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Biomedical subjects

J B Kostis

Publications and source records attributed to J B Kostis.

At least 37 records · Page 2Linked to original sources
PubMed1999

Impact of availability of hospital-based invasive cardiac services on racial differences in the use of these services.

BACKGROUND: Reports indicate that black patients are less likely than white patients to receive invasive cardiac services after hospitalization for acute myocardial infarction (AMI). There is still uncertainty as to why racial differences exist and how they affect patient outcomes. This is the first study to focus on the availability of invasive cardiac services and racial differences in procedure use. Study objectives were to (1) document whether racial differences existed in the use of invasive cardiac procedures, (2) study whether these racial differences were related to availability of hospital-based invasive cardiac services at first admission for AMI, and (3) determine whether there were racial differences in long-term mortality rates. METHODS: A historical cohort study was conducted with discharge records from all acute care hospitals in New Jersey for 1993 linked to death certificate records for 1993 and 1994. There were 13,690 black and white New Jersey residents hospitalized with primary diagnosis of AMI. Use of cardiac catheterization within 90 days, revascularization within 90 days (percutaneous transluminal coronary angioplasty [PTCA] or coronary artery bypass graft surgery [CABG]), and death within 1 year after admission for AMI were the main outcome measures. Patterns for PTCA and CABG as separate outcomes were also studied. Hospital-based cardiac services available were described as no invasive cardiac services, catheterization only, or PTCA/CABG. To account for payer status and comorbidity differences, patients 65 years and older with Medicare coverage were analyzed separately from those younger than 65 years. RESULTS: Black patients aged 65 and older were generally less likely to receive catheterization and revascularization than white patients, regardless of facilities available at first admission. For patients younger than 65 years, the greatest differences between black and white patients in catheterization and PTCA/CABG use within 90 days after AMI occurred when no hospital-based invasive cardiac services were available. However, use of invasive cardiac procedures within 90 days after AMI was substantially increased if the first hospital offered catheterization only or PTCA/CABG services, among all patients, especially among blacks younger than age 65. No significant racial differences or interactions with available services were found in 1-year mortality rates. CONCLUSIONS: Availability of invasive cardiac services at first hospitalization for AMI was associated with increased procedure use for both races. However, use of invasive cardiac procedures was generally lower for black patients than for white patients, regardless of services available. Long-term mortality rates after hospitalization for AMI did not differ between blacks and whites.

Black or African American↗
PubMed1999

Factors contributing to trends in prescription drug expenditures.

Between 1970 and 1995, national prescription drug expenditures and Medicaid drug expenditures increased proportionately less than did total health care expenditures and total Medicaid expenditures, respectively, although they increased to a greater extent than did expenditures in other sectors of the economy. General inflation, which cannot be controlled by health care policy, has been the major factor contributing to the growth in national prescription drug expenditures. Other contributors were population growth, increases in per capita prescription use, increases in per-prescription intensity (ie, real drug expenditures), and the fact that prescription drug prices exceeded general inflation. Medicaid drug expenditures have increased mainly because of growth in the number of drug recipients, increases in prescription drug prices, and economy-wide inflation.

Data Collection↗
PubMed1998

Does withdrawal of antihypertensive medication increase the risk of cardiovascular events? Trial of Nonpharmacologic Interventions in the Elderly (TONE) Cooperative Research Group.

The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommends that attempts to discontinue antihypertensive drug therapy be considered after blood pressure (BP) has been controlled for 1 year. However, discontinuation of drug therapy could unmask underlying conditions and precipitate clinical cardiovascular events. The Trial of Nonpharmacologic Interventions in the Elderly (TONE) was a clinical trial of the efficacy of weight loss and/or sodium reduction in controlling BP after withdrawal of drug therapy in patients with a BP< 145/85 mm Hg on 1 antihypertensive medication. Of 975 participants, 886 entered the drug withdrawal phase of the trial and 774 were successfully withdrawn from their medications. Thirty-three events (stroke, transient ischemic attack, myocardial infarction, arrhythmia, congestive heart failure, angina, other) occurred between randomization and the onset of drug withdrawal (median time 3.6 months), 57 events occurred either during or after drug withdrawal (14.0 months), and 36 events occurred after resumption of antihypertensive therapy (15.9 months). Event rates per 100 person-years were 5.5, 5.5, and 6.8 for the 3 time periods (p=0.84) in the nonoverweight group and 7.2, 5.2, and 5.6 (p=0.08) in the overweight group. The study shows that antihypertensive medication can be safely withdrawn in older persons without clinical evidence of cardiovascular disease who do not have diastolic pressure > or = 150/90 mm Hg at withdrawal, providing that good BP control can be maintained with nonpharmacologic therapy.

Aged↗
PubMed1998

Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group.

CONTEXT: Nonpharmacologic interventions are frequently recommended for treatment of hypertension in the elderly, but there is a paucity of evidence from randomized controlled trials in support of this recommendation. OBJECTIVE: To determine whether weight loss or reduced sodium intake is effective in the treatment of older persons with hypertension. DESIGN: Randomized controlled trial. PARTICIPANTS: A total of 975 [corrected] men and women aged 60 to 80 years with systolic blood pressure lower than 145 mm Hg and diastolic blood pressure lower than 85 mm Hg while receiving treatment with a single antihypertensive medication. SETTING: Four academic health centers. INTERVENTION: The 585 obese participants were randomized to reduced sodium intake, weight loss, both, or usual care, and the 390 nonobese participants were randomized to reduced sodium intake or usual care. Withdrawal of antihypertensive medication was attempted after 3 months of intervention. MAIN OUTCOME MEASURE: Diagnosis of high blood pressure at 1 or more follow-up visits, or treatment with antihypertensive medication, or a cardiovascular event during follow-up (range, 15-36 months; median, 29 months). RESULTS: The combined outcome measure was less frequent among those assigned vs not assigned to reduced sodium intake (relative hazard ratio, 0.69; 95% confidence interval [CI], 0.59-0.81; P<.001) and, in obese participants, among those assigned vs not assigned to weight loss (relative hazard ratio, 0.70; 95% CI, 0.57-0.87; P<.001). Relative to usual care, hazard ratios among the obese participants were 0.60 (95% CI, 0.45-0.80; P<.001) for reduced sodium intake alone, 0.64 (95% CI, 0.49-0.85; P=.002) for weight loss alone, and 0.47 (95% CI, 0.35-0.64; P<.001) for reduced sodium intake and weight loss combined. The frequency of cardiovascular events during follow-up was similar in each of the 6 treatment groups. CONCLUSION: Reduced sodium intake and weight loss constitute a feasible, effective, and safe nonpharmacologic therapy of hypertension in older persons.

Aged↗
PubMed1998

Angiotensin-converting enzyme gene polymorphism in systemic hypertension.

We determined the angiotensin-converting enzyme (ACE) insertion/deletion genotype in 209 hypertensive individuals and in 100 matched normotensive controls. A significant association was detected between hypertension and the deletion/deletion (D/D) genotype of the ACE gene when the relation was adjusted for age, sex, and body mass index.

Aged↗
PubMed1998

Factors associated with atrial fibrillation in patients with mitral stenosis: a cardiac catheterization study.

Atrial fibrillation (AF) is frequently found in association with rheumatic mitral valve disease. To study the interrelation of factors contributing to the risk of AF in patients with mitral stenosis, we examined a cardiac catheterization database of a series of 314 patients. Patients with AF were older, 53.4 +/- 6.1 years versus 51.7 +/- 7.2 years (p = 0.03), and had a lower cardiac index, 2.3 +/- 0.6 L/min/m2 versus 2.6 +/- 0.7 L/min/m2 (p = 0.0002), than patients in sinus rhythm at catheterization. The mitral valve area was significantly smaller in patients with AF than in patients in sinus rhythm, 1.2 +/- 0.5 cm2 versus 1.6 +/- 0.7 cm2 (odds ratio 1.40/0.25 cm2 decrease; p = 0.0001) as was mitral valve index. The pressure-AF association with the highest statistical significance was seen with mean right atrial pressure, 10.6 +/- 4.9 mm Hg versus 7.6 +/- 3.8 mm Hg (odds ratio 2.24; p < 0.0001). Other variables with significant positive associations by univariate analysis were pulmonary artery wedge pressure, pulmonary artery mean pressure, and pulmonary resistance. When stepwise logistic multiple regression analysis was performed, the results indicated that both severity of mitral stenosis and increased right atrial pressure were independently associated with AF in this population with mitral stenosis. After adjustment was performed for these variables, age was not independently associated with AF.

Adult↗
PubMed1998

The cost and cardioprotective effects of enalapril in hypertensive patients with left ventricular dysfunction.

This study examined the effect of enalapril on survival, resource use, and cost of care in patients with left ventricular dysfunction and hypertension using a retrospective analysis of patients who participated in the Studies of Left Ventricular Dysfunction (SOLVD). Among the 6797 SOLVD participants, 1917 patients had either elevated systolic (> or = 140 mm Hg) or diastolic (> or = 90 mm Hg) blood pressure. Therapy with enalapril was associated with a significant relative risk reduction for mortality (RR = 0.819, 95% CI: 0.68 to 0.98; P = .03). This resulted in a gain of 0.11 years (95% CI: 0.00 to 0.20 years) of survival during the average 2.8 year follow-up for this subgroup and was projected to result in a gain of 2.14 years (95% CI: 0.05 to 4.21 years) during the patient's lifetime. Enalapril significantly reduced the risk of first hospitalization for heart failure by 37%. For all types of hospitalizations, there was an average reduction of 32 hospitalizations per 100 patients treated with enalapril during the trial period (95% CI: 11.8 to 52.2 hospitalizations avoided per 100 patients), resulting in an estimated net savings of $1656 per patient during the trial period (95% CI: increased cost of $191 to savings of $3502). Although the projected lifetime net savings of $1456 was not significant (95% CI: increased cost of $9243 to saving of $12,527), evaluation of the cost per life year saved indicated that enalapril represented a cost-effective strategy. The estimated clinical benefit of enalapril among the hypertensive subgroup in SOLVD supports the recommendation that angiotensin converting enzyme (ACE) inhibitors should be considered as first line pharmacologic therapy for hypertensive patients with left ventricular dysfunction. From both the clinical and economic viewpoints, ACE inhibitors provide important clinical benefits and are cost-effective.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1997

Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group.

CONTEXT: Heart failure is often preceded by isolated systolic hypertension, but the effectiveness of antihypertensive treatment in preventing heart failure is not known. OBJECTIVE: To assess the effect of diuretic-based antihypertensive stepped-care treatment on the occurrence of heart failure in older persons with isolated systolic hypertension. DESIGN: Analysis of data from a multicenter, randomized, double-blind, placebo-controlled clinical trial. PARTICIPANTS: A total of 4736 persons aged 60 years and older with systolic blood pressure between 160 and 219 mm Hg and diastolic blood pressure below 90 mm Hg who participated in the Systolic Hypertension in the Elderly Program (SHEP). INTERVENTION: Stepped-care antihypertensive drug therapy, in which the step 1 drug is chlorthalidone (12.5-25 mg) or matching placebo, and the step 2 drug is atenolol (25-50 mg) or matching placebo. MAIN OUTCOME MEASURES: Fatal and nonfatal heart failure. RESULTS: During an average of 4.5 years of follow-up, fatal or nonfatal heart failure occurred in 55 of 2365 patients randomized to active therapy and 105 of the 2371 patients randomized to placebo (relative risk [RR], 0.51; 95% confidence interval [CI], 0.37-0.71; P<.001; number needed to treat to prevent 1 event [NNT], 48). Among patients with a history of or electrocardiographic evidence of prior myocardial infarction (MI), the RR was 0.19 (95% CI, 0.06-0.53; P=.002; NNT, 15). Older patients, men, and those with higher systolic blood pressure or a history of or electrocardiographic evidence of MI at baseline had higher risk of developing heart failure. CONCLUSION: In older persons with isolated systolic hypertension, stepped-care treatment based on low-dose chlorthalidone exerted a strong protective effect in preventing heart failure. Among patients with prior MI, an 80% risk reduction was observed.

Aged↗
PubMed1997

Association of calcium channel blocker use with increased rate of acute myocardial infarction in patients with left ventricular dysfunction.

The Studies of Left Ventricular Dysfunction (SOLVD) assessed the effect of enalapril in patients with systolic left ventricular dysfunction (LVD). We performed retrospective analyses of the association between calcium channel blocker (CCB) use and fatal and nonfatal myocardial infarction (MI) in these patients. MI occurred in 11.5% of 845 patients receiving CCBs versus 7.5% of 2551 patients not receiving CCBs in the enalapril group and in 14.4% of 874 patients receiving CCBs versus 9.3% of 2527 patients not receiving CCBs in the placebo group. By multivariate Cox regression analysis, adjusting for comorbidity, cause and severity of LVD, heart failure, and concomitant drug use, CCB use was an independent predictor of MI (relative risk [RR] 1.37, confidence interval [CI] 1.14 to 1.63). The increase in MI risk was greater among patients with a higher heart rate (RR 1.46, CI 1.14 to 1.86) and lower blood pressure (RR 1.45, CI 1.14 to 1.86). The adjusted risk ratio for all-cause mortality associated with CCB use was 1.14 (CI 1.00 to 1.28; p = 0.0454). In this analysis of patients with LVD, CCB use was associated with significantly increased risk of fatal or nonfatal MI.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1997

Association of hemostatic factors with peripheral vascular disease.

Hemostatic risk factors have been well established in coronary artery disease but less well studied in peripheral vascular disease. The relationship of coagulation and fibrinolytic proteins to lower limb arterial occlusive disease and other vascular risk factors remains poorly defined. Fibrinogen, factor VII coagulant activity, von Willebrand factor (vWf) antigen, and plasminogen activator inhibitor-1 (PAI-1) activity were measured in 46 adult participants in the Arterial Disease Multiple Intervention Trial (ADMIT) and in 76 control subjects and related to ankle-brachial systolic pressure index (ABI), a measure of lower limb arterial stenosis. The primary inclusion criterion for the ADMIT study population was an average of two ABIs <0.85. Fibrinogen and PAI-1 in ADMIT subjects were significantly higher than in control subjects (331 +/- 52 mg/dl vs 273 +/- 46 mg/dl, p < 0.0001; 18.7 +/- 10 units/ml vs 13.5 +/- 8.9 units/ml, p < 0.04). There were significant correlations of fibrinogen with ABI, factor VII coagulant activity, and systolic and diastolic blood pressures; PAI-1 with body mass index and age; and factor VII coagulant activity with cholesterol levels. Logistic regression analysis, considering hemostatic variables and several known nonhemostatic risk factors of peripheral arterial disease, showed that fibrinogen and systolic blood pressure were independently associated with ABI status in this population. The results demonstrate a strong independent correlation between fibrinogen levels and the presence of lower limb arterial stenosis. PAI-1 levels were elevated in ADMIT participants, but multivariate analysis did not demonstrate an independent relationship between PAI-1 and ABI.

Aged↗
PubMed1997

Interleukin-1 response to arterial antigen, lipopolysaccharide, and oxidized low density lipoprotein in ischemic heart disease.

UNLABELLED: Monocytes responding to oxidized low density lipoprotein (LDL) or other antigens may initiate atherogenesis through production of interleukin-1 (IL-1) and additional cytokines. Interleukin-1 is chemotactic for circulating leukocytes, can stimulate growth of fibroblasts or smooth muscle cells, and causes activation of T- and B-lymphocytes. METHODS: Peripheral blood mononuclear cells (PBMCs) were isolated from 42 patients with angiographically verified ischemic heart disease (IHD) and 35 age-matched control subjects without a history of cardiac disease. Rates of proliferation and production of IL-1 beta were measured after peripheral blood mononuclear cells were cultured for 7 days in the presence of mitogens, arterial antigen, lipopolysaccharide, or native and oxidized forms of LDL. RESULTS: In patients with IHD, proliferation in response to arterial antigen was either diminished or unchanged from control values. Peripheral blood mononuclear cells from IHD and control patients had similar levels of proliferation after treatment with different mitogens. Levels of IL-1 beta, produced after stimulation with arterial antigen or lipopolysaccharide, also did not differ for PBMCs obtained from control and IHD patients. For patients with either a stable angina pattern or no history of cardiac disease, PBMC cultured in the presence of native and oxidized forms of LDL released similar amounts of IL-1 beta. In contrast, PBMCs from 4 patients with unstable angina had increased levels of IL-1 beta after culture in the presence of oxidized LDL (group means +/- standard deviation of 1.63 +/- 1.08 pg/mL for 17 control patients, 0.96 +/- 0.23 pg/mL for 4 cases with stable angina, and 4.02 +/- 5.91 pg/mL, for 19 cases with unstable angina). These values reflect a greater than 5-fold increase in variability for IL-1 beta produced on exposure to oxidized LDL for patients with unstable angina relative to control patients. CONCLUSIONS: Effects of in vitro stimulation with mitogens or lipopolysaccharide are similar for PBMC obtained from normal or IHD patients. The response to arterial antigen is also not increased in cells from patients with IHD. However, PBMCs obtained from a subset of patients with unstable angina produce greater levels of IL-1 beta after treatment with oxidized, but not native, LDL.

Adult↗
PubMed1996

Diabetes mellitus, a predictor of morbidity and mortality in the Studies of Left Ventricular Dysfunction (SOLVD) Trials and Registry.

Diabetes is an independent predictor of morbidity and mortality in patients with symptomatic heart failure, patients with asymptomatic left ventricular dysfunction (defined as an ejection fraction of 35% or less), and in a broader registry population with less stringent entry criteria. Although the SOLVD Trials made a major clinical contribution by proving the value of enalapril, diabetes remains a significant predictor of outcome even after adjusting for treatment with enalapril.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1996

Adverse effects of enalapril in the Studies of Left Ventricular Dysfunction (SOLVD). SOLVD Investigators.

In the Studies of Left Ventricular Dysfunction (LVD), enalapril or placebo was administered in a double-blind fashion to 6797 participants with ejection fraction < or = 0.35. During 40 months' average follow-up, 28.1% of participants randomized to enalapril reported side effects compared with 16.0% in the placebo group (p < 0.0001). Enalapril use was associated with a higher rate of symptoms related to hypotension (14.8% vs 7.1%, p < 0.0001), azotemia (3.8% vs 1.6%, p < 0.0001), cough (5.0% vs 2.0%, p < 0.0001), fatigue (5.8% vs 3.5%, p < 0.0001), hyperkalemia (1.2% vs 0.4%, p = 0.0002), and angioedema (0.4% vs 0.1%, p < 0.05). Side effects resulted in discontinuation of blinded therapy in 15.2% of the enalapril group compared with 8.6% in the placebo group (p < 0.0001). Thus enalapril is well tolerated by patients with LVD; however, hypotension, azotemia, cough, fatigue, and other side effects result in discontinuation of therapy in a significant minority of patients.

Aged↗
PubMed1996

Attenuation of myocardial stunning in isolated rat hearts by a 21-aminosteroid lazaroid (U74389G).

The purpose of this study was to evaluate the effects of reperfusion or in vivo pretreatment with a lipid peroxidation inhibitor, lazaroid (U74389G), on attenuating systolic and diastolic alterations occurring during myocardial stunning in isolated rat hearts. Male Sprague-Dawley rats (350-400 g) were randomized into three groups: control animals (n = 13) received no drugs; hearts from reperfused animals (n = 11) received 5 microM U74389G in the reperfusion solution; pretreated animals (n = 11) received 6 mg/kg U74389G by i.v. infusion 30 min before killing. Isolated, isovolumic rat hearts were subjected to 20 min of ischemia at 37 degrees C and subsequent reperfusion for 30 min. Left ventricular isovolumic developed pressure (LVDP), its first derivative (LVDPdP/dt), end-diastolic pressure (LVEDP), and the time constant of diastolic relaxation (tau) were measured. At baseline, no statistically significant differences were detected in systolic or diastolic function in hearts of rats with or without U74389G treatment. After reperfusion, LVDP stabilized at 87 and 92% in both drug-treated groups compared with 52% in the control group (p < 0.01) and dP/dtmax recovered to 101 and 110% of baseline compared with 58% in the control group (p < 0.01). Diastolic dysfunction showed significant improvement in both U74389G pretreatment groups. The increases in LVEDP and tau were 2.0- and 1.2-fold in pretreated hearts and 2,8-fold and 1.5-fold in drug-reperfused hearts, respectively (compared with 6-fold increases in LVEDP and a 2.5-fold increase in tau in controls; p < 0.05). In conclusion, whether administered before ischemia or during reperfusion, U74389G effectively attenuated the systolic and diastolic dysfunction in this model of myocardial stunning, probably protecting cell membranes from peroxidation by oxygen-derived metabolites.

Animals↗
PubMed1996

Antihypertensive medication use among recruits for the Trial of Nonpharmacologic Interventions in the Elderly (TONE).

OBJECTIVES: To examine the distribution and correlates of the classes of antihypertensive medications taken by persons aged 60 to 80. DESIGN: Cross-sectional screening. SETTING: Four academic medical centers in the southern and eastern United States. PARTICIPANTS: Volunteers (N = 2601) entering a clinical trial testing the value of nonpharmacologic approaches to control blood pressure who were either taking one or two (single or combined) medications for the treatment of hypertension and expressed willingness to be withdrawn from these medications according to a standardized protocol. MEASUREMENTS: Medication use, blood pressure, and data from self-administered questionnaires collected during standardized clinic visits. RESULTS: Calcium channel blockers (23.9%) were the most frequent single agent antihypertensive medications used by cohort members, followed by diuretics (17.9%) and angiotension-converting enzyme (ACE) inhibitors (17.5%). The most common combination agents were composed of diuretics with either calcium channel blockers (5.4%), ACE inhibitors (4.0%), or beta-blockers (3.7%). Women were twice as likely to be taking diuretics, and less likely to be taking ACE inhibitors and beta-blockers, than men. Blacks were more likely to be taking diuretics and calcium channel blockers, and less likely to be taking beta-blockers and ACE inhibitors, than others. These relationships could not be attributed to differences in geographical area, other demographic factors, age, or medical history. CONCLUSIONS: These usage patterns appear to mirror those in the population of the United States as a whole, which has trended toward greater usage of calcium channel blockers and ACE inhibitors with declining use of diuretics. The distribution of antihypertensive medications among older hypertensives is markedly different between women and men and between black Americans and others.

Academic Medical Centers↗
PubMed1995

Effect of diabetes mellitus on short- and long-term mortality rates of patients with acute myocardial infarction: a statewide study. Myocardial Infarction Data Acquisition System Study Group.

We studied the effect of diabetes mellitus (DM) on mortality rate in 42,595 patients in the statewide Myocardial Infarction Data Acquisition System (MIDAS), which included patients with myocardial infarction from 90 nonfederal hospitals in New Jersey during the years 1986 and 1987. Of these patients 9695 (22.8%) had DM. DM was more prevalent among female, black, and older patients. DM was associated with higher mortality rates, both in-hospital (21.5% vs 19.2%, p < 0.001) and during 3-year follow-up (46.7% vs 37.8%, p < 0.001). This relation persisted in both men and women, blacks and whites, and all age groups. DM was an independent predictor of mortality by multivariate Cox proportional hazards regression analysis after adjustments were made for gender, race, age, hypertension, left ventricular dysfunction, chronic pulmonary disease, chronic liver disease, and anemia. This effect of DM was most pronounced in the younger age groups. Relative risk was 1.87 for age group 30 to 49, 1.36 for 50 to 69, and 1.17 for 70 to 89 years (p < 0.0001).

Adult↗