Health status and clinical outcomes in older adults with chronic coronary disease: the ISCHEMIA trial

BACKGROUND: Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown. OBJECTIVES: The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. METHODS: One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure. RESULTS: Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29). CONCLUSIONS: Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease: The ISCHEMIA Trial.

BACKGROUND: Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown. OBJECTIVES: The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. METHODS: One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure. RESULTS: Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29). CONCLUSIONS: Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Outcomes of Participants With Diabetes in the ISCHEMIA Trials.

BACKGROUND: Among patients with diabetes and chronic coronary disease, it is unclear if invasive management improves outcomes when added to medical therapy. METHODS: The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trials (ie, ISCHEMIA and ISCHEMIA-Chronic Kidney Disease) randomized chronic coronary disease patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, hemoglobin A1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with versus without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease severity or left ventricular function). RESULTS: Of 5900 participants with complete baseline data, the median age was 64 years (interquartile range, 57-70), 24% were female, and the median estimated glomerular filtration was 80 mL·min-1·1.73-2 (interquartile range, 64-95). Among the 2553 (43%) of participants with diabetes, the median percent hemoglobin A1c was 7% (interquartile range, 7-8), and 30% were insulin-treated. Participants with diabetes had a 49% increased hazard of death or MI (hazard ratio, 1.49 [95% CI, 1.31-1.70]; P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI, 0.48-0.60) and 0.66 (95% bootstrapped CI, 0.61-0.71) for patients with diabetes versus without diabetes, respectively, with a 12% (95% bootstrapped CI, 4%-20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI, 0.42-0.56) and 0.49 (95% bootstrapped CI, 0.42-0.56), respectively. There was no difference in death or MI between strategies for patients with diabetes versus without diabetes, or for clinical (female sex or insulin use) or anatomic features (coronary artery disease severity or left ventricular function) of patients with diabetes. CONCLUSIONS: Despite higher risk for death or MI, chronic coronary disease patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

[Cardiovascular prevention - 2016]. / Cardiovascularis prevenció - 2016.

Cardiovascular diseases are the main causes of premature death worldwide despite the fact that cardiovascular mortality decreased significantly in the last few decades in financially developed countries. This reduction is partly due to the modern medical and revascularisation treatments, and partly because of the effectiveness of prevention strategies such as lowering blood pressure and cholesterol level, as well as successful strategies against smoking. However, this positive trend is undermined by the striking growth in obesity and in type 2 diabetes mellitus, which could also be successfully controlled by lifestyle changes. This summary is based on an overview of the recent (2016) European Guideline for the Prevention of Cardiovascular Diseases. Here the authors describe preventive strategies and goals to be achieved, the most important lifestyle suggestions, and the secondary prevention medical treatment for patients with already established cardiovascular disease. Orv. Hetil., 2016, 157(38), 1526-1531.

[Short and long term prognosis of patients with myocardial infarction. Hungarian Myocardial Infarction Registry]. / Szívinfarktus miatt kezelt betegek korai és késoi prognózisa. Magyar Infarctus Regiszter Vizsgálat.

INTRODUCTION: Mortality data of patients with acute myocardial infarction are incomplete in Hungary. AIM: The aim of the authors was to analyse the data of 8582 myocardial infarction patients (4981 with ST-elevation myocardial infarction) registered in the Hungarian Myocardial Infarction Register in order to define the hospital, 30-day, and 1-year mortality. To evaluate the prehospital mortality of myocardial infarction, all myocardial infarction and sudden death were registered in five districts of Budapest. METHOD: Multivariate logistic regression was performed to define risk factors of mortality and the model were assessed using c statistics. RESULTS: The hospital, 30-day and 1-year mortality of patients with ST elevation myocardial infarction were 3.7%, 9.5% and 16.5%, respectively. In patients without ST elevation myocardial infarction these figures were 4%, 9.8% and 21.7%, respectively. The 1-year mortality of patients without ST elevation was higher than those of with ST elevation and the difference was statistically significant. Age, Killip class, diabetes mellitus, history of stroke and myocardial infarction were independent predictors of death. Coronary intervention improved the prognosis of patients with myocardial infarction significantly. CONCLUSIONS: The rate of pre-hospital mortality was considerably high; 72.5% of 30 day mortality occurred before admission to hospital.

[Myocardial Infarction Registry--2010. Experience and first results in Hungary]. / Myocardialis Infarctus Regiszter--2010. Tapasztalatok--elso eredmények.

Authors present the methodology and first data of Hungarian Myocardial Infarction Register Pilot Study started 1st of January, 2010. The aim of the study is to collect epidemiological data on myocardial infarction, to examine the natural history of the disease and to investigate the main characteristics on patient care in the pilot area. The program is using standardized diagnostic criteria and predefined electronic data record forms (eCRF). The pilot area consists of 5 districts in the capital, and Szabolcs-Szatmár-Bereg county. The area has 997 324 inhabitants. Eight cardiology departments, 5 with heart catheterization facility (C) in Budapest, four hospitals with one C in Szabolcs-Szatmar-Bereg county have been responsible of the patients' care. After starting the program 16 other hospitals joined the program from different parts of Hungary. Between 1st of January 2010 and 1st of May 2011 4293 patients were registered, among them 52.1% with ST segment elevation myocardial infarction (STEMI), 42.1% with non-ST segment elevation myocardial infarction (NSTEMI), while 3% of the patients had unstable angina, and 2.8% of the cases had other diagnosis or the hospital diagnosis was missing in the eCRF. Authors compare the patients care with STEMI in five districts of Budapest and Szabolcs-Szatmár-Bereg county. In Budapest 79.7% of the 301 STEMI patients were treated in C and 84.6% of them were treated with primary percutaneous intervention (pPCI). In Szabolcs-Szatmár-Bereg county 402 patients were registered with STEMI, 62.9% of them were treated in C, where 77% of them were treated with pPCI. The drugs (beta blockers, ACE inhibitors, statins) important for secondary prevention were given more often to patients treated in the capital, however no difference was found in the platelet aggregation inhibitors therapy. Hospital mortality of STEMI patients was 8% in the capital, and 10% in Szabolcs- Szatmár-Bereg county. Authors conclude that the web based myocardial infarction register is feasible and important to have reliable data on patient care and a necessary quality control tool. Authors propose to broaden this pilot program and to start a nationwide myocardial infarction register.

[The significance of generic valsartan in the treatment of patients]. / A generikus valsartan jelentosege a betegek ellátásában.

The renin-angiotensin-aldosterone system (RAAS) is involved in the regulation of electrolyte and water balance primarily; however, it also influences vascular function and increases blood pressure--especially under pathological conditions. Hypertension, post-myocardial infarction state, and heart failure are, for example, associated with excessive systemic and/or local activation of the RAAS. Angiotensin II (AT-II) generated by the latter, contributes--along with additional factors and through its deleterious effects (vasoconstriction, endothelial dysfunction, atherosclerosis, prothrombotic state, fibrosis, etc.)--to damage to the target organs involved in the sequence of cardiovascular events. Inhibiting the RAAS at different levels is of therapeutic importance--its purpose is to delay disease progression, to prevent end organ damage, and to achieve a better outcome. As AT-II acts on several (AT1 and AT2) receptors, using angiotensin receptor blocking (ARB) agents with a high selectivity for the AT1 receptor is the rational choice. In view of its favourable therapeutic properties and efficacy demonstrated by morbidity and mortality studies, a generic formulation of appropriate quality, containing valsartan as active substance could prove to be the ideal treatment for patients with hypertension and other cardiovascular disorders.

[Cardiovascular prevention with peripheral artery disease]. / Cardiovascularis prevenció perifériás érszukületben szenvedo betegek esetében.

Peripheral artery disease is a global disease. When present, the occurrence of cardiovascular events and death rises. Patients suffering from peripheral artery disease belong to the high CV risk category. Based on the prevention recommendations when PAD is present, treatments with and without medicine are equally necessary. A change in life-style, blood pressure reduction, diabetes mellitus treatment, reaching the target cholesterol values, treatments with ACE inhibitor, statin and thrombocyte inhibitor all lower the occurrence of CV events. The early identification of the Doppler index can help in the early diagnosis of atherothrombosis.

[Prevention of cardiovascular diseases: collaborative program]. / A szív- es erbetegségek megelozése: prevenciós osszefogás program.

The so-called Program for preventive collaboration model joins the expertise of specialists and GPs and as such allocates for the effective, cost saving, secure screening of individuals with high and intermediate cardiovascular risk and identifying asymptomatic patients within a big population. Based on SCORE risk assessment GPs define their patients cardiovascular risk. In Gottsegen György Institute of Hungarian Cardiology on patients with intermediate or high risk ankle-brachial doppler index, carotis intima media thickness, artery stiffness, microalbuminuria and left ventricular hypertrophy are diagnosed. Based on the results of non-invasive cardiovascular marker tests a mixed score is elaborated. The applicability of the score is then measured for the further risk assessment of individuals with intermediate or high CV risk. The collaboration of GPs and specialists along with the non-invasive cardiological tests are helpful in the early identification of patients with high cardiovascular risk and when making a decision about drug or non-drug treatments.

[Noninvasive tests of atherosclerotic burden in asymptomatic people with high cardiovascular risk]. / Tünetmentes, nagy cardiovascularis rizikójú egyének szrovizsgálatára alkalmas nem invazív módszerek.

Objective of cardiovascular prevention to reduce the risk of major cardiovascular events and morbidity and prolong the quality of life. Strategy of prevention is identification of high risk individuals, and action to reduce their risk factors levels. Noninvasive tests such as carotis artery duplex scanning, ultrasound-based endothelial function studies, ankle-brachial blood pressure ratios, coronary calcium score by electron-beam CT, and high-sensitivity testing for C-reactive protein offer the potential for directly and indirectly measuring atherosclerosis in asymptomatic people. If a patient is found to have abnormal non-invasive test, this patient can be elevated to a higher risk category.

[Correlation of lower extremity Doppler index with flow-mediated vasodilation and the extent of coronary disease]. / Az alsó végtagi Doppler-index összefüggése az áramlásmediált vasodilatatióval és a coronariabetegség kiterjedésével.

AIMS: The aim of this study was to examine relationship between resting ankle-brachial pressure index and flow mediated vasodilation, and that of the extent of coronary artery disease. PATIENTS AND METHODS: Authors examined 77 subjects. All had peripheral arterial disease (with ankle-brachial pressure index less than 0.8), and angina pectoris (coronary artery disease verified by coronary angiography). Mean age was 64.6 years (range 41-82 years). Flow mediated (endothelial dependent) vasodilatation was measured for all participiant. RESULTS: Authors stated, that ankle-brachial pressure index significantly correlates with flow mediated vasodilatation and the same connection can be supposed between Doppler index and coronary artery disease's extension.

[Endothelium-dependent and independent vasodilation in young males with previous myocardial infarction]. / Endotheliumdependens és -independens vasodilatatio vizsgálata fiatal, myocardialis infarctust szenvedett férfiakban.

INTRODUCTION: Flow-mediated vasodilatation of brachial arteries, a non-invasive parameter of endothelial function, is correlated with cardiovascular risk factors. An impairment of flow-mediated vasodilatation in the brachial artery is related to the extent of coronary artery disease. AIMS: The authors examined the relationship between flow-mediated vasodilatation and coronary artery disease morphology in young patients who had myocardial infarction. PATIENTS AND METHODS: 28 young patients (all men) with myocardial infarction (age 22-40, mean age: 35 years). Coronarography revealed one vessel disease in 16 patients (A group) and multivessel disease in 12 patients (B group). The control group was 14 healthy, young patients (age 18-36 years mean age: 30 years) (C group). The authors examined in all subjects flow-mediated, endothelium-dependent vasodilatation following reactive hyperaemia and nitroglycerin induced (NTG), endothelium-independent vasodilatation in the brachial artery with high resolution ultrasound (Acuson 128 X P/10). RESULTS: Patients after myocardial infarction showed impaired flow-mediated vasodilatation compared to those of controls. (p < 0.01). Flow-mediated vasodilatation was lower in multivessel disease compare to one vessel disease. Nitroglycerin induced similar degrees of vasodilatation in the myocardial infarction and control groups. CONCLUSION: Young patients with myocardial infarction may have impaired endothelium-dependent dilatation and the decrease of flow-mediated vasodilatation is related to the angiographic extent of coronary artery disease.