Sudden Death in Women – as in Men – Predicted by Coronary Heart Disease Risk Factors
Like their male counterparts, women who die of sudden cardiac death had at least 1 coronary heart disease risk factor, even though they had no history of cardiac ailment before their deaths, said researchers in a report in this week’s issue of the journal Circulation (Circulation. 2003;107:2096–2101).
The researchers from The Brigham and Women’s Hospital and Harvard Medical School and School of Public Health conducted a prospective cohort study of 121 701 women who were between 30 to 55 years of age at the beginning of the study. Sudden cardiac death was defined as death within 1 hour of the onset of symptoms. From 1976 until 1998, 244 incidents of sudden cardiac death occurred. The incidence of sudden cardiac death increased markedly with age. However, the greatest rate of cardiac death in older women was not in the group who suffered sudden death, but rather in the group who died of other kinds of heart disease.
Sixty-nine percent of women who suffered a sudden cardiac death had no prior history of heart disease. However, 94% of the women who suffered sudden death had reported at least 1 risk factor for coronary heart disease. The risk factors that conferred the greatest risk of death were smoking, high blood pressure, and diabetes. A family history of heart attack before the age of 60 years and obesity resulted in moderate risk elevations.
Eighty-eight percent of the sudden deaths were associated with arrhythmias, the researchers reported. In 76%, the first documented rhythm was ventricular tachycardia or ventricular fibrillation. The researchers wrote, “[O]ur data suggest that CHD risk factors do indeed predict SCD in women, and, therefore, CHD risk factor modification should favorably impact risk of SCD in women.”
Impaired Glucose Metabolism Associated With Arterial Stiffness
Arterial stiffness to a significant degree occurs when a patient has impaired glucose metabolism but has not yet progressed to type 2 diabetes, said researchers from the VU University Medical Center in Amsterdam, The Netherlands. in a report in this week’s issue of the journal Circulation (Circulation. 2003;107:2089–2095).
The study, led by Ronald M.A. Henry, MD, of the Department of Internal Medicine, involved the ultrasound evaluation of 278 patients with normal glucose metabolism, 168 with impaired glucose metabolism, and 301 with type 2 diabetes. The researchers used ultrasound to estimate distensibility and compliance of the carotid, femoral, and brachial arteries, as well as the carotid elastic modulus.
After the findings were adjusted for age, sex, and mean arterial pressure, the researchers found that type 2 diabetes was associated with increased stiffness of the carotid, femoral, and brachial arteries. Impaired glucose metabolism was associated with increased femoral and brachial stiffness. Carotid stiffness was increased in type 2 diabetes compared with that seen in impaired glucose metabolism.
The researchers said that the arterial stiffness was explained by decreases in distension, increases in pulse pressure, an increase in carotid intima-media thickness and in the femoral artery, and a decrease in arterial diameter. Only 30% of arterial changes associated with glucose tolerance could be explained by hyperglycemia or hyperinsulinemia.
The researchers noted that the increased stiffness that occurred before the onset of type 2 diabetes could not be explained by conventional cardiovascular risk factors or by hyperglycemia or hyperinsulinemia. They wrote, “These data provide a pathophysiological framework for understanding why glucose tolerance is associated with an increased risk of stiffness-related complications.”
Heart Attack Death Rates Increase in Uninsured New Jersey Patients
A reduction in state subsidies for uninsured medical care combined with market-based competition to New Jersey’s hospitals is associated with increased mortality rates among heart attack patients, according to researchers at the University of Pennsylvania School of Medicine. The report appears in the April 1, 2003, issue of the journal Health Services Research.
The researchers analyzed information on 286 640 heart attack patients admitted to hospitals in New Jersey and New York from 1990 until 1996. During that period, the New Jersey healthcare system suffered dramatic financial reforms and cut its subsidies for the care of uninsured patients by 50%.
During that same period, the mortality rate from acute myocardial infarction in uninsured patients in New York dropped from 12% to 8%. In New Jersey, however, the death rate from heart attack in uninsured patients increased from 7.8% to 8.3%. The use of procedures to help such patient increased at a higher rate in New York than in New Jersey during that time. Mortality rates for insured patient declined at virtually the same rate in both states.
“Although market-based reforms in medicine are becoming more widespread, little is known about how they affect quality-of-care,” said Kevin Volpp, MD, PhD, the principal investigator for the study and an assistant professor of internal medicine at the University of Pennsylvania, the Philadelphia Veterans Affairs Medical Center, and the Department of Health Care Systems at the Wharton School. “The effects of the change in hospital reimbursement that we observed in this study represent only one segment of the patient population in one state, but may be an indication that we need to pay close attention to how cost-saving reforms may affect the quality of care across the country.”
Veterans Affairs Heart Attack Patients’ Care Suffers
The US Department of Veterans Affairs has reported that patients with heart disease treated at its hospitals have consistently higher mortality rates than similar patients treated in community institutions.
According to a report in the April 12, 2003, issue of the Washington Post, VA officials said a larger proportion of veterans die in the first month after suffering a heart attack and a larger proportion of them die in the next three years after the heart attack than do patients treated in the community (Washington Post. April 12, 2003:A7). The new study of VA care also found that patients in the government institutions are less likely to undergo cardiac catheterization, angioplasty, or coronary artery bypass surgery than patients in community hospitals.
The findings of the VA-commissioned study were issued at a new conference held by Veterans Affairs Secretary Anthony J. Principi, who was quoted in the Post as saying, “The findings are unacceptable and immediate action is required and will be taken.” Among the changes he has ordered is development of a better system for moving VA heart attack patients quickly to hospitals that offer all cardiac services in the event that the nearest VA hospital does not offer them.
Secretary Principi said VA doctors will also be counseled to follow clinical guidelines for treating heart attack patients. He said indicators of the quality of care will be carefully monitored while changes in the treatment of veterans are being implemented.