John Pantazopoulos

Trends in Mortality of Acute Myocardial Infarction After Discharge From the Hospital

Background—We assessed trends in the prognosis of patients with acute myocardial infarction hospitalized in New Jersey hospitals. In recent decades, in-hospital mortality has declined markedly but the decline in longer-term mortality is less pronounced, implying that mortality after discharge has worsened. Methods and Results—Using the Myocardial Infarction Data Acquisition System (MIDAS), we examined the outcomes of 285 397 patients hospitalized for a first acute myocardial infarction between 1986 and 2007. Mortality at discharge decreased by 9.4% from 16.9% to 7.5% (annual change, −0.44; 95% confidence interval, −0.49 to −0.40), but the decrease at 1 year was less pronounced (6.4%) because of an increase in mortality from discharge to 1 year after discharge (from 12.1% to 13.9%; annual change, +0.15; 95% confidence interval, +0.10 to +0.20). Mortality from 30 days after discharge to 1 year, a measure not affected by length of stay, increased by 1.2% (annual change, +0.10; 95% confidence interval, +0.06 to +0.23). The effect was more evident in the older age groups and was due to noncardiovascular mortality, especially from respiratory and renal diseases, septicemia, and cancer. All effects remained statistically significant (P<0.0001) after adjustment for demographics, comorbidities, infarction type, complications, and interventions. Piecewise linear regressions confirmed these trends. Conclusions—Postdischarge mortality of patients with acute myocardial infarction is increasing, primarily because of higher noncardiovascular mortality in the older age groups.

Visit‐to‐Visit Blood Pressure Variability and Cardiovascular Death in the Systolic Hypertension in the Elderly Program

Most studies of an association of visit‐to‐visit variability of blood pressure with increased risk of future adverse cardiovascular events are of short duration and rarely include a placebo group. Using data from the double‐blind, placebo‐controlled Systolic Hypertension in the Elderly Program, the authors examined mortality from cardiovascular causes up to 17 years of follow‐up using the National Death Index. Visit‐to‐visit blood pressure variability was associated with cardiovascular death after adjustment for sex, age, serum creatinine, diabetes, body mass index, smoking status, left ventricular failure, and high‐density lipoprotein cholesterol. The relationship was significantly stronger in the active treatment group compared with the placebo group. Although this could be the result of an effect of the medications used unrelated to visit‐to‐visit variability, the data are compatible with the hypothesis that inconsistent adherence leading to missing active medication doses may be an additional explanation for the relationship of visit‐to‐visit variability with cardiovascular death.

Cardiovascular outcomes after preeclampsia or eclampsia complicated by myocardial infarction or stroke.

OBJECTIVE: To assess the relationship between preeclampsia or eclampsia and stroke, myocardial infarction (MI), subsequent cardiovascular outcomes, and long-term survival. METHODS: Using the Myocardial Infarction Data Acquisition System in New Jersey (1994–2009), we analyzed cardiovascular outcomes in women with and without preeclampsia or eclampsia and a first MI or stroke but with a hospitalization for a first MI or stroke (analysis 1: MI case group, n=57; MI control group, n=155; stroke case group, n=132; stroke control group, n=379). We also compared these outcomes in women with preeclampsia or eclampsia and a first MI or stroke during pregnancy with women with preeclampsia or eclampsia without MI or stroke during pregnancy (analysis 2: MI case group, n=23; MI control group, n=67; stroke case group, n=90; stroke control group, n=263). A subsequent occurrence of MI, stroke, and cardiovascular death, as well as a combined cardiovascular outcome, was ascertained. RESULTS: In analysis 1, women with preeclampsia or eclampsia were at significantly lower risk for combined cardiovascular outcome with all deaths (frequency of outcome 16.7%) and with cardiovascular deaths (10.6%) compared with women without preeclampsia or eclampsia after a first stroke (33.8% and 23.5%, respectively). In analysis 2, women with preeclampsia or eclampsia and a first stroke during admission were at significantly higher risk of all death (11.1%) and the combined cardiovascular outcome with all deaths (11.1%) compared with women with preeclampsia or eclampsia without a stroke (1.9% and 2.7%, respectively) during that admission. CONCLUSION: Our study indicates that preeclampsia or eclampsia not complicated by MI or stroke during pregnancy may not confer a very high risk for subsequent MI and stroke in up to 16 years of follow-up. Our data suggest that other known risk factors put women at greater risk for stroke than preeclampsia or eclampsia complicated by a stroke. LEVEL OF EVIDENCE: II

Cardiovascular outcomes in patients with intraventricular conduction blocks: A sixteen-year follow-up in a state-wide database

BACKGROUND To assess the adverse clinical effects of left anterior hemiblock alone or in combination with right bundle branch block and of complete left bundle branch block in comparison with isolated right bundle branch block and the relationship of these effects with altered mechanoelectric factors resulting in left ventricular dysfunction. METHODS In a 16-year follow-up study using a statewide database, we studied the occurrence of mortal and morbid cardiovascular (CV) events among patients without apparent ischemic heart disease who had left anterior hemiblock (LAHB, n=4273, right bundle branch block (RBBB) with LAHB (BFBB, n=1857) and left bundle branch block (LBBB, n=9484 compared to isolated RBBB (n=25288). RESULTS After adjustment for demographics, co-morbidities and insurance, LAHB was associated with a significant excess risk of all-cause death (HR 1.134, 95% CI 1.061-1.213, p=0.0002) and CV death (HR 1.329, 95% CI 1.174-1.501, p<0.0001). BFBB was associated with excess HF (HR 1.190, 95% CI 1.048-1.351, p<0.0071), all-cause death (HR 1.440, 95% CI 1.045-1.252, p=0.0036) and CV death (HR 1.210, 95% CI 1.020-1.436, p<0.0001). LBBB was associated with an excess risk of MR (HR 1.307, 95% CI 1.116-1.530, p<0.0009), HF 1.177, 95% CI1.097-1.263, p<0.0001) and CV death (HR 1.220, 95% CI 1.106-1.345, p<0.0001). CONCLUSIONS In patients without apparent ischemic heart disease, the presence of LAHB alone or in combination with RBBB imparts increased risk of CV and all-cause death compared to isolated RBBB. BFBB is also associated with an increased risk of HF.

STEEP DECREASE IN THE RATE OF MYOCARDIAL INFARCTION FROM 2000 TO 2008

Background: The incidence of myocardial infarction (MI) has been decreasing for several decades. However, scant data are available on whether this decline has been magnified, diminished, or remained stable over the recent 15 year period. Methods: Using the Myocardial Infarction Data Acquisition

LEFT AXIS DEVIATION AS A RISK MARKER IN PATIENTS WITHOUT ISCHEMIC HEART DISEASE

Previous studies on the prognostic value of left axis deviation in patients with or without ischemic heart disease are inconclusive. Using the Myocardial Infarction Data Acquisition System (MIDAS), a statewide database of hospitalized patients, we studied long-term outcomes of left axis deviation in

ASSOCIATION OF ORTHOSTATIC HYPERTENSION WITH MORTALITY IN THE SYSTOLIC HYPERTENSION IN THE ELDERLY PROGRAM

History and physical, target organ damage, and biomarkers are used to estimate risk in patients with hypertension. Orthostatic hypertension is a marker of elevated risk that can be identified during physical examination but is not usually appreciated by clinicians. Vital status and cause of death

POST PROCEDURAL STROKE IN CORONARY ARTERY BYPASS GRAFTING AND PERCUTANEOUS INTERVENTIONS: AN 11 YEAR STATEWIDE ANALYSIS

Stroke is a catastrophic complication of coronary artery revascularization. Data comparing stroke incidence with on pump (ONP) versus off pump (OFFP) coronary artery bypass grafting (CABG) are conflicting, as are the rates of stroke with ONP and OFFP CABG versus percutaneous coronary intervention (

A Normal Coronary Arteriogram at Age 65 and Older: Does It Fortell a Long Survival?

A normal coronary arteriogram (CA) has been reported to confer a good prognosis. However, how this applies to patients (Pts) age 65 and older is not well known. Between 1986 -1996, 11,625 CA were performed on Pts 65 and older. We identified 217 with either normal (NORM, n=159) coronary arteries or

THE RELATIONSHIP BETWEEN BODY MASS INDEX AND MORTALITY AMONG 60,000 CORONARY ARTERY BYPASS GRAFT PATIENTS; DOES THE OBESITY PARADOX EXIST?

Results: Of a total of 60,635 pts, 27.3% were women and 85.2% White. 21.9% had normal BMI, 42.3% were overweight and 35.8% were obese. Average age was 66. Overweight and obese pts were younger, less likely to be women or smokers and to have myocardial infarction, left main disease, heart failure, chronic renal disease, cerebrovascular disease and chronic lung disease. They were more likely to have diabetes and hypertension. Post CABG mortality at 30 days, 90 days and between 90 days and 2 years was higher (p <0.0001 for all) in normal BMI pts than in either the overweight or obese group. Multivariate analyses indicated that mortality among normal BMI pts was significantly higher at 90 days and even more so at 2 years after CABG surgery (see figure).