Underdiagnosis of Isolated Systolic and Isolated Diastolic Hypertension.

Systolic and diastolic hypertension independently predict the risk of adverse cardiovascular events. It remains unclear how systolic pressure, diastolic pressure, and other patient characteristics influence the initial diagnosis of hypertension. Here, we use a cohort of 146,816 adults in a large healthcare system to examine how elevated systolic and/or diastolic blood pressure measurements influence initial diagnosis of hypertension and how other patient characteristics influence the diagnosis. Thirty-four percent of the cohort were diagnosed with hypertension within 1 year. In multivariable logistic regression of the diagnosis of hypertension, controlling for covariates, isolated systolic hypertensive measures (odds ratio [OR] 0.42 [95% confidence interval {CI} 0.41 to 0.43]) and isolated diastolic hypertensive measures (OR 0.32 [95% CI 0.31 to 0.33]) were less likely to lead to hypertension diagnosis when compared with combined hypertensive measures. Higher levels of systolic blood pressure had a greater impact on hypertension diagnosis (OR 1.77 [95% CI 1.75 to 1.79] per Z-score) than did higher levels of diastolic blood pressure (OR 1.34 [95% CI 1.32 to 1.36] per Z-score). Older age, non-white race/ethnicity, and medical comorbidities all predicted the establishment of a diagnosis of hypertension. Isolated systolic and isolated diastolic hypertension are underdiagnosed in clinical practice, and several patient-centered factors also strongly influence whether a diagnosis is made. In conclusion, our findings uncover a care gap that can be closed with increased attention to the independent influence of systolic and diastolic hypertension and the various patient-centered factors that may impact hypertension diagnosis.

Effect of Systolic and Diastolic Blood Pressure on Cardiovascular Outcomes.

BACKGROUND: The relationship between outpatient systolic and diastolic blood pressure and cardiovascular outcomes remains unclear and has been complicated by recently revised guidelines with two different thresholds (≥140/90 mm Hg and ≥130/80 mm Hg) for treating hypertension. METHODS: Using data from 1.3 million adults in a general outpatient population, we performed a multivariable Cox survival analysis to determine the effect of the burden of systolic and diastolic hypertension on a composite outcome of myocardial infarction, ischemic stroke, or hemorrhagic stroke over a period of 8 years. The analysis controlled for demographic characteristics and coexisting conditions. RESULTS: The burdens of systolic and diastolic hypertension each independently predicted adverse outcomes. In survival models, a continuous burden of systolic hypertension (≥140 mm Hg; hazard ratio per unit increase in z score, 1.18; 95% confidence interval [CI], 1.17 to 1.18) and diastolic hypertension (≥90 mm Hg; hazard ratio per unit increase in z score, 1.06; 95% CI, 1.06 to 1.07) independently predicted the composite outcome. Similar results were observed with the lower threshold of hypertension (≥130/80 mm Hg) and with systolic and diastolic blood pressures used as predictors without hypertension thresholds. A J-curve relation between diastolic blood pressure and outcomes was seen that was explained at least in part by age and other covariates and by a higher effect of systolic hypertension among persons in the lowest quartile of diastolic blood pressure. CONCLUSIONS: Although systolic blood-pressure elevation had a greater effect on outcomes, both systolic and diastolic hypertension independently influenced the risk of adverse cardiovascular events, regardless of the definition of hypertension (≥140/90 mm Hg or ≥130/80 mm Hg). (Funded by the Kaiser Permanente Northern California Community Benefit Program.).

Statin Adherence Is Associated With Reduced Recurrent Stroke Risk in Patients With or Without Atrial Fibrillation.

BACKGROUND AND PURPOSE: Outpatient statin use reduces the risk of recurrent ischemic stroke among patients with stroke of atherothrombotic cause. It is not known whether statins have similar effects in ischemic stroke caused by atrial fibrillation (AFib). METHODS: We studied outpatient statin adherence, measured by percentage of days covered, and the risk of recurrent ischemic stroke in patients with or without AFib in a 21-hospital integrated healthcare delivery system. RESULTS: Among 6116 patients with ischemic stroke discharged on a statin over a 5-year period, 1446 (23.6%) had a diagnosis of AFib at discharge. The mean statin adherence rate (percentage of days covered) was 85, and higher levels of percentage of days covered correlated with greater degrees of low-density lipoprotein suppression. In multivariable survival models of recurrent ischemic stroke over 3 years, after controlling for age, sex, race/ethnicity, medical comorbidities, and hospital center, higher statin adherence predicted reduced stroke risk both in patients without AFib (hazard ratio, 0.78; 95% confidence interval, 0.63-0.97) and in patients with AFib (hazard ratio, 0.59; 95% confidence interval, 0.43-0.81). This association was robust to adjustment for the time in the therapeutic range for international normalized ratio among AFib subjects taking warfarin (hazard ratio, 0.61; 95% confidence interval, 0.41-0.89). CONCLUSIONS: The relationship between statin adherence and reduced recurrent stroke risk is as strong among patients with AFib as it is among patients without AFib, suggesting that AFib status should not be a reason to exclude patients from secondary stroke prevention with a statin.

Doppler-detected valve movement in aortic stenosis: a predictor of adverse outcome.

BACKGROUND: The absence of auscultatory aortic valve closure sound is associated with severe aortic stenosis. The absence of Doppler-derived aortic opening (Aop ) or closing (Acl ) may be a sign of advanced severe aortic stenosis. HYPOTHESIS: Absent Doppler-detected Aop or Acl transient is indicative of very severe aortic stenosis and is associated with adverse outcome. METHODS: A total of 118 consecutive patients with moderate (n = 63) or severe aortic stenosis (n = 55) were included. Aop and Acl signals were identified in a blinded fashion by continuous-wave Doppler. Patients with and without Aop and Acl were compared using χ(2) test for dichotomous variables and analysis of variance for continuous variables. The associations of Aop and Acl with aortic valve replacement were determined. RESULTS: Aop or Acl were absent in 22 of 118 patients. The absence of Aop or Acl was associated with echocardiographic parameters of severe aortic stenosis. The absence of Aop or Acl was associated with incident aortic valve replacement (36.4% vs 7.3%, respectively, P < 0.001). Even in patients with aortic valve area <1 cm(2) , the absence of Aop or Acl was still associated with increased rate of aortic valve replacement (42.1% vs 13.9%, respectively, P = 0.019) and provided incremental predictive value over peak velocity. CONCLUSIONS: In a typical population of patients with aortic stenosis, approximately 1 in 6 has no detectible aortic valve opening or closing Doppler signal. The absence of an Aop or Acl signal is a highly specific sign of severe aortic stenosis and is associated with incident aortic valve replacement.

Remote monitoring of implantable pacemakers: in-office setup significantly improves successful data transmission.

BACKGROUND: Remote wireless follow-up of implanted pacemakers (PM) has become an attractive method of follow-up. Although wireless PM follow-up has several advantages compared with transtelephonic and office-based follow-up, its utility depends on successful transmission. HYPOTHESIS: Initial in-office setup of wireless PM will improve transmission rate as compared with home setup. METHODS: A total of 202 consecutive patients from 2 medical centers were included in this retrospective study. Patients in the home setup group (N = 101) had traditional home setup of wireless PM, whereas patients in the in-office group (N = 101) had setup of PMs by allied health professionals during the postoperative office visit. Successful transmission was defined as successful initial wireless transmission of PM data by 2 months postimplant. RESULTS: Of the 101 patients in the home setup group, 22 (22%) patients had successful transmission. Of the 101 patients in the in-office group, 92 (91%) patients had successful transmission (P < 0.0001). Logistic regression analysis showed that that the in-office group was independently associated with successful transmission (odds ratio: 114.5; 95% confidence interval: 32.1-408.4; P < 0.0001). CONCLUSIONS: In patients implanted with PM capable of remote wireless data transmission, initial home setup of the wireless monitoring device was frequently unsuccessful. In-office PM setup was associated with a significantly higher rate of successful transmission.

Detection of paroxysmal atrial fibrillation by 30-day event monitoring in cryptogenic ischemic stroke: the Stroke and Monitoring for PAF in Real Time (SMART) Registry.

BACKGROUND AND PURPOSE: Patients with cryptogenic ischemic stroke may have undetected paroxysmal atrial fibrillation (PAF). We established the Stroke and Monitoring for PAF in Real Time (SMART) Registry to determine the yield of 30-day outpatient PAF monitoring in cryptogenic ischemic stroke. METHODS: The SMART Registry was a 3-year, prospective multicenter registry of 239 patients with cryptogenic ischemic stroke undergoing 30-day outpatient autotriggered PAF detection in Kaiser Permanente Northern California. RESULTS: In intention-to-monitor analysis, PAF was detected in 29 of 239 patients (12.1%; 95% CI, 8.6%-16.9%). After retrospective chart review was performed, a new diagnosis of PAF was confirmed in 26 of 236 patients (11.0%; 95% CI, 7.6%-15.7%). The majority of detected PAF events were asymptomatic; only 6 of 98 recorded PAF events (6.1%) were patient-triggered or associated with symptoms. CONCLUSIONS: -Approximately 1 in every 9 patients with cryptogenic ischemic stroke was found to have new PAF within 30 days. Routine monitoring in this population should be strongly considered.

Clinical significance of elevated B-type natriuretic peptide in patients with acute lung injury with or without right ventricular dilatation: an observational cohort study.

BACKGROUND: The primary objective of this study was to examine levels of B-type natriuretic peptide (BNP) in mechanically ventilated patients with acute lung injury and to test whether the level of BNP would be higher in patients with right ventricular dilatation and would predict mortality. METHODS: This was a prospective, observational cohort study of 42 patients conducted in the intensive care unit of a tertiary care university hospital. BNP was measured and transthoracic echocardiography was performed within 48 hours of the onset of acute lung injury. The left ventricular systolic and diastolic function, right ventricular systolic function, and cardiac output were assessed. BNP was compared in patients with and without right ventricular dilatation, as well as in survivors versus nonsurvivors. RESULTS: BNP was elevated in mechanically ventilated patients with acute lung injury (median 420 pg/ml; 25-75% interquartile range 156-728 pg/ml). There was no difference between patients with and without right ventricular dilatation (420 pg/ml, 119-858 pg/ml vs. 387 pg/ml, 156-725 pg/ml; p = 0.96). There was no difference in BNP levels between the patients who died and those who survived at 30 days (420 pg/ml, 120-728 pg/ml vs. 385 pg/ml, 159-1070 pg/ml; p = 0.71). CONCLUSIONS: In patients with acute lung injury the level of BNP is increased, but there is no difference in the BNP level between patients with and without right ventricular dilatation. Furthermore, BNP level is not predictive of mortality in this population.

Relation of concentric remodeling to adverse outcomes in patients with stable coronary artery disease (from the Heart and Soul Study).

Concentric remodeling (CR) is defined as increased left ventricular (LV) wall thickness with normal total LV mass. When encountered in populations with hypertension or patients undergoing aortic valve replacement, some studies have shown that CR predicts cardiovascular (CV) events and stroke. To expand our understanding of the prognostic implications of this common echocardiographic finding, we examined the association of CR and adverse CV events in ambulatory patients with coronary artery disease (CAD). We tested the hypothesis that finding CR on echocardiogram in ambulatory CAD independently predicts heart failure hospitalizations and CV death. Transthoracic echocardiograms were recorded in 973 participants from the Heart and Soul Study. Participants were divided into 4 groups: normal, CR, concentric LV hypertrophy, and eccentric LV hypertrophy. CV events were determined by 2 independent adjudicators and these were analyzed by Cox proportional hazards models. After mean 4.9 ± 1.5 years of follow-up, adverse outcomes occurred more frequently in those with concentric and eccentric LV hypertrophy but not in those with CR. After multivariate adjustment, concentric and eccentric LV hypertrophies were associated with increased risk of death and heart failure hospitalization, whereas CR was not. In conclusion, our hypothesis was not supported because CR was not associated with adverse CV events in our cohort of patients with stable CAD.

Successful retrograde recanalization of a left anterior descending artery chronic total occlusion through a previously placed left anterior descending-to-diagonal artery stent.

Since the introduction of the retrograde technique, the success rate of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has increased significantly in patients with suitable anatomy. To our knowledge, retrograde recanalization of a CTO from the abluminal side of a previously placed stent has not been reported. We describe a case of retrograde PCI of a mid left anterior descending (LAD) artery CTO through a previously placed proximal LAD stent which extended into the diagonal artery. The occluded mid LAD was recanalized using the retrograde approach in which retrograde wire crossing into the proximal LAD was successful only after high pressure balloon expansion of the previously placed proximal LAD-to-diagonal stent. Intravascular ultrasound imaging was also used to confirm an intraluminal location of the retrograde guidewire.

Comparison of outcomes using bare metal versus drug-eluting stents in coronary artery disease patients with and without human immunodeficiency virus infection.

Patients with human immunodeficiency virus (HIV) who undergo percutaneous coronary intervention have a substantial risk of subsequent cardiovascular events. However, outcome data from HIV-infected patients who receive drug-eluting stents (DESs) are limited. We hypothesized that HIV-infected patients treated with DESs would have fewer recurrent cardiac events compared with those who receive bare metal stents (BMSs). We evaluated 97 HIV-infected patients and 97 non-HIV control patients who had undergone percutaneous coronary intervention between January 2000 and July 2007. Clinical, laboratory, and angiographic data were obtained by chart review. Major adverse cardiovascular events (MACE), defined as clinically driven coronary revascularization, nonfatal myocardial infarction, and cardiovascular death, were adjudicated by 2 independent physicians. The mean age of the HIV cohort was 53 years, and all patients were men. Compared with non-HIV patients, HIV-infected patients were less likely to have hypertension, diabetes mellitus, and previous coronary artery disease and were more likely to have been treated with longer stent length and more stents. During a mean follow-up of 3.1 years, patients who received a DES had a lower rate of MACE compared with those who had received a BMS, regardless of HIV status. After multivariate adjustment for baseline characteristic differences, non-HIV-DES patients had 65% fewer MACE and HIV-DES patients had 60% fewer MACE compared with non-HIV-BMS patients. In conclusion, these data suggest that treatment with DESs in the HIV population is safe and efficacious.