID to the presence/extent of CAD, and to a CAD prognostic index. TID was also correlated with patient survival. To address referral bias, survival in a separate cohort of 3,691 patients with a normal perfusion MPI who did not undergo angiography in the 6-month interval was correlated with the presence and severity of TID. RESULTS: For 28 (29.2%) patients with normal MPI perfusion patterns but with TID, there was no increased incidence of CAD, multivessel or left main disease, or a higher prognostic index compared with no TID. In addition, there was no increased mortality associated with TID in both the angiography cohort and in the patients who did not undergo immediate angiography. CONCLUSIONS: TID in patients with an otherwise normal SPECT MPI study does not increase the likelihood of CAD, its extent or severity, and is not associated with worsened patient survival.

A prior myocardial infarction: how does it affect management and outcomes in recurrent acute coronary syndromes?

BACKGROUND: Despite improved secondary prevention efforts, acute coronary syndrome (ACS) recurrence among patients with prior history of coronary events remains high. The differences in presentation, management, and subsequent clinical outcomes in patients with and without a prior myocardial infarction (MI) and presenting with another episode of ACS remain unexplored. METHODS: A total of 3,624 consecutive patients admitted to the University of Michigan with ACS from January 1999 to June 2006 were studied retrospectively. In-hospital management, outcomes, and postdischarge outcomes such as death, stroke, and reinfarction in patients with and without a prior MI were compared. RESULTS: Patients with a prior MI were more likely to be older and have a higher incidence of diabetes mellitus, hypertension, hyperlipidemia, and peripheral vascular disease. In-hospital outcomes were not significantly different in the 2 groups, except for a higher incidence of cardiac arrest (4.3% versus 2.5%, p < 0.01) and cardiogenic shock (5.7% versus 3.9%, p = 0.01) among patients without a prior MI. However, at 6 mo postdischarge, the incidences of death (8.0% versus 4.5%, p < 0.0001) and recurrent MI (10.0% versus 5.1%, p < 0.0001) were significantly higher in patients with a prior history of MI compared with those without. CONCLUSION: Patients with prior MI with recurrent ACS remain at a higher risk of major adverse events on follow-up. This may be partly explained by the patients not being on optimal medications at presentation, as well as disease progression. Increased efforts must be directed at prevention of recurrent ACS, as well as further risk stratification of these patients to improve their overall outcomes.

Cardiovascular risk, obesity, and myocardial blood flow in postmenopausal women.

BACKGROUND: This study was designed to determine whether overweight or obese status is independently associated with myocardial flow reserve (MFR), an established predictor of cardiovascular mortality, in a group of postmenopausal women with no previous cardiovascular disease. Postmenopausal women are the largest group of overweight and physically inactive individuals in the United States. Increased body mass index (BMI) is consistently associated with increased cardiovascular mortality in this population. Whether this is because of obesity itself or the accompanying increase in cardiovascular risk factors (CRFs) remains controversial. METHODS: We examined the relationship of myocardial blood flow (MBF), coronary vascular resistance, and MFR to BMI in 60 postmenopausal women with no coronary heart disease. Subjects underwent dynamic N-13 ammonia positron emission tomography for the measurement of MBF and MFR. Baseline demographics, CRF, and hemodynamic parameters were recorded for each subject. Datasets were divided into 3 groups according to BMI: normal (18 to 24), overweight (25 to 29), and obese (>or=30). RESULTS: The overweight and obese groups showed significantly higher resting MBF and lower MFR than the normal-weight group (both P < .001), even after adjusting for CRF. A further analysis of subjects without any CRF (n = 35) showed that the MFR remained significantly lower in the obese compared with normal-weight subjects (P = .05). Levels of known markers of vascular inflammation (high-sensitivity C-reactive protein and homocysteine) and high-density lipoprotein cholesterol levels correlated with declining MFR. CONCLUSIONS: These findings provide a mechanistic link between obesity and coronary heart disease in this population.

Temporal trends in antiplatelet/antithrombotic use in acute coronary syndromes and in-hospital major bleeding complications.

Antithrombotic and antiplatelet agents are essential for the management of patients with acute coronary syndromes (ACSs). These pharmacologic agents have the potential for increased risk of bleeding. It is not clear if the increased uptake of these therapies has resulted in a clinically evident increase in bleeding complications over time. In this study, we included 3,193 consecutive patients who were admitted to the University of Michigan with an ACS (unstable angina or myocardial infarction) between January 1999 and December 2004. These patients were analyzed for temporal trends in antithrombotic and antiplatelet agent use, thrombolytic therapy, cardiac catheterizations, percutaneous coronary interventions, and major bleeding complications (including gastrointestinal, vascular access, and intracranial hemorrhage). We found a decreasing temporal trend in the incidence of major in-hospital bleeding complications (p <0.001) despite an increasing use of ticlopidine/clopidogrel (p <0.0001), unfractionated heparin (p <0.01), glycoprotein IIb/IIIa inhibitors (p <0.0001), and percutaneous coronary intervention (p <0.0001) in the management of patients with ACSs. In conclusion, major bleeding remains a significant complication of ACS management but has decreased significantly over time. We believe that this decreasing bleeding trend may be because of better identification of higher risk patients, attention to correct dosing, appropriate monitoring, and incorporation of various periprocedural strategies in routine clinical practice.