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Valentina Boyko

Publications and source records attributed to Valentina Boyko.

At least 37 records · Page 2Linked to original sources
PubMed2005

Monocyte chemoattractant protein-1 and recurrent cardiovascular events in patients with stable coronary heart disease.

BACKGROUND: Monocyte chemoattractant protein-1 (MCP-1) participates in the recruitment of mononuclear cells to the vessel wall. HYPOTHESIS: The aim of the study was to evaluate the potential association between serum concentration of MCP-1 and risk of future cardiovascular events in patients with chronic coronary heart disease. METHODS: A nested case control design was used. Baseline serum samples were taken from patients with coronary heart disease who were enrolled in a secondary prevention study. The MCP-1 levels were measured in those patients who had recurrent cardiovascular events during follow-up (n = 233) and compared with levels in age- and gender-matched controls. RESULTS: There were no differences in serum MCP-1 levels between cases and controls. The relative odds of a recurrent cardiovascular event for each 1 standard deviation difference in MCP-1 serum concentration (160 pg/ml) was 1.19 (95% confidence interval, 0.95-1.45). No increase in the relative odds for recurrent cardiovascular events was observed per increasing tertiles of MCP-1 concentrations. CONCLUSION: Elevated MCP-1 levels are not associated with long-term risk of cardiovascular events in patients with stable coronary disease.

Aged↗
PubMed2005

Does current treatment of cardiogenic shock complicating the acute coronary syndromes comply with guidelines?

BACKGROUND: The purpose of our study was to evaluate the implementation of guidelines for the treatment of cardiogenic shock (CS) complicating the acute coronary syndromes (ACS). METHODS AND RESULTS: Of the 10 136 patients in the Euro-Heart-Survey-ACS with complete data, CS occurred in 549 (5.4%), of whom 28.6% had CS upon presentation. We examined the use of coronary angiography (CA), percutaneous (PCI) and surgical (CABG) revascularization, and intra-aortic balloon counterpulsation (IABP) among ACS patients with and without CS. During the hospital course, there were no significant differences between patients with and without CS in referral to CA (52.4% vs 53.3%, respectively) or CABG (4.4% vs 4.5%), but CS patients were more likely to undergo IABP (17.7% vs 0.8%, P < .001) and PCI (40.8% vs 31.8%, P < .001), especially younger (<75 years) patients (52.2% vs 31.8%, P < .001). A similar trend was observed when comparing ST-elevation-ACS patients with (368 [8.5%]) and without CS (3945): CA (58.1% vs 56.2%), CABG (3.6% vs 3.3%), IABP (20.0% vs 0.9%, P < .01), and PCI (47.3% vs 40.6%, P < .01; 54.4% vs. 44.6% for patients <75 years, P < .003). Of the 94 ST-elevation-ACS patients presenting with CS, only 39 (41.4%) received any reperfusion treatment, more often fibrinolysis (64.1%). The in-hospital mortality was 52.1% for all CS pts vs 2.0% for all others ( P < .001). CONCLUSIONS: Our contemporary survey demonstrates prohibitively-high mortality rates among ACS patients complicated by CS and poor implementation of recent guidelines advocating an aggressive invasive approach, including low rates of revascularization and IABP. Improved adherence to the guidelines pertaining to ACS patients developing CS may hopefully improve outcomes.

Aged↗
PubMed2004

The outcome of coronary artery bypass grafting surgery among patients hospitalized with acute coronary syndrome: the Euro Heart Survey of acute coronary syndrome experience.

AIM: To determine the frequency and outcomes of coronary artery bypass graft (CABG) surgery in patients with a wide spectrum of acute coronary syndromes (ACS). METHODS AND RESULTS: We prospectively enrolled 10,484 ACS patients from 103 hospitals in 25 countries across Europe and the Mediterranean basin. Of the 10,204 patients with complete data, 460 (4.5%) underwent CABG while in hospital; 3.4% had ST elevation ACS, 5.4% had non-ST elevation ACS, and 4.4% had undetermined ECG ACS (p=0.001 for non-ST elevation ACS vs. others). In general, patients who underwent CABG were more likely to be males, to have diabetes mellitus, hyperlipidemia, a positive family history of premature coronary disease, and prior angina pectoris, but had less often prior heart failure. While in hospital, all CABG patients underwent coronary angiography and 15.2% also underwent percutaneous revascularization, as compared with 51.3 and 33.1% in the remaining patients, respectively. The in-hospital mortality was 3.7% for ACS patients who underwent CABG and 4.8% for non-CABG ACS patients (p=nonsignificant) with an adjusted odds ratio of in-hospital death for CABG patients of 1.00 (95% CI 0.59-1.61). CONCLUSIONS: Approximately 4.5% of ACS patients underwent CABG during their initial hospitalization, with a greater likelihood among non-ST elevation ACS patients. Of the CABG patients, 15.2% also underwent percutaneous revascularization. The outcome of CABG patients was as good as non-CABG patients, indicating that CABG remains an effective and safe means to achieve revascularization among ACS patients in current clinical practice.

Aged↗
PubMed2004

Family history of coronary artery disease and prognosis after first acute myocardial infarction in a national survey.

A positive family history (FH) of coronary artery disease (CAD) is considered an independent risk factor for developing CAD. However, the natural history, coronary angiographic findings and prognosis of patients with a positive FH developing first acute myocardial infarction (AMI) are not well defined. A cohort of 2,690 consecutive patients with first AMI from two prospective nationwide surveys conducted during 1996 and 1998 in all coronary care units operating in Israel was studied. Baseline characteristics, hospital course, management and outcome of 405 patients with first AMI and a positive FH were compared with 2,285 controls without a positive FH. Coronary angiograms of patients with and without a positive FH were reviewed and compared. Patients with a positive FH were younger (53 vs. 64 years), more often male, current smokers and patients with hyperlipidemia, but less often patients with diabetes or hypertension than patients without a positive FH. Patients with a positive FH developed heart failure during hospital stay less frequently. Thrombolytic therapy was similarly administered to both groups. During the hospital stay, coronary angiography, percutaneous coronary intervention or coronary artery bypass grafting were more frequently performed in patients with a positive FH. The coronary anatomy and the extent of the CAD were similar in patients with and without a positive FH. Crude and covariate-adjusted mortality rates were significantly lower in patients with a positive FH than in patients without a positive FH on day 30 (2.2 vs. 9.6%, p < 0.001; odds ratio 0.50, 95% confidence interval 0.22-0.99) and at 1 year (3.5 vs. 14%, p < 0.001; hazard ratio 0.58, 95% confidence interval 0.42-0.80). Patients with a positive FH developed their first AMI more than 1 decade earlier in comparison to those without such a history. The extent of their coronary disease is similar to the older patients without a positive FH. The better prognosis of patients with a positive FH is mostly explained by their younger age.

Adult↗
PubMed2004

Long-term prognostic significance of left atrial volume in acute myocardial infarction.

OBJECTIVES: The aim of this study was to evaluate the significance of increased left atrial (LA) volume determined within the first 48 h of admission as a long-term predictor of outcome in patients with acute myocardial infarction (MI). BACKGROUND: The LA volume reflects left ventricular (LV) diastolic properties. Whereas other LV Doppler diastolic characteristics are influenced by acute changes in LV function, LA volume is stable and reflects diastolic properties before MI. METHODS: Clinical and echocardiographic parameters were prospectively collected in 395 consecutive patients with acute MI. Patients with LA volume index (LAVI) >32 ml/m(2) (normal + 2 standard deviations) were compared with those with LAVI <==32 ml/m(2). Independent clinical and echocardiographic prognostic risk factors for five years' mortality were determined by the Cox proportional hazard model. RESULTS: Left atrial volume index >32 ml/m(2) was found in 63 patients (19%) who had a higher incidence of congestive heart failure on admission (24% vs. 12%, p < 0.01), a higher incidence of mitral regurgitation, increased LV dimensions, and reduced LV ejection fraction when compared with patients with LAVI <==32 ml/m(2). Their five-year mortality rate was 34.5% versus 14.2% (p < 0.001). Significant independent risk predictors of five years' mortality were age (10 years) (odds ratio [OR] 1.45; 95% confidence interval [CI]1.14 to 1.86), Killip class >/=2 on admission (OR 2.30; 95% CI 1.29 to 4.09), LAVI >32 ml/m(2) (OR 2.22; 95% CI 1.25 to 3.96), diabetes (OR 1.94; 95% CI 1.15 to 3.28), and LV restrictive filling pattern (OR 1.89; 95% CI 1.09 to 3.31). CONCLUSIONS: In patients with acute MI, increased LA volume, determined within the first 48 h of admission, is an independent predictor of five-year mortality with incremental prognostic information to clinical and echocardiographic data.

Aged↗
PubMed2004

Peroxisome proliferator-activated receptor ligand bezafibrate for prevention of type 2 diabetes mellitus in patients with coronary artery disease.

BACKGROUND: Recent studies have shown that type 2 diabetes is preventable by both lifestyle interventions and medications that influence primary glucose metabolism. Whether pharmacological interventions that influence primary lipid metabolism can also delay development of type 2 diabetes is unknown. The goal of this study was to evaluate the effect of the peroxisome proliferator-activated receptor ligand bezafibrate on the progression of impaired fasting glucose phase to type 2 diabetes in patients with coronary artery disease over a 6.2-year follow-up period. METHODS AND RESULTS: The study sample comprised 303 nondiabetic patients 42 to 74 years of age with a fasting blood glucose level of 110 to 125 mg/dL (6.1 to 6.9 mmol/L). The patients received either 400 mg bezafibrate retard (156 patients) or placebo (147 patients) once a day. No patients were using statins, and use of ACE inhibitors, which also reduce diabetes incidence, was relatively low. During follow-up, development of new-onset diabetes was recorded in 146 patients: in 80 (54.4%) from the placebo group and 66 (42.3%) from the bezafibrate group (P=0.04). The mean time until onset of new diabetes was significantly delayed in patients on bezafibrate compared with patients on placebo: 4.6+/-2.3 versus 3.8+/-2.6 years (P=0.004). Multivariate analysis identified bezafibrate treatment as an independent predictor of reduced risk of new diabetes development (hazard ratio, 0.70; 95% CI, 0.49 to 0.99). Other significant variables associated with future overt type 2 diabetes in patients with impaired fasting glucose were total cholesterol level (hazard ratio, 1.22; 95% CI 1.0 to 1.51) and body mass index (hazard ratio, 1.10; 95% CI, 1.05 to 1.16). CONCLUSIONS: Bezafibrate reduces the incidence and delays the onset of type 2 diabetes in patients with impaired fasting glucose. Whether the combination of bezafibrate with other recommended drugs for secondary prevention (statins and ACE inhibitors) would be as efficacious as suggested by our results remains to be determined.

Aged↗
PubMed2004

Predictive value of elevated white blood cell count in patients with preexisting coronary heart disease: the Bezafibrate Infarction Prevention Study.

BACKGROUND: Inflammation is implicated in the pathogenesis of atherosclerosis and acute coronary syndromes. White blood cell (WBC) count increases during infections and inflammatory illnesses and has been shown to predict coronary heart disease (CHD) independent of traditional cardiovascular risk factors. This apparent association may reflect a relationship between the WBC count and other coronary risk factors. Studies in patients with CHD are scarce and give conflicting results. The aim of the present study was to investigate the association between WBC count and subsequent coronary events and total mortality in a large cohort of patients with CHD. METHODS: We evaluated the relationship between WBC count and 6-year risk of coronary events and mortality in a large cohort of patients with chronic CHD who were enrolled in a secondary prevention study of bezafibrate. RESULTS: In univariate analysis, WBC count was associated with an elevated 6-year risk of myocardial infarction, cardiac death, and total mortality. On multivariate adjustment, the positive association with risk of myocardial infarction and cardiac death was eliminated, but WBC count remained predictive of total mortality: relative risk, 1.47; 95% confidence interval, 1.13 to 1.92, in the upper tertile of WBC count (as compared with the lowest). For every 1000/ microL increase in WBC count, risk of total death increased by 6% (relative risk, 1.06; 95% confidence interval, 1.03-1.10). CONCLUSIONS: Elevated WBC count in patients with CHD was associated with higher long-term risk of all-cause mortality. This excess risk of mortality was not due to cardiac causes.

Bezafibrate↗
PubMed2004

Increased survival among severe trauma patients: the impact of a national trauma system.

HYPOTHESIS: The survival of severe trauma patients is affected by the implementation of a national trauma system, which brought about developments both at the hospital and prehospital levels during the past decade. DESIGN: A retrospective cohort study of all severely injured patients (Injury Severity Score >16) recorded in the Israeli National Trauma Registry at all level I trauma centers in Israel from January 1, 1997, to December 31, 2001. Inpatient death rates were examined overall and by subgroups. SETTING: The National Trauma Registry includes trauma (International Statistical Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes 800-959) hospitalizations, patients who were transferred to or from other hospitals, and those who died in the emergency department. It excludes patients who were dead on arrival, discharged following treatment in the emergency department, and patients who do not fall into the definition of trauma. Main Outcome Measure Inpatient death. RESULTS: Seven thousand four hundred twenty-three severe trauma patients were recorded. Inpatient death rates decreased significantly from 21.6% in 1997 to 14.7% in 2001. The odds ratios of mortality in 1998 through 2001 vs 1997, adjusted for year, age, sex, penetrating injury, and severity of injury (Injury Severity Score >25), were 0.92, 0.89, 0.70, and 0.65, respectively, confirming the downward trend. CONCLUSIONS: A steady significant reduction in the inpatient death rate of severe trauma patients hospitalized at all level I trauma centers in Israel between 1997 and 2001 was observed. Although a single factor that explains the reduction was not identified, it is evident that the establishment of the trauma system brought about a significant decrease in mortality. We believe that integrated cooperation of various components of the national trauma system in Israel across the years may explain the reduction.

Adolescent↗
PubMed2004

Anterior wall myocardial infarction in real world: does reperfusion strategy make any differences?

Some prospective randomized trials have established the superiority of primary percutaneous coronary intervention (PCI) over fibrinolytic treatment in patients with acute myocardial infarction (MI). These excellent PCI results are not duplicated in smaller hospitals where there may be delays in getting the cardiac catheterization team to the laboratory. This study aimed to compare the outcome of patients with anterior wall MI, without cardiogenic shock on admission, treated with primary PCI or thrombolytic therapy, in everyday practice. The data of all patients with MI hospitalized in all coronary care units operating in Israel during three consecutive national surveys was analyzed. A total of 1,038 patients with anterior wall MI were treated by reperfusion (886 received thrombolytic therapy, 152 primary PCI). Overall, the outcome of patients treated using primary PCI was better compared to patients treated with thrombolysis, with 68% relative risk reduction of 30-day mortality (mortality at 30 days: 2% vs. 6.3%; P = 0.04). A subanalysis of patients according to age showed that the beneficial effect of primary PCI on mortality was mainly clustered among the younger. In our study, patients (especially younger than 75 years) with anterior wall MI allocated to primary PCI have a better clinical outcome.

Age Factors↗
PubMed2004

High fasting glucose levels as a predictor of worse clinical outcome in patients with coronary artery disease: results from the Bezafibrate Infarction Prevention (BIP) study.

BACKGROUND: A high fasting glucose level may be a marker not only for microvascular complications, but also for macrovascular complications. We evaluated the clinical significance of a high fasting glucose level (> or =110 mg/dL), detected either at baseline or during follow-up, in the Bezafibrate Infarction Prevention (BIP) study. METHODS: The BIP study was a secondary prevention prospective double-blind study comparing bezafibrate to placebo. A total of 3122 patients with documented coronary artery heart disease who were aged 45 to 74 years and had a total cholesterol level between 180 and 250 mg/dL, low-density lipoprotein cholesterol level < or =180 mg/dL, a high-density lipoprotein cholesterol level < or =45 mg/dL, a triglyceride level < or =300 mg/dL, and a fasting glucose < or =160 mg/dL were randomized to receive 400 mg of bezafibrate daily or placebo. RESULTS: The primary end point of the BIP study was fatal myocardial infarction, non-fatal myocardial infarction, or sudden death. Secondary end points included hospitalization for unstable angina, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting. At baseline, 330 patients (11%) had diabetes mellitus, and 293 patients (9%) had an impaired fasting blood glucose level (IFG). During 6.2 years of follow-up, diabetes mellitus developed in 186 patients (6%), IFG developed in 366 patients (12%), and 62% of patients remained with normal fasting glucose levels (NFG). Patients with diabetes mellitus and IFG both at baseline or developing during follow-up had a significantly higher rate of secondary end points than paients with NFG (P <.0001). Bezafibrate treatment reduced secondary end points only in patients with NFG (P =.04). CONCLUSION: Diabetes mellitus and IFG were common in the BIP study and were predictive of a worse clinical outcome that was not attenuated with bezafibrate treatment.

Aged↗
PubMed2004

Acute coronary syndromes complicated by symptomatic and asymptomatic heart failure: does current treatment comply with guidelines?

BACKGROUND: Patients with acute coronary syndromes (ACS) complicated by heart failure (HF) are at increased risk of death. Treatment with angiotensin-converting enzyme inhibitors (ACEI), beta-blockers, and early invasive risk stratification are recommended for these patients. AIM: The purpose of the current study was to assess adherence to treatment guidelines of patients with ACS complicated by HF in Europe and the Mediterranean region. METHODS AND RESULTS: Of the 10,484 patients who participated in Euro-Heart ACS survey, 9587 had known HF status and were without cardiogenic shock; 7058 (74%) did not have symptomatic HF and 2529 (26%) presented with or developed symptomatic HF during hospitalization. HF patients were older and had more cardiovascular risk factors. ACEI were more commonly used in HF patients (75% vs 56%, P < .01), whereas beta-blockers were less frequently used (75% vs 82%, P < .01). Coronary angiography and in hospital revascularization rates were lower among HF patients (42% vs 57% for coronary angiography, P < .01, and 32% vs 42% for revascularization, P < .01). Similar trends were noticed among patients with left ventricular dysfunction (symptomatic and asymptomatic).Adjusted in-hospital mortality risk was higher among patients with ACS complicated by symptomatic HF regardless of electrocardiographic type of ACS: (ST-elevation ACS, OR 2.5, 95% CI 1.6-3.9; non-ST-elevation ACS, OR 8.9,95% CI 4.5-17.7; undetermined-ECG ACS, OR 9.3, 95% CI 2.5-34). CONCLUSIONS: Patients with ACS complicated by HF were at increased risk of dying. A relatively high percentage of HF patients were treated with ACEI and beta-blockers in accordance with current recommendations. Rates of coronary angiography and revascularization were significantly lower in ACS patients with HF versus those without HF, which potentially contributed to their worse mortality [corrected]

Adrenergic beta-Antagonists↗
PubMed2004

Chlamydia pneumoniae and future risk in patients with coronary heart disease.

AIM: To evaluate the association between previous exposure to Chlamydia pneumoniae and future coronary risk in patients with coronary heart disease. METHODS: A prospective, nested, case-control design was used. The patient sample was derived from a trial study of bezafibrate for the treatment of coronary heart disease. Anti-Chlamydia pneumoniae antibodies (IgG and IgA) in the baseline sera of 136 patients who had coronary events during follow-up (mean 6.2 years) were compared with those in 136 age- and gender-matched patients from the same trial without subsequent coronary events. RESULTS: Mean titers of IgG and IgA antibodies were similar in cases and controls. The relative odds of future coronary events in patients who were seropositive at baseline were 1.0 (95% CI, 0.54-1.84) for IgG and 0.74 (95% CI, 0.41-1.31) for IgA. The relative odds did not change after adjustment for multiple confounding variables. The risk of future coronary events did not increase with increasing anti-Chlamydia pneumoniae antibody titers. CONCLUSIONS: Prior exposure to Chlamydia pneumoniae in patients with chronic coronary heart disease is not associated with increased risk of recurrent coronary events.

Antibodies, Bacterial↗
PubMed2004

Treatment modalities of diabetes mellitus and outcomes of acute coronary syndromes.

BACKGROUND: Oral treatments for diabetes mellitus (DM) may have a deleterious effect on acute coronary syndromes (ACS) outcomes. AIM: We aimed to examine in-hospital mortality among patients with ACS and DM and the impact of anti-DM treatment modalities. METHODS AND RESULTS: The Euro Heart Survey ACS prospectively enrolled 10484 patients across Europe and the Mediterranean basin. Of the 10214 patients with recorded DM status, 2352 (23.0%) had DM, of whom 562 were on diet alone, 1112 received oral hypoglycaemics, 561 received insulin, and 117 received both. The in-hospital mortality for ST-elevation-ACS was 9.8 and 5.7% for patients with and without DM, respectively, with an adjusted risk (95% confidence interval) of in-hospital mortality of 1.6 (1.2, 2.1). The in-hospital mortality for non-ST-elevation-ACS was 2.8 and 2.0%, accordingly, with an adjusted risk (95% confidence interval) of in-hospital mortality of 1.2 (0.8, 1.9). The in-hospital mortality for undetermined-electrocardiographic-pattern-ACS was 11.5 and 10.9%, accordingly, with an adjusted risk of in-hospital mortality of 1.1 (0.6, 2.0). Among DM patients with ST-elevation-ACS, the adjusted risks of in-hospital mortality were 1.0 for diet therapy, 0.8 (0.4, 1.5) for oral hypoglycaemics, and 1.9 (1.0, 3.8) for insulin; for DM patients and non-ST-elevation-ACS, 1.0 for diet therapy, 2.2 (0.6, 7.8) for oral hypoglycaemics, and 3.5 (1.0, 12.5) for insulin; for DM patients and undetermined-electrocardiographic-pattern-ACS, the adjusted risks of in-hospital mortality were 1.0 for diet therapy, 0.9 (0.2, 4.6) for oral hypoglycaemics, and 2.1 (0.5, 9.5) for insulin. CONCLUSIONS: Acute coronary syndrome patients with DM, especially those with ST-elevation, had increased in-hospital mortality. Among ACS patients with DM, those receiving insulin had worse outcomes. Outcomes were similar for those on hypoglycaemics or on diet alone.

Acute Disease↗
PubMed2004

Is hypoglycaemia a marker for increased long-term mortality risk in patients with coronary artery disease? An 8-year follow-up.

BACKGROUND: No information is available regarding the association between low plasma glucose levels and cause-specific and all-cause mortality in patients with coronary artery disease (CAD). We aimed to investigate the relationship between hypoglycaemia and all-cause, cardiovascular and cancer mortality in a large population of patients with CAD. DESIGN: Patients were recruited from the BIP (Bezafibrate Infarction Prevention) registry, a secondary prevention prospective multicentre randomized, placebo-controlled, double-blind trial aimed to assess the efficacy of bezafibrate in reduction of coronary events. METHODS: The study included 14,670 CAD patients aged 45-74, divided into six groups: (1) hypoglycaemic (up to 69 mg/dl); (2) low normal (70-79 mg/dl); (3) euglycaemic (80-109 mg/dl); (4) impaired fasting glucose (IFG) (110-125 mg/dl); (5) borderline diabetics (126-139 mg/dl); (6) diabetics (> or 140 mg/dl). RESULTS: Patients comprised 131 with hypoglycaemia (0.9%), 731 with low normal glucose (5%), 9308 euglycaemic (63.4%), 1577 with IFG (10.7%), 617 borderline diabetics (4.2%) and 2306 diabetics (15.7%). Over a mean 8-year follow-up, crude all-cause mortality was higher in both diabetic (31.8%) and hypoglycaemic groups (25.2%) as compared with euglycaemics (14.9%; P<0.0001); CAD mortality was higher in diabetic and borderline groups (17.8 and 13.3%, respectively, versus 7.9% in euglycaemics; P<0.0001). The highest prevalence of cancer mortality was documented in the hypoglycaemic group (6.1 versus 2.9% in euglycaemics; P<0.02). Actuarial survival curves showed the lowest mortality in euglycaemic and low normal groups; the highest was seen in diabetic and hypoglycaemic patients. Intermediate values were found in borderline and IFG patients. After adjustment for variables, a significantly higher mortality rate was seen in hypoglycaemics when compared with euglycaemics (P<0.0001). Hypoglycaemia was identified as a predictor of increased all-cause and cancer mortality with a hazard ratio (HR) of 1.84 [95% confidence interval (CI) 1.29-2.61] and 2.26 (95% CI 1.12-4.57), respectively, but not of increased CAD mortality, with HR 1.30 (95% CI 0.73-2.29). CONCLUSIONS: Over a mean 8-year follow-up, hypoglycaemia emerges as a marker for substantially increased all-cause and cancer mortality among patients with CAD presenting with low fasting glucose levels.

Aged↗
PubMed2003

Comparison of effectiveness of angiotensin-converting enzyme inhibitors after acute myocardial infarction in diabetic versus nondiabetic patients.

Mortality and morbidity after acute myocardial infarction (AMI) is higher in diabetic than in nondiabetic patients. Angiotensin-converting enzyme (ACE) inhibitors have been shown to exert a beneficial effect after AMI. We sought to evaluate the association between treatment with ACE inhibitors and 1-year outcome after AMI in diabetic and nondiabetic patients in a national survey. The study population was drawn from a national survey conducted in all coronary care units operating in Israel during a 5-month period in 1996, and included 2,179 patients with AMI: 533 diabetics (24%), 322 of whom received ACE inhibitors (60%) and 211 who did not; and 1,646 nondiabetics, 805 of whom received ACE inhibitors and 841 who did not. In both groups of patients, those treated with ACE inhibitors were older, included more women, more had a history of AMI, anterior wall AMI, or hypertension, and more had worse Killip class on admission. Diabetic patients treated with ACE inhibitors experienced lower 1-year mortality rates than diabetics not treated with ACE inhibitors (16.2% vs 18.8%, respectively; covariate adjusted hazard ratio 0.47, 95% confidence interval 0.30 to 0.74). In nondiabetic patients, however, ACE inhibitor treatment was not associated with a better outcome (10.2% vs 7.3%, respectively; covariate adjusted hazard ratio 0.80; 95% confidence interval 0.56 to 1.15). Thus, treatment with ACE inhibitors after AMI appears to be particularly beneficial in diabetic patients. The beneficial effect observed supports the widespread use of ACE inhibitors in diabetic patients after AMI.

Aged↗
PubMed2003

Current smoking, smoking cessation, and the risk of sudden cardiac death in patients with coronary artery disease.

BACKGROUND: Cigarette smoking is a known risk factor for sudden cardiac death (SCD). However, the effect of continued cigarette smoking and smoking cessation on SCD risk in patients with established coronary artery disease (CAD) is subject to controversy. We, therefore, evaluated the effect of cigarette smoking on SCD risk in a large cohort of patients with established CAD. METHODS: The study population was composed of 3122 patients with a previous myocardial infarction or stable angina who participated in the Bezafibrate Infarction Prevention Trial. Patients were prospectively followed up for a mean of 8.2 years. The primary end point was the incidence of SCD according to smoking status. RESULTS: Among the 370 patients who were current smokers, 30 (8.1%) experienced SCD; 83 (4.6%) of the 1821 patients who had quit smoking and 43 (4.6%) of the 931 patients who had never smoked experienced SCD (P =.01). In multivariate analyses, current smoking was associated with a significant increase in the risk of SCD (hazard ratio, 2.47; 95% confidence interval, 1.46-4.19). Patients who had stopped smoking had no significant increase in the risk of SCD compared with patients who had never smoked (hazard ratio, 1.06; 95% confidence interval, 0.70-1.62). CONCLUSIONS: Current cigarette smoking is a powerful independent predictor of SCD risk in patients with CAD. Patients who quit smoking experienced a significant reduction in SCD risk. Thus, efforts to reduce mortality from SCD in patients with CAD should include vigorous smoking cessation strategies.

Aged↗
PubMed2003

Prospective study of serum homocysteine and risk of ischemic stroke among patients with preexisting coronary heart disease.

BACKGROUND AND PURPOSE: Substantial evidence is accumulating suggesting that hyperhomocysteinemia may be a risk factor for ischemic stroke. Results of prospective studies are, however, conflicting, and the role of hyperhomocysteinemia in patients with preexisting atherosclerotic vascular disease is not clear. Our aim was to assess prospectively the risk of incident ischemic stroke conferred by serum total homocysteine among patients with preexisting stable coronary heart disease (CHD). METHODS: We obtained baseline fasting serum samples from patients with chronic CHD enrolled in the Bezafibrate Infarction Prevention (n=3090) secondary prevention study cohort. With a nested case-control design, we measured baseline total homocysteine concentration by a high-performance liquid chromatography-based method in sera (n=160) of matched case-control pairs: patients who developed ischemic stroke during a mean follow-up of 8.2 years (cases) and age- and sex-matched controls without subsequent cardiovascular events. RESULTS: An increase of 1 natural log unit in homocysteine concentration was associated with a >3-fold increase in relative odds of incident ischemic stroke (3.3; 95% CI, 1.2 to 10.2). Homocysteine concentrations at the highest quartile (>17.4 micromol/L) were associated with significantly higher odds of ischemic stroke compared with the lowest quartile in matched-pair analysis (3.1; 95% CI, 1.1 to 9.8) and after multivariable adjustments (4.6; 95% CI, 1.3 to 18.9). Adding fibrinogen or soluble intercellular adhesion molecule-1 concentrations, markers of inflammation, to the model did not attenuate this association. The linear trends across the quartiles were significant for all models (P<0.05). CONCLUSIONS: Serum total homocysteine concentration is a strong predictor for incident ischemic stroke among patients at increased risk because of chronic CHD. The graded association observed is independent of traditional risk factors or inflammatory markers and indicates the importance of serum homocysteine levels in patients with preexisting vascular disease.

Brain Ischemia↗