Statin therapy is associated with significant decreases in cardiovascular events and in all-cause mortality in women and men. Statin therapy should be used in appropriate patients without regard to sex.

ACE-I are frequently used therapeutic agents that are associated with angioedema. Their use should be avoided in high-risk individuals and early diagnosis, tracheal intubation in cases of airway compromise, and absolute avoidance of re-challenge are important.

for the Myocardial Infarction Data Acquisition System (MIDAS14) Study Group Background-We assessed trends in the prognosis of patients with acute myocardial infarction hospitalized in New Jersey hospitals. In recent decades, in-hospital mortality has declined markedly but the decline in longer-term mortality is less pronounced, implying that mortality after discharge has worsened. Methods and Results-Using the Myocardial Infarction Data Acquisition System (MIDAS), we examined the outcomes of 285 397 patients hospitalized for a first acute myocardial infarction between 1986 and 2007. Mortality at discharge decreased by 9.4% from 16.9% to 7.5% (annual change, Ϫ0.44; 95% confidence interval, Ϫ0.49 to Ϫ0.40), but the decrease at 1 year was less pronounced (6.4%) because of an increase in mortality from discharge to 1 year after discharge (from 12.1% to 13.9%; annual change, ϩ0.15; 95% confidence interval, ϩ0.10 to ϩ0.20). Mortality from 30 days after discharge to 1 year, a measure not affected by length of stay, increased by 1.2% (annual change, ϩ0.10; 95% confidence interval, ϩ0.06 to ϩ0.23). The effect was more evident in the older age groups and was due to noncardiovascular mortality, especially from respiratory and renal diseases, septicemia, and cancer. All effects remained statistically significant (PϽ0.0001) after adjustment for demographics, comorbidities, infarction type, complications, and interventions. Piecewise linear regressions confirmed these trends. Conclusions-Postdischarge mortality of patients with acute myocardial infarction is increasing, primarily because of higher noncardiovascular mortality in the older age groups. (Circ Cardiovasc Qual Outcomes. 2010;3:581-589.)Key Words: epidemiology Ⅲ mortality Ⅲ myocardial infarction I n recent decades, a marked decrease of in-hospital mortality of patients with acute myocardial infarction (AMI) has been documented in clinical trials, in prospective registries, and in epidemiological studies. [1][2][3][4][5] Although longer-term mortality of AMI has also declined, in some studies this decline is less pronounced than mortality at discharge, implying that mortality after discharge has worsened. 1,4,6 -9 In recent years, AMI patients are older and have more comorbidities, the length of hospital stay has decreased, the diagnostic criteria have changed, and better control of risk factors may have resulted in smaller AMIs. 4 -6,9 -12 Many improvements have been made in the management of AMI and in secondary prevention with reperfusion, medications, revascularization, and emphasis on process improvement. 1,3,4,6,7,[13][14][15][16][17][18] Editorial see p 568The purpose of the present study was to examine mortality trends observed among AMI patients admitted to New Jersey hospitals while considering changes in patient characteristics, comorbidities, complications, interventions, and length of stay. Methods Data SourcesThe data for this study were obtained from the Myocardial Infarction Data Acquisition System (MIDAS) from January 1, 1986, to December 31, 2008...

Objective Using a feasibility analysis and matched subgroup analysis, this study investigated the implementation/safety/outcomes of a stroke recovery program (SRP) integrating modified cardiac rehabilitation for stroke survivors. Design This prospective cohort study of 783 stroke survivors were discharged from an inpatient rehabilitation facility to an outpatient setting; 136 SRP-participants completed a feasibility study and received the SRP including modified cardiac rehabilitation, 473 chose standard of care rehabilitation (nonparticipants), and a group (n = 174) were excluded. The feasibility study assessed the following: safety/mortality/pre-post cardiovascular performance/pre-post function/patient/staff perspective. In addition to the feasibility study, a nonrandomized subgroup analysis compared SRP-participants (n = 76) to matched pairs of nonparticipants (n = 66, with 10 nonparticipants used more than once) for mortality/pre-post function. Results The feasibility study showed the SRP to have the following (a) excellent safety, (b) markedly low 1-yr poststroke mortality from hospital admission (1.47%) compared with national rate of 31%, (c) improved cardiovascular performance over 36 sessions (103% increase in metabolic equivalent of tasks times minutes), (d) improved function in Activity Measure of Post-Acute Care domains (P < 0.001), (e) positive reviews from SRP-participants/staff. Subgroup analysis showed the SRP to (a) positively impact mortality, nonparticipants had a 9.09 times higher hazard of mortality (P = 0.039), and (b) improve function in Activity Measure of Post-Acute Care domains (P < 0.001). Conclusions Stroke survivors receiving a SRP integrating modified cardiac rehabilitation may potentially benefit from reductions in all-cause mortality and improvements in cardiovascular performance and function.

Introduction--- Statin therapy decreases the risk of myocardial infarction and ischemic stroke. However, an increased risk of intracerebral hemorrhage (ICH) has been observed in some studies. To investigate this issue we performed a meta-analysis of all randomized controlled trials (RCTs) using statins that reported ICH. Methods--- We performed a Medline literature search through March 18, 2011 and identified additional RCTs by reviewing reference lists of retrieved studies and prior meta-analyses. All RCTs of statin therapy versus placebo or high dose versus low dose statin therapy that reported ICH or hemorrhagic stroke were included. The primary outcome variable was ICH. 26 RCTs were included. All analyses used random effects models and heterogeneity was not observed in any of the analyses. Results--- 84 831 subjects were included in the Active group, and 84 851 in the Control group. A trend towards a higher incidence of ICH was observed in the Active treatment group compared to Control (OR = 1.15; 95% CI = 0.91 to 1.45, p =0.24) (Figure). Significant relationships were not observed between the log OR for ICH with achieved LDL in the Active group (slope = 0.0002; 95% CI = -0.0098 to 0.0101, p =0.96) or with the difference in LDL drop between the Active and Control groups (slope = 0.0030; 95% CI = -0.0089 to 0.0149, p =0.62). Total stroke (OR = 0.84; 95% CI = 0.78 to 0.91, p <0.001) and all-cause mortality (OR = 0.91; 95% CI = 0.86 to 0.96, p <0.001) were significantly reduced in the Active group. A significant relationship between all-cause mortality and the difference in LDL drop between the Active and Control groups was observed (slope = -0.0030; 95% CI = -0.0009 to -0.0051, p<0.005). There was not evidence of publication bias in this meta-analysis. Conclusions--- Active therapy was associated with a trend towards increased ICH in this meta-analysis of 26 RCTs of statin therapy. However, this risk does not appear to be related to the degree of decline or achieved LDL. The risk of ICH is offset by a significant reduction in ischemic stroke and all-cause mortality and should not dissuade practitioners from prescribing statins in otherwise appropriate patients.

The aim of this study was to assess the relationship between pulse pressure (PP) and the occurrence of heart failure (HF) in older persons with isolated systolic hypertension. Data from a prospective, multicenter, randomized, double-blind, placebo-controlled clinical trial were analyzed. A total of 4736 persons aged > or = 60 years with systolic blood pressure (SBP) between 160 and 219 mm Hg and diastolic blood pressure (DBP) < 90 mm Hg who participated in the Systolic Hypertension in the Elderly Program (SHEP) were studied. The main outcome measures were fatal and nonfatal HF. During 4.5 years average follow-up, fatal or nonfatal HF occurred in 160 of 4736 patients. The SBP, PP, and mean arterial pressure (MAP) were strong predictors of the development of HF (P < .0002). Cox proportional hazards regression using time-dependent covariates and controlling for MAP indicated that HF was inversely related to DBP (P = 0.002) and was directly related to pulse pressure (P = 0.002). Data were similar when patients who developed myocardial infarction during follow up were excluded. These data indicate that, in older persons with isolated systolic hypertension, high pulse pressure is associated with increased risk of heart failure independently of MAP and of the occurrence of acute myocardial infarction during follow-up.

Abstract-Long-term follow-up of clinical trials of blood pressure-lowering medications has suggested a continuation of event reduction after study completion. We evaluated the persistence of mortality benefit of these agents after the end of clinical trials, when all of the patients were advised to take the same open-label therapy. We performed a meta-analysis of randomized clinical trials using blood pressure-lowering medications, used in patients with hypertension, myocardial infarction, or left ventricular systolic dysfunction, (nϭ18; 132 854 patients; 11 988 deaths) when a second report describing results after the end of the trial was available. Key Words: ACEIs Ⅲ blood pressure-lowering medications Ⅲ ␤-blockers Ⅲ diuretics Ⅲ clinical trials Ⅲ mortality Ⅲ legacy effect C linical trials of blood pressure-lowering medications, usually lasting Յ5 years, and meta-analyses of such studies showed lower mortality among patients randomized to active therapy. [1][2][3][4][5] Investigators of some of the clinical trials have published findings of a persistent benefit of these medications after the end of the trials when all of the participants were advised to take active therapy. A legacy effect has been described in diabetes mellitus when persistent microvascular and macrovascular benefits were maintained or realized years after the end of an intensive glucose control randomized study. 6 To address the question of whether blood pressure-lowering medications confer a similar legacy effect, we performed a meta-analysis of randomized, controlled trials of these drugs. Studies where these medications were used for the treatment of hypertension, acute myocardial infarction (AMI), or systolic left ventricular dysfunction/heart failure (HF-LVD) are included in the analysis. The purpose of this article is to present a quantitative overview of the persistence of the effect on all-cause mortality after discontinuation of randomized therapy and to relate this effect to the actual percentages of patients in the intervention and control groups who received active therapy during the randomized and open-label follow-up phases of each study. Methods Data Sources and SearchesA systematic literature search of randomized clinical trials of the effect of blood pressure-lowering medications was performed up to June 2010 using Medline, Embase, the Cochrane Library, and clinicaltrials.gov according to the QUOROM statement. 7 Study SelectionWe identified 3428 titles with open-label follow-up after the end of randomized trials, using a search strategy as described in Figure 1 andonlinesupplementaryTableS1(pleaseseehttp://hyper.ahajournals. org). One additional study pair was obtained from the published abstract of an oral presentation. 8,9 Trials were eligible for inclusion Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.

We examined the association of orthostatic hypertension with all-cause mortality in the active treatment and placebo randomized groups of the Systolic Hypertension in the Elderly Program (SHEP). SHEP was a multicenter, randomized, double-blind, placebo-controlled clinical trial of the effect of chlorthalidone-based antihypertensive treatment on the rate of occurrence of stroke among older persons with isolated systolic hypertension (ISH). Men and women aged 60 years and above with ISH defined by a systolic blood pressure (SBP) of 160 mm Hg or higher and diastolic blood pressure lower than 90 mm Hg were randomized to chlorthalidone-based stepped care therapy or matching placebo. Among 4736 SHEP participants, 4073 had a normal orthostatic response, 203 had orthostatic hypertension, and 438 had orthostatic hypotension. Compared with normal response, orthostatic hypertension was associated with higher all-cause mortality at 4.5 and 17 years in analyses adjusted for age, gender, treatment, SBP, and pulse pressure (PP, HR 1.87, 95% CI 1.30–2.69, p = 0.0007; HR 1.40, 95% CI 1.17–1.68, p = 0.0003, respectively). These associations remained significant after additional adjustment for risk factors and comorbidities (HR 1.43, 95% CI 0.99–0.08, p = 0.0566 at 4.5 years, and HR 1.27, 95% CI 1.06–1.53, p = 0.0096 at 17 years). The increased risk of all-cause mortality associated with orthostatic hypertension was observed in both the active and placebo groups without significant interaction between randomization group and the effect on mortality. Orthostatic hypertension is associated with future mortality risk, is easily detected, and can be used in refining cardiovascular risk assessment.