Circulation: Clinical Summaries
Original Research Put Into Perspective for the Practicing Clinician
- Wolff-Parkinson-White Syndrome in the Era of Catheter Ablation: Insights From a Registry Study of 2169 Patients
- Temporal Trends in the Population Attributable Risk for Cardiovascular Disease: The Atherosclerosis Risk in Communities Study
- 30-Year Mortality After Venous Thromboembolism: A Population-Based Cohort Study
- Chronic Inflammatory Disorders and Risk of Type 2 Diabetes Mellitus, Coronary Heart Disease, and Stroke: A Population-Based Cohort Study
- Temporal Trends in Patient Characteristics and Outcomes Among Medicare Beneficiaries Undergoing Primary Prevention Implantable Cardioverter-Defibrillator Placement in the United States, 2006–2010: Results from the National Cardiovascular Data Registry’s Implantable Cardioverter-Defibrillator Registry
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Wolff-Parkinson-White Syndrome in the Era of Catheter Ablation: Insights From a Registry Study of 2169 Patients
Currently, in the era of radiofrequency catheter ablation (RFA), the management of Wolff-Parkinson-White is based on the distinction between asymptomatic and symptomatic presentations. However, whether symptomatic subjects are at higher risk of ventricular fibrillation is still unclear. The purpose of this prospective, single-center registry study was to evaluate the long-term outcomes and predictors of ablated and nonablated Wolff-Parkinson-White patients. Among 2169 enrolled patients, 1001 (550 asymptomatic and 451 symptomatic) did not have RFA (no-RFA group) and 1168 (206 asymptomatic and 962 symptomatic) did (RFA group). Primary end points were the percentage of patients who experienced ventricular fibrillation (VF) and predictors. During a median follow-up of 96 months, nonfatal cardiac arrest/VF occurred in 15 no-RFA patients, of whom 13 were originally asymptomatic (2.4%; median age, 11 years), and in none of the RFA group. The risk of cardiac arrest/VF was estimated at 2.4 per 1000 person-years (95% confidence interval, 1.3–3.9). Independent risk factors of VF were the induction of atrioventricular reentrant tachycardia degenerating into atrial fibrillation (P<0.001) and short effective refractory period of the accessory pathway (P<0.001), whereas time-dependent receiver-operating characteristic curves identified an optimal cutoff point at 240 milliseconds. These data, while confirming that the vast majority of the Wolff-Parkinson-White population have an excellent prognosis, indicate for the first time that the risk of VF/cardiac arrest essentially depends on intrinsic electrophysiological properties of accessory pathways. In a small percentage of patients found to be at risk after electrophysiological testing, predominantly children and regardless of symptoms, RFA can definitively change the patient’s natural history, eliminating the risk of VF and sudden death. See p 811.
Temporal Trends in the Population Attributable Risk for Cardiovascular Disease: The Atherosclerosis Risk in Communities Study
Improvements over time in the prevention of cardiovascular disease may be lagging in certain subgroups. To better understand changes over time in the contribution of risk factors to incident cardiovascular disease in the population at large, as well as in important subgroups, we studied 13 541 participants of the Atherosclerosis Risk in Communities Study who were aged 52 to 66 years and free of cardiovascular disease at exams in 1987 through 1989, 1990 through 1992, 1993 through 1995, or 1996 through 1998. At each examination, we estimated the population attributable risks (PAR) of traditional risk factors (hypertension, diabetes mellitus, obesity, hypercholesterolemia, and smoking) for the 10-year incidence of cardiovascular disease. Overall, the PAR of all risk factors combined was higher in women than men in 1987 through 1989 (P<0.001) but not by 1996 through 1998 (P=0.08). The combined PAR was higher in blacks than whites in 1987 through 1989 (P=0.049), and this difference was more pronounced by 1996 through 1998 (P=0.002). By 1996 through 1998, the PAR of hypertension had become higher in women than men (P=0.02) and also appeared higher in blacks than whites (P=0.08). By 1996 through 1998, the PAR of diabetes mellitus remained higher in women than men (P<0.0001) and in blacks than whites (P<0.0001). In summary, we observed that the contribution to cardiovascular disease of all traditional risk factors combined is greater in blacks than whites, and this difference may be increasing. The contributions of hypertension and diabetes mellitus remain especially high, in women as well as blacks. These findings underscore the continued need for individual as well as population approaches to cardiovascular risk factor modification. See p 820.
30-Year Mortality After Venous Thromboembolism: A Population-Based Cohort Study
Venous thromboembolism (VTE), encompassing deep venous thrombosis and pulmonary embolism (PE), is a common condition. The existing literature has focused mainly on short-term outcomes after VTE, but critical unanswered questions remain about long-term mortality. What is the absolute long-term mortality risk after deep venous thrombosis and PE, and is recurrent VTE an important cause of death? How does underlying comorbidity affect mortality? Has mortality associated with VTE improved over the last 3 decades? We examined 30-year VTE mortality and compared it with that of the general population. We estimated mortality according to VTE subtypes, underlying comorbidity, and calendar periods of diagnosis. We demonstrated high 30-day mortality for patients with PE, caused directly by the thromboembolic event or immediate complications. Mortality risk remained increased up to 30 years after the initial diagnosis for both deep venous thrombosis and PE, with VTE an important cause of death. We confirmed an increased overall mortality among patients with underlying cancer, congestive heart failure, and several other chronic and acute conditions. We observed no mortality improvement for patients with deep venous thrombosis, whereas 1-year mortality among patients with PE was markedly reduced over the last 3 decades. Our finding of increased short-term and long-term mortality after VTE may apply to most industrial Western societies in which changes in lifestyle, risk factor modification, and treatment regimens followed international recommendations. The clinical implications of our study point to the need for individual patient counseling with a focus on optimizing treatment of VTE and reducing risk factors for VTE recurrence to prevent VTE-related death. See p 829.
Chronic Inflammatory Disorders and Risk of Type 2 Diabetes Mellitus, Coronary Heart Disease, and Stroke: A Population-Based Cohort Study
Previous research has not evaluated cardiovascular outcomes across a range of chronic inflammatory disorders. This research sought to estimate the risk of type 2 diabetes mellitus and cardiovascular disease across a wide range of organ-specific and multisystem inflammatory disorders. We conducted a prospective cohort study including 156 108 patients with inflammatory disease and 373 851 controls. The study included patients with organ-specific inflammatory disorders affecting the skin (psoriasis and bullous skin diseases), gastrointestinal tract (inflammatory bowel disease), and joints (inflammatory arthritis), as well as multisystem diseases (systemic vasculitis and systemic autoimmune disorders). The study showed a 20% higher risk of type 2 diabetes mellitus, coronary heart disease, and stroke in patients with chronic inflammatory disorders compared with matched controls, even after adjustment for conventional cardiovascular risk factors. There was evidence that the severity of inflammation, with C-reactive protein used as an indicator, is associated with the increase in risk. Future research should seek to identify the common mechanisms underlying these shared associations of different chronic inflammatory disorders. Research should also explore the effects of anti-inflammatory therapies on cardiovascular outcomes in patients with chronic inflammatory disorders. Cardiovascular risk assessment and preventive medical intervention should be an important element in the management of patients with chronic inflammatory disorders. Electronic health records provide a valuable resource for comparative research on cardiovascular outcomes and the impact of therapy for patients with chronic inflammation. See p 837.
Temporal Trends in Patient Characteristics and Outcomes Among Medicare Beneficiaries Undergoing Primary Prevention Implantable Cardioverter-Defibrillator Placement in the United States, 2006–2010: Results from the National Cardiovascular Data Registry’s Implantable Cardioverter-Defibrillator Registry
Implantable cardioverter-defibrillators (ICDs) are frequently used for the primary prevention of sudden cardiac death among high-risk patients. The patterns of use and outcomes of ICD therapy have been an important focus of research and are influenced by an evolving understanding of patient populations that benefit most from therapy, changes in practice guidelines, evolution of device technology, and increasing experience of implanting clinicians. We analyzed data from the National Cardiovascular Data Registry’s ICD Registry to assess temporal trends in patient characteristics and outcomes of patients undergoing primary prevention ICD implantation in US hospitals between 2006 and 2010. Over this time, there were modest changes in the clinical characteristics of patients receiving ICDs, suggesting a consistent approach to patient selection. Second, 6-month mortality and rehospitalization improved significantly over time after accounting for patient characteristics. Finally, lower complication rates were observed despite increased use of more complex devices, including cardiac resynchronization therapy. These temporal trends suggest meaningful improvement in the care of patients receiving primary prevention ICD therapy. See p 845.
- © 2014 American Heart Association, Inc.
- 30-Year Mortality After Venous Thromboembolism: A Population-Based Cohort Study
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