James Mathew

Prevention of Heart Failure in Patients in the Heart Outcomes Prevention Evaluation (HOPE) Study

Background—Previous trials in the prevention of heart failure have been restricted to patients with low ejection fraction or hypertension. We assessed an angiotensin-converting enzyme (ACE) inhibitor, ramipril, to prevent the development of heart failure in high-risk patients without known low ejection fraction or heart failure. Methods and Results—We randomly assigned 9297 patients to receive double-blind ramipril (10 mg daily) or matching placebo for 4.5 years. Death attributable to heart failure, hospitalization for heart failure, initiation of open-label ACE inhibitor for heart failure, or development of typical signs or symptoms of heart failure developed in 951 patients and was associated with a 4.01-fold increase in the risk of death (P <0.0001). The rate of developing heart failure was significantly increased with coronary disease (risk ratio, 2.17), microalbuminuria (1.82), left ventricular hypertrophy (1.47), increasing age (by decade, 1.37), and diabetes (1.36). Ramipril reduced new-onset heart failure rate from 11.5% to 9.0% (relative risk, 0.77; 95% CI, 0.68 to 0.87;P <0.0001). Ramipril consistently reduced heart failure rate both in those with (relative risk, 0.87) and those without an interim myocardial infarction (relative risk, 0.78). Ramipril also reduced the heart failure rate more in patients with baseline systolic pressure above the median (139 mm Hg) (relative risk, 0.67) compared with those below the median (relative risk, 0.91;P =0.024 for interaction of group by treatment). Conclusion—Ramipril significantly reduces the rate of development of heart failure in patients at high risk of cardiovascular events.

Physical activity levels, ownership of goods promoting sedentary behaviour and risk of myocardial infarction: results of the INTERHEART study

AIMS To evaluate the association between occupational and leisure-time physical activity (PA), ownership of goods promoting sedentary behaviour, and the risk of myocardial infarction (MI) in different socio-economic populations of the world. Studies in developed countries have found low PA as a risk factor for cardiovascular disease; however, the protective effect of occupational PA is less certain. Moreover, ownership of goods promoting sedentary behaviour may be associated with an increased risk. METHODS In INTERHEART, a case-control study of 10 043 cases of first MI and 14 217 controls who did not report previous angina or physical disability completed a questionnaire on work and leisure-time PA. RESULTS Subjects whose occupation involved either light [multivariable-adjusted odds ratio (OR) 0.78, confidence interval (CI) 0.71-0.86] or moderate (OR 0.89, CI 0.80-0.99) PA were at a lower risk of MI, whereas those who did heavy physical labour were not (OR 1.02, CI 0.88-1.19), compared with sedentary subjects. Mild exercise (OR 0.87, CI 0.81-0.93) as well as moderate or strenuous exercise (OR 0.76, CI 0.69-0.82) was protective. The effect of PA was observed across countries with low, middle, and high income. Subjects who owned both a car and a television (TV) (multivariable-adjusted OR 1.27, CI 1.05-1.54) were at higher risk of MI compared with those who owned neither. CONCLUSION Leisure-time PA and mild-to-moderate occupational PA, but not heavy physical labour, were associated with a reduced risk, while ownership of a car and TV was associated with an increased risk of MI across all economic regions.

Relationship of electrocardiographic left ventricular hypertrophy to mortality and cardiovascular morbidity in high-risk patients

Background The prognostic significance of left ventricular hypertrophy (LVH) identified by simple electrocardiographic (ECG) criteria in high-risk patients with established cardiovascular (CV) diseases is not clearly understood. Design and methods The Heart Outcomes Prevention Evaluation (HOPE) trial was a randomized trial, which evaluated the effects of ramipril and of vitamin E on major CV outcomes in 9541 men and women aged 55 years or older with a history of coronary artery disease, stroke, peripheral vascular disease or diabetes mellitus with at least one additional CV risk factor. Patients were followed for an average of 4.5 years. We evaluated the association between simple ECG criteria for LVH and the risk for major vascular events, for CV and all-cause mortality and for heart failure. Results Electrocardiographic LVH was present in 793 (8.3%) HOPE study participants. Of these, 19.0% sustained a major CV event (MI, stroke or CV death), 15.6% died and 6.1% developed heart failure compared with 15.6%, 10.8% and 2.9% respectively of those without ECG-LVH (P = 0.0023; P < 0.0001 and P < 0.0001). In multivariate analysis ECG-LVH was an independent predictor of CV and all-cause death and of heart failure. Conclusions In patients with CV disease simple, easily applicable ECG criteria for LVH identify a subset of individuals at particularly high risk for death and for heart failure.

Etiology and characteristics of congestive heart failure in blacks

In this study of 301 black patients with congestive heart failure (CHF), systemic hypertension is the most common cause of CHF and is the primary etiology of CHF in 61%. Left ventricular hypertrophy is highly prevalent and is seen in 63% of the patients who had an echocardiogram.

The Prognostic Significance of Bundle Branch Block in High‐Risk Chronic Stable Vascular Disease Patients: A Report from the HOPE Trial

Objective: The prognostic significance of left and right bundle branch block (LBBB and RRBB) in patients with chronic stable cardiovascular (CV) disease is not well characterized and was evaluated in the Heart Outcomes Prevention Evaluation (HOPE) study cohort.

Clinical and angiographic findings in black patients with suspected coronary artery disease

To determine the clinical variables and coronary angiographic findings in black patients with suspected coronary artery disease, we analyzed the data on consecutive black patients undergoing their first coronary angiogram over a three year period at the Cook County Hospital, Chicago, Illinois. We compared these findings to those of black and white patients from previous studies. There were 654 patients with a mean age+/-standard deviation of 56+/-10 years; 309 (47%) were men. Two hundred nineteen patients (33%) presented with unstable angina, 75 patients (12%) with acute myocardial infarction and 338 patients (52%) with chronic stable angina. Three hundred forty-six patients (53%) had 50% or greater stenosis in at least one of the major vessels. Among the patients with coronary artery disease, 128 patients (37%) had one vessel disease, 102 patients (29%) had two-vessel disease, and 116 patients (34%) had three-vessel disease. Black patients who undergo coronary angiography for suspected coronary artery disease have a high frequency of normal coronary angiogram or non-obstructive coronary artery disease. The frequency of 1-, 2- and 3-vessel disease in blacks with coronary artery disease is comparable to those observed in whites in previous reports.

Lessons learned from the DIG trial

The Digitalis Investigation Group (DIG) trial was the first large simple trial conducted by the National Heart, Lung, and Blood Institute in conjunction with the Department of Veterans Affairs. A large simple trial is a major undertaking. Simplification at the sites requires careful planning and discipline. Lessons learned from the DIG trial were: (1) keep a large simple trial very simple and keep all study procedures very simple; (2) ancillary studies are important and can complement a large simple trial but require careful advanced planning; (3) anticipate special needs when shipping study drugs internationally; (4) regional coordinating centers can be very useful; (5) recruit as many capable sites as possible; (6) provide research-inexperienced sites/investigators with extra help to obtain federalwide assurance statements from the Office for Human Research Protections and institutional review board approvals; (7) adequately reimburse sites for the work completed; (8) maintain investigator enthusiasm; (9) monitor the slow performers and sites with numerous personnel changes; (10) choose an endpoint that is easy to ascertain; (11) keep the trial simple for participants; and (12) plan early for closeout and for activities between the end of the trial and publication of results.

Fungal Mass on the Tricuspid Valve

A 33-year-old man with a history of intravenous drug use was admitted to the hospital with fever, cough, and shortness of breath lasting for about 4 weeks. Physical examination was remarkable for evidence of tricuspid valve (TV) regurgitation. A transthoracic echocardiogram revealed a mass …