The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) examined the effect of 2 different disease management programs on outcome in 1023 patients with heart failure. During 18 months of follow-up, 40% of patients were readmitted for heart failure or died, but there was no difference between the 3 groups for this composite primary end point. All-cause mortality alone, however, tended to be lower in the 2 intervention groups combined vs controls (hazard ratio, 0.85; P = .18). The data of this trial will contribute to the discussion about optimal design and execution of disease management in patients with heart failure.
The search for nongenetic ways to increase lifespan while maintaining good health and function in old age continues in this prospective cohort investigation of men in the Physicians' Health Study. Yates and colleagues examined whether favorable health and lifestyle factors in early elderly years are associated with subsequent longevity and good function in late life. Among 970 men who lived to 90 years or older, the authors found that regular vigorous exercise and the absence of smoking, overweight, diabetes, and hypertension were associated with exceptional lifespan. In addition, exercise was associated with better late-life physical function, while overweight and history of smoking were associated with worse function. Smoking also was associated with significant decrements in late-life mental function. Men with exceptional longevity had lower incidence of age-associated diseases, later onset of disease, and better late-life function in domains of physical, mental, and self-rated health than did men with shorter lifespan.
It is difficult to predict morbidity and mortality in individual patients with bacterial endocarditis. Verhagen et al prospectively studied the value of serial C-reactive protein (CRP) measurements as a predictor of clinical outcome in 123 consecutive patients with left-sided native valve endocarditis. High CRP levels in the first week of treatment and a slow decline of CRP value during the first week were indicators for poor clinical outcomes. At no point in time did CRP levels predict cardiac surgery.
This study assessed the association between antihypertensive medication nonadherence and therapy intensification with blood pressure (BP) control based on serial BP measurements over time among patients with known coronary artery disease. Three systolic BP (SBP) trajectory groups were identified: (1) patients with controlled BP over time (ie, SBP ≤140 mm Hg); (2) patients with high BP that became controlled; and (3) patients with BP that remained high over time. In multivariable analyses, therapy intensification and medication nonadherence were both associated with uncontrolled SBP over time compared with high SBP that became controlled. These findings suggest that medication nonadherence can help explain why SBP levels remained elevated despite intensification of antihypertensive medications and that both therapy intensification and medication adherence are important factors for BP control in community cohorts.
In the prospective, observational Canadian Acute Coronary Syndrome (ACS) Registry II, patients with non–ST-segment ACS were divided into tertiles according to Thrombolysis in Myocardial Infarction (TIMI) risk score and the rates of catheterization were compared. Higher-risk patients were referred at a similar rate as low-risk patients. Among the reasons provided by the most responsible physician as to why patients were not referred for catheterization, 68% of patients were thought to be “not at high enough risk”; however, 59% of these patients were found to be at intermediate to high risk according to their baseline TIMI risk score. Thus, despite better in-hospital and 1-year outcomes in those patients who are referred for catheterization, many higher-risk patients are not being referred because of the perception that they are not at high enough risk. There remains a significant opportunity to improve on accurate risk stratification and adherence to an early invasive strategy for higher-risk patients.
One-year mortality rate for all patients and higher-risk patients according to whether in-hospital cardiac catheterization was performed.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2008;168(3):258. doi:10.1001/archinternmed.2007.88