Risk Stratification for Cardiovascular Disease in Women in the Primary Care Setting.

BACKGROUND: Traditional risk assessment tools classify the majority of middle-aged women at low risk despite cardiovascular (CV) disease's affecting >50% of women and remaining the leading cause of death. Ultrasound-determined carotid intima-media thickness (CIMT) and/or computed tomographic coronary artery calcium score (CACS) quantify subclinical atherosclerosis and add incremental prognostic value. The aim of this study was to assess the utility of CIMT and CACS to detect subclinical atherosclerosis in younger women. METHODS: Asymptomatic women aged 50 to 65 years with at least one CV risk factor and low Framingham risk scores were identified prospectively at primary care and cardiology clinics. Mean intimal thickness, plaque on CIMT, and Agatston calcium score for CACS were obtained. RESULTS: Of 86 women (mean age, 58 ± 4.6 years; mean Framingham risk score, 1.9 ± 1.2; mean low-density lipoprotein cholesterol level, 138.9 ± 37.0 mg/dL), 53 (62%) had high-risk CIMT (51% plaque, 11% CIMT > 75th percentile). In contrast, three women (3.5%) had CACS > 100, all of whom had plaque by CIMT. Of the 58 women with CACS of 0, 32 (55%) had high-risk CIMT (48% plaque, 7% CIMT > 75th percentile). CONCLUSIONS: In patients referred by their physicians for assessment of CV risk, CIMT in asymptomatic middle-aged women with at least one CV risk factor and low risk by the Framingham risk score identified a large number with advanced subclinical atherosclerosis despite low CACS. Our results suggest that CIMT may be a more sensitive method for CV risk assessment than CACS or traditional risk tools in this population. Further studies are needed to determine if earlier detection would be of clinical benefit.

Hiatal Hernia Is Associated With an Increased Prevalence of Atrial Fibrillation in Young Patients.

Purpose: Hiatal hernia (HH) causes protrusion of the stomach into the chest cavity, directly impinging on the left atrium and possibly increasing predisposition to atrial arrhythmogenesis. However, such association has not been fully explored. The objective was to determine if an association between HH and atrial fibrillation (AF) exists and whether there are age- and sex-related differences. Methods: Adult patients diagnosed with HH from 1976 to 2006 at Mayo Clinic Rochester, Minnesota, were evaluated for AF. The number of patients with AF and HH was compared to age- and sex-matched patients with AF reported in the general population. Long-term outcomes were compared to corresponding county and state populations. Results: During the 30-year period, 111,429 patients were diagnosed with HH (mean age 61.4 ± 13.8 years, 47.9% male) and 7,865 patients (7.1%) also had a diagnosis of AF (mean age 73.1 ± 10.5 years; 55% male). In younger patients (<55 years), the occurrence of AF was 17.5-fold higher in men with HH and 19-fold higher in women with HH compared to the frequency of AF reported in the general population. Incidence of heart failure for patients with AF and HH was worse compared to the overall county population, but better than for those with AF. Similarly, mortality was worse in patients with AF and HH compared to the overall state population, but better than for those with AF in the county. Conclusion: Hiatal hernia appears to be associated with increased frequency of AF in both men and women of all age groups, but particularly in young patients. Further studies are needed to investigate this possible association and underlying mechanism.

Long-term risk of atrial fibrillation with symptomatic gastroesophageal reflux disease and esophagitis.

The mechanisms underlying the triggers and maintenance of atrial fibrillation (AF) are not fully understood. One potential unproved mechanism is that gastroesophageal reflux disease (GERD), in which acid reflux induces local and systemic inflammation, may increase triggered activity in the myocardium and pulmonary veins and increase AF risk. A self-report questionnaire was mailed to a random sample of 5,288 residents of Olmsted County, Minnesota, aged 25 to 74 years to assess the presence and frequency of GERD from 1988 to 1994. The long-term risk for AF over a period of 11.4 +/- 5.0 years was determined through review of clinical evaluations and the electrocardiographic database in those without previous AF. The average age was 53 +/- 17 years, and 2,571 subjects (49%) were man. Of these patients, 741 developed AF (cumulative probability of AF at 18 years 20%, 95% confidence interval [CI] 17% to 22%). Age (hazard ratio [HR] 1.09, 95% CI 1.08 to 1.10, p <0.001), male gender (HR 1.81, 95% CI 1.53 to 2.14, p <0.001), hypertension (HR 1.36, 95% CI 1.14 to 1.61, p = 0.0006), and heart failure (HR 1.74, 95% CI 1.16 to 2.60, p = 0.007) were independently associated with the risk of AF. The presence of any GERD was not associated with risk for AF (HR 0.81, 95% CI 0.68 to 0.96, p = 0.014) after adjustment for other risk factors. The frequency of GERD did not significantly affect the risk for AF, although patients with more frequent GERD had a slightly higher AF risk. Esophagitis increased the risk for AF (HR 1.94, 95% CI 1.35 to 2.78, p <0.001), but the association did not persist when accounting for other risk factors (p = 0.72). In conclusion, in this large population-based study of patients surveyed for GERD, no association was found with the presence or frequency of symptoms and AF. Patients with esophagitis were more likely to develop AF, although this association requires further study.