OBJECTIVE This study examined the prognostic significance of diabetes and microvascular complications in patients with heart failure with preserved ejection fraction (HFpEF). RESEARCH DESIGN AND METHODS This analysis included 3,385 patients (mean age 69±9.6 years; 49%male; 89%white) with HFpEF fromthe Treatment of Preserved Cardiac Function Heart FailureWith an Aldosterone Antagonist Trial (TOPCAT). Diabetes and microvascular complications were ascertained by self-reported history and medical record review.Microvascular complications included neuropathy, nephropathy, and retinopathy. Outcomes included hospitalization, hospitalization for heart failure, death, and cardiovascular death. Cox regressionwas used to examine the risk of each outcome associatedwith diabetes and microvascular complications. RESULTS Of the 1,109 subjects (32%) with diabetes, 352 (32%) had at least one microvascular complication. Patients with diabetes and microvascular complications had an increased risk for hospitalization (no diabetes: Referent; diabetes + no microvascular complication: Hazard ratio [HR] 1.18, 95% CI 1.01, 1.37; diabetes + microvascular complications: HR 1.54, 95% CI 1.25, 1.89; P-trend <0.001), hospitalization for heart failure (no diabetes: Referent; diabetes + no microvascular complication: HR 1.51, 95%CI 1.14, 1.99; diabetes + microvascular complications: HR 1.97, 95%CI 1.38, 2.80; P-trend <0.001), death (no diabetes: Referent; diabetes + no microvascular complication: HR 1.35, 95% CI 1.04, 1.75; diabetes + microvascular complications: HR 1.73, 95%CI 1.22, 2.45; P-trend = 0.0017), and cardiovascular death (no diabetes: Referent; diabetes + no microvascular complication: HR 1.34, 95% CI 0.96, 1.86; diabetes + microvascular complications: HR 1.70, 95% CI 1.09, 2.65; P-trend = 0.018). When the analysis was limited to participants who reported prior hospitalization for heart failure (n = 2,449), a higher risk of rehospitalization for heart failure was observed across diabetes categories (no diabetes: Referent; diabetes + no microvascular complication: HR 1.40, 95%CI 1.01, 1.96; diabetes +microvascular complications:HR 1.78, 95% CI 1.18, 2.70; P-trend = 0.0036). CONCLUSIONS Diabetes is associated with adverse cardiovascular outcomes in HFpEF, and the inherent risk of adverse outcomes in HFpEF patients with diabetes varies by the presence of microvascular complications.
Background—Food deserts (FDs), defined as low-income communities with limited access to healthy food, are a growing public health concern. We evaluated the impact of living in FDs on incident cardiovascular events. Methods and Results—We recruited 4944 subjects (age 64±12, 64% male) undergoing cardiac catheterization into the Emory Cardiovascular Biobank. Using the US Department of Agriculture definition of FD, we determined whether their residential addresses had (1) poor access to healthy food, (2) low income, or (3) both (=FD). Subjects were prospectively followed for a median of 3.2 years for myocardial infarction (MI) and death. Fine and Gray’s subdistribution hazard models for MI and Cox proportional hazard models for death/MI were used to examine the association between area characteristics (FD, poor access, and low income) and the rates of adverse events after adjusting for traditional risk factors. A total of 981 (20%) lived in FDs and had a higher adjusted risk of MI (subdistribution hazard ratio, 1.44 [95% CI, 1.06–1.95]) than those living in non-FDs. In a multivariate analysis including both food access and area income, only living in a low-income area was associated with a higher adjusted risk of MI (subdistribution hazard ratio, 1.40 [1.06–1.85]) and death/MI (hazard ratio, 1.18 [1.02–1.35]) while living in a poor-access area was not significantly associated with either (subdistribution hazard ratio, 1.05 [0.80–1.38] and hazard ratio, 0.99 [0.87–1.14], respectively). Conclusions—Living in an FD is associated with a higher risk of adverse cardiovascular events in those with coronary artery disease. Specifically, low area income of FDs, not poor access to food, was significantly associated with worse outcomes.
Background--With the recent implementation of the Medicare Quality Payment Program, providers face increasing accountability for delivering high-quality care. Such pay-for-performance programs aim to leverage systematic data captured by electronic health record (EHR) systems to measure performance; however, the fidelity of EHR query for assessing performance has not been validated compared with manual chart review. We sought to determine whether our institution's methodology of EHR query could accurately identify cases in which providers failed to prescribe statins for eligible patients with coronary artery disease. Methods and Results--A total of 9459 patients with coronary artery disease were seen at least twice at the Emory Clinic between July 2014 and June 2015, of whom 1338 (14.1%, 95% confidence interval 13.5-14.9%) had no statin prescription or exemption per EHR query. A total of 120 patient cases were randomly selected and reviewed by 2 physicians for further adjudication. Of the 120 cases initially classified as statin prescription failures, only 21 (17.5%; 95% confidence interval, 11.7-25.3%) represented true failure following physician review. Conclusions--Sole reliance on EHR data query to measure quality metrics may lead to significant errors in assessing provider performance. Institutions should be cognizant of these potential sources of error, provide support to medical providers, and form collaborative data management teams to promote and improve meaningful use of EHRs. We propose actionable steps to improve the accuracy of EHR data query that require hypothesis testing and prospective validation in future studies.
The pooled cohort Atherosclerotic Cardiovascular Disease (ASCVD) risk calculator is designed to improve cardiovascular risk estimation compared with the Framingham Risk Score, particularly in blacks. Although the ASCVD risk score better predicts mortality and incident cardiovascular disease in blacks, less is known about its performance for subclinical vascular disease measures, including arterial stiffness and carotid intima-media thickness. We sought to determine if the ASCVD risk score better identifies subclinical vascular disease in blacks compared with the Framingham risk score. We calculated both the Framingham and ASCVD cohort risk scores in 1,231 subjects (mean age 53 years, 59% female, 37% black) without known cardiovascular disease and measured the extent of arterial stiffness, as determined by pulse wave velocity (PWV), central pulse pressure (CPP), and central augmentation index (CAIx), and subclinical atherosclerosis, as determined by carotid-IMT (C-IMT). Compared with whites, blacks had higher CAIx (23.9 ± 10.2 vs 22.1 ± 9.6%, p = 0.004), CPP (36.4 ± 10.5 vs 34.9 ± 9.8 mmHg, p = 0.014), PWV (7.6 ± 1.5 vs 7.3 ± 1.3 m/s, p = 0.004), and C-IMT (0.67 ± 0.10 vs 0.65 ± 0.10 mm, p = 0.005). In a multivariable analysis including race and Framingham risk score, race remained an independent predictor of all measures of subclinical vascular disease; however, models with race and the ASCVD risk score showed that race was not an independent predictor of subclinical vascular disease. In conclusion, greater subclinical vascular disease in blacks was not estimated by the Framingham risk score. The new ASCVD risk score provided a better estimate of racial differences in vascular function and structure.
Background: Strong evidence supports positive correlation of physical activity with health benefits. Current recommendations by the American Heart Association are a minimum 30 minutes of moderate physical activity 5 days per week. This goal has been equilibrated with 10,000 steps per day.
Hypothesis: Work-related physical activity of cardiovascular (CV) specialists does not meet the currently recommended daily physical activity.
Methods: Eight cardiothoracic (CT) surgeons, 7 general cardiologists, 5 procedural cardiologists, and 8 cardiac anesthesiologists (N = 28) participated in the study. Demographic information on each participant was recorded including age, resting heart rate, body mass index, and medical and social history. Subjects were asked to wear a spring-levered pedometer on their hip for 2 weeks while at work and to record the total number of steps as well as number of hours worked each day.
Results: The average daily steps walked during work were 6540, 6039, 5910, and 5553 for general cardiologists, CT surgeons, procedural cardiologists, and cardiac anesthesiologists, respectively. There were no statistically significant differences in the average number of steps taken per day among the groups. CT surgeons worked 12.4 hours per day compared to 9.3 hours by the cardiac anesthesiologists (P = 0.03).
Conclusions: In this small, single-center study, work-related physical activity of CV specialists did not meet the recommended guidelines. Obtaining the recommended activity level might be a challenge, given their busy work schedule. Therefore, CV specialists must engage in additional, out-of-hours exercise to achieve the recommended daily exercise.
Cardiovascular disease (CVD) remains the leading cause of death in the United States. Healthcare expenditures have been principally allocated toward treatment of CVD at the end of the health/disease continuum, rather than toward health promotion and disease prevention. A focused effort on both primordial and primary prevention can promote cardiovascular health and reduce the burden of CVD. Risk-factor assessment for predicting atherosclerotic CVD events serves as the foundation of preventive cardiology and has been driven by population-based scoring algorithms based on traditional risk factors. Incorporating individual nontraditional risk factors, biomarkers, and selective use of noninvasive measures may help identify more at-risk patients as well as truly low-risk individuals, allowing for better targeting of treatment intensity. Using a combination of validated population-based atherosclerotic CVD risk-assessment tools, nontraditional risk factors, social health determinants, and novel markers of atherosclerotic disease, we should be able to improve our ability to assess CVD risk. Through scientific evidence, clinical judgment, and discussion between the patient and clinician, we can implement an effective evidence-based strategy to assess and reduce CVD risk.
Individuals age >65 years represent the fastest-growing subpopulation in the United States. Although these individualswith the highest cardiovascular risk profile would be anticipated to be themost aggressively treated, paradoxically, treatment and baseline risk are inversely related. Presumably, the elderly population would benefit from high-intensity statin therapy; however, as per the 2013 American College of Cardiology/American Heart Association guidelines, given the scarcity of evidence in patients age >75, there are only sufficient data from randomized controlled trials to support use of moderate-intensity statin therapy for secondary prevention. Despite evidence demonstrating statins are beneficial in the elderly, the decision to initiate and sustain treatment should be a well-informed and collaborative decision. One must balance the benefits (secondary atherosclerotic cardiovascular prevention, stroke reduction, decreased morbidity and mortality) with the potential risks to the elderly (altered metabolism, comorbidities, polypharmacy and drug-drug interactions, side effects, cognitive limitations, and cost).
Evidence for the role of inflammation in the pathogenesis of atherosclerosis is compelling and has generated interest in high-sensitivity C-reactive protein (hs-CRP) as a marker of cardiovascular risk. Data regarding hs-CRP and cardiovascular risk, though largely consistent, is of unclear clinical relevance. Most recently, the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) trial has led to further debate regarding the utility of hs-CRP. This article provides a comprehensive review of the data regarding cardiovascular risk and hs-CRP with an emphasis on the JUPITER trial and concludes with an evidence-based analysis of the current role of hs-CRP in cardiovascular risk assessment.
As the population ages and our ability to care for patients with cardiac disease improves, an increasing number of passengers with cardiovascular conditions will be traveling long distances. Many have had cardiac symptoms, recent interventions, devices, or surgery. Air travel is safe for most individuals with stable cardiovascular disease. However, a thorough understanding of the physiologic changes during air travel is essential given the potential impact on cardiovascular health and the risk of complications in passengers with preexisting cardiac conditions. It is important for clinicians to be aware of the current recommendations and precautions that need to be taken before and during air travel for passengers with cardiovascular concerns.