Roger, Véronique L.

Abstract Aims We hypothesize that poor quality of life (QOL) is highly prevalent in frail older adults and is associated with worse prognosis. Methods and results Predismissal standardized tests for frailty and QOL were prospectively administered to patients included in two cohorts. In Cohort 1, 629 patients ≥65 years who underwent percutaneous coronary intervention (PCI) from 2005 to 2008, frailty (Fried criteria), and QOL [SF-36 and Seattle Angina Questionnaires (SAQ)] were ascertained. Cohort 2 included 921 patients ≥55 years who underwent cardiac catheterization (535 had PCI) from 2014 to 2018 and frailty was determined by Rockwood criteria and QOL by single-item, self-reported health questionnaire. In Cohort 1, 19% were frail and 20% patients in Cohort 2 were frail with a frailty index >0.30. The median SAQ for physical limitation (58.9 vs. 82.2, P < 0.001), physical (29.5 vs. 43.9, P < 0.001), and mental (49.2 vs. 57.4, P < 0.001) component scores of SF-36 in Cohort 1 were lower and self-rating of fair/poor health (56% vs 18%, P < 0.001) in Cohort 2 was significantly higher in frail patients. As compared to patients without frailty, frail patients were five times more likely (59% vs. 11%, P < 0.001) in Cohort 1 and seven times more likely (56% vs. 8%) in Cohort 2 to be classified with poor QOL. Age- and gender-adjusted 3-year all-cause death and death or myocardial infarction (MI) was significantly higher for patients undergoing PCI with frailty; [hazard ratio (95% confidence interval) death, 4.20 (2.63–6.68, P < 0.001) and death or MI hazard ratio (HR) 2.72 (1.91–3.87, P < 0.001)] and with poor QOL [HR death 2.47 (1.59–3.84, P < 0.001)] and death or MI 1.61 (1.16–2.24, P < 0.001). There was no significant interaction between frailty and QOL (P = 0.64) and only modest attenuation was observed when considered together indicating their independent prognostic influence. Conclusion In elderly patients undergoing cardiac catheterization or PCI, poor QOL is seen more frequently in frail patients. Both frailty and poor QOL had significant and independent association with long-term survival.

AbstractIntroductionThe best management strategy for patients with atrial fibrillation (AF) with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) is unknown.Methods and ResultsThis cohort study was conducted in Olmsted County, Minnesota, with resources of the Rochester Epidemiology Project. Patients with incident AF occurring between 2000 and 2014 with a prior or concurrent HF were included. Patients with LVEF ≥ 50% were designated as HF and preserved ejection fraction (HFpEF) and those with LVEF < 50% were designated as HF and reduced ejection fraction (HFrEF). Rhythm control in the first year after AF diagnosis was defined as prescriptions for an antiarrhythmic drug, catheter ablation, or maze procedure. The primary endpoint was all‐cause mortality. The secondary endpoints were cardiovascular death, cardiovascular hospitalization, and stroke or transient ischemic attack. Of 859 patients (age, 77.2 ± 12.1 years; 49.2%, female), 447 had HFpEF‐AF, and 412 had HFrEF‐AF. There was no difference in all‐cause mortality (10‐year mortality, 83% vs 79%; p = .54) or secondary endpoints between the HFpEF‐AF and HFrEF‐AF, respectively. Compared with the rate control strategy, rhythm control in HFpEF‐AF patients (n = 40, 15.9%) offered no survival benefits (adjusted HR, 0.70; 95% CI, 0.42–1.16; p = .16), whereas rhythm control in HFrEF‐AF patients (n = 52, 22.5%) decrease cardiovascular mortality (HR, 0.38; 95% CI, 0.17–0.86; p = .02).ConclusionsPatients with HFpEF‐AF and HFrEF‐AF had similar poor prognoses. Rhythm control strategy was seldom adopted in community care in patients with HF and AF. A rhythm control strategy may provide survival benefit for patients with HFrEF‐AF and the benefit of rhythm control in patients with HFpEF‐AF warrants further study.

Importance Black individuals are more likely than white individuals to develop dementia. Whether higher blood pressure (BP) levels in black individuals explain differences between black and white individuals in dementia risk is uncertain. Objective To determine whether cumulative BP levels explain racial differences in cognitive decline. Design, Setting, and Participants Individual participant data from 5 cohorts (January 1971 to December 2017) were pooled from the Atherosclerosis Risk in Communities Study, Coronary Artery Risk Development in Young Adults Study, Cardiovascular Health Study, Framingham Offspring Study, and Northern Manhattan Study. Outcomes were standardized as t scores (mean [SD], 50 [10]); a 1-point difference represented a 0.1-SD difference in cognition. The median (interquartile range) follow-up was 12.4 (5.9-21.0) years. Analysis began September 2018. Main Outcomes and Measures The primary outcome was change in global cognition, and secondary outcomes were change in memory and executive function. Exposures Race (black vs white). Results Among 34 349 participants, 19 378 individuals who were free of stroke and dementia and had longitudinal BP, cognitive, and covariate data were included in the analysis. The mean (SD) age at first cognitive assessment was 59.8 (10.4) years and ranged from 5 to 95 years. Of 19 378 individuals, 10 724 (55.3%) were female and 15 526 (80.1%) were white. Compared with white individuals, black individuals had significantly faster declines in global cognition (−0.03 points per year faster [95% CI, −0.05 to −0.01]; P = .004) and memory (−0.08 points per year faster [95% CI, −0.11 to −0.06]; P &amp;lt; .001) but significantly slower declines in executive function (0.09 points per year slower [95% CI, 0.08-0.10]; P &amp;lt; .001). Time-dependent cumulative mean systolic BP level was associated with significantly faster declines in global cognition (−0.018 points per year faster per each 10–mm Hg increase [95% CI, −0.023 to −0.014]; P &amp;lt; .001), memory (−0.028 points per year faster per each 10–mm Hg increase [95% CI, −0.035 to −0.021]; P &amp;lt; .001), and executive function (−0.01 points per year faster per each 10–mm Hg increase [95% CI, −0.014 to −0.007]; P &amp;lt; .001). After adjusting for cumulative mean systolic BP, differences between black and white individuals in cognitive slopes were attenuated for global cognition (−0.01 points per year [95% CI, −0.03 to 0.01]; P = .56) and memory (−0.06 points per year [95% CI, −0.08 to −0.03]; P &amp;lt; .001) but not executive function (0.10 points per year [95% CI, 0.09-0.11]; P &amp;lt; .001). Conclusions and Relevance These results suggest that black individuals’ higher cumulative BP levels may contribute to racial differences in later-life cognitive decline.

Background Temporal declines in cardiac stress tests results, coronary revascularization, and cardiovascular mortality have suggested a decline in the population burden of coronary disease until the 2000s. However, recent data indicate these favorable trends could be ending. We aimed to assess the evolution of the population burden of coronary disease in the community by examining trends in angiography and revascularization. Methods and Results We analyzed age‐ and sex‐adjusted trends from all coronary angiographic diagnostic procedures and revascularizations performed in Olmsted County, MN from 2000 to 2018. A total of 12 981 invasive angiograms were performed among 9049 individuals (64% men; 55% aged ≥65 years). Adjusted angiography rates decreased by 30% (95% CI , 25%–34%) between 2000 and 2009 and leveled off thereafter. Including computed tomography, angiography uncovered an increase in angiography use in recent years (risk ratio=1.15 [95% CI , 1.07–1.23] for 2018 versus 2014) and a decline in the prevalence of anatomic CAD from 2000 to 2018. CAD severity declined substantially from 2000 to 2009, followed by a plateau. Among 6570 revascularizations (72% men; 57% aged ≥65 years), 77% were percutaneous coronary interventions and 23% coronary artery bypass graft surgeries. The adjusted revascularization rates declined by 34% (95% CI , 27%–39%) from 2000 to 2009, followed by a plateau (risk ratio=1.10 [95% CI , 1.00–1.22]). Conclusions Between 2000 and 2018 in the community, coronary angiography use declined initially, leveled off, and then increased. Trends in CAD severity and revascularization use decreased then plateaued. The most recent trends are concerning as they suggest the burden of coronary disease is no longer declining. This warrants reinvigorated primary prevention and population surveillance.

Background: The effective self-management of heart failure (HF) is highly dependent on cognitive function. Dementia frequently coexists with HF, but its exact prevalence and impact on health care utilization and death is not well understood. Methods: Residents from 7 southeast Minnesota counties with a first-ever code for HF (ICD-9 428 and ICD-10 I50) between 1/1/2012 and 12/31/2017 were identified. Dementia before and after the HF diagnosis was ascertained with codes recommended by the US Department of Health and Human Services. Patients were followed through 12/31/2018 for death and hospitalizations. Cox and Andersen-Gill models were used to examine associations between dementia (prior and post HF) and death and hospitalizations, respectively. Dementia after HF was analyzed as a time-dependent variable. Results: Among 6,312 patients with HF (mean age 75 years, 49% female), 636 (10%) had a prior diagnosis of dementia. After a mean (SD) follow-up of 3.1 (1.8) years, 601 (9.5%) patients were diagnosed with dementia post HF. The median time from HF to dementia was 1.3 years, with 43% of dementia cases occurring within 1 year and 64% within 2 years post HF. During follow-up, 2,678 deaths and 15,095 hospitalizations occurred. After adjustment, patients with dementia before HF had nearly a 2-times increased risk of death and 10% increased risk of hospitalization compared to those that did not have dementia (Table). Dementia after HF was associated with a 78% increased risk of death and 63% increased risk of hospitalization compared to those that did not have dementia. Conclusions: Approximately 10% of patients had dementia prior to HF and 10% develop dementia shortly after HF diagnosis. Patients with HF and dementia have an increased risk of death and hospitalization compared to dementia-free counterparts. These data underscore the importance of recognizing the presence and impact of dementia on outcomes in HF to optimize care delivery.

Introduction: Alcohol use is common in the United States. Most studies describe a J-shaped relationship between alcohol consumption and cognitive function: frequent heavy consumption alters brain functions and decreases cognitive performance; regular light and moderate consumption may have protective impact. We are unaware of any reports utilizing longitudinally collected data to derive a cumulative exposure of alcohol use and assess its association with cognitive function. Hypothesis: Cumulative 30-year exposure to alcohol has a J-shaped association with mid-life cognitive function. Methods: We included 3,068 participants aged 18-30 years at the baseline examination (1985-86) and having up to 8 follow-up exams at 2- to 5-year intervals including at 30 years (2015-16). Cumulative “drink-years” exposure to alcohol was estimated at each exam by multiplying the usual number of drinks/day reported by the number of years since last exam, and then summing across exams. We used multivariable adjusted linear regression models to assess the independent associations of number of drink-years with 6 measures of cognitive function studied at Year 30: Rey Auditory Verbal Learning Test (RAVLT), Digit Symbol Substitution Test (DSST), Stroop Test, Montreal Cognitive Assessment (MoCA), Category Fluency Test, and Letter Fluency Test. We used inverse probability of censoring weighting to account for potential informative censoring. Linear regression models estimated standardized mean test scores for the cumulative alcohol use categories (drink-years: >0 and <15, 15-29.9, 30+). Too few participants were available for assessment of higher categories of use. Results: Compared with never drinking, the 3 categories of cumulative exposure were unassociated with any of the cognitive function measures. Conclusions: Cumulative 30-year alcohol use is not associated with cognitive function in middle-aged adults in the CARDIA study.

Background: Current cardiovascular disease (CVD) risk scores are derived from research cohorts and are particularly inaccurate in women, older adults, and those with missing data. To overcome these limitations, we aimed to develop a cohort to capitalize on the depth and breadth of clinical data within electronic health record (EHR) systems in order to develop next-generation sex-specific risk prediction scores for incident CVD. Methods: All individuals 30 years of age or older residing in Olmsted County, Minnesota on 1/1/2006 were identified. We developed and validated algorithms to define a variety of risk factors, thus building a comprehensive risk profile for each patient. Outcomes including myocardial infarction (MI), percutaneous intervention (PCI), coronary artery bypass graft (CABG), and CVD death were ascertained through 9/30/2017. Results: We identified 73,069 individuals without CVD (Table). We retrieved a total of 14,962,762 lab results; 14,534,466 diagnoses; 17,062,601 services/procedures; 1,236,998 outpatient prescriptions; 1,079,065 heart rate measurements; and 1,320,115 blood pressure measurements. The median number of blood pressure and heart rate measurements ascertained per individuals were 11 and 9, respectively. The five most prevalent conditions were: hypertension, hyperlipidemia, arthritis, depression, and cardiac arrhythmias. During follow-up 1,455 MIs, 1,581 PCI, 652 CABG, and 2,161 CVD-related deaths occurred. Conclusions: We developed a cohort with comprehensive risk profiles and follow-up for each patient. Using sophisticated machine learning approaches, this electronic cohort will be utilized to develop next-generation sex-specific CVD risk prediction scores. These approaches will allow us to address several challenges with use of EHR data including the ability to 1) deal with missing values, 2) assess and utilize a large number of variables without over-fitting, 3) allow non-linear relationships, and 4) use time-to-event data.