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Vera Bittner

Publications and source records attributed to Vera Bittner.

At least 19 recordsLinked to original sources
PubMed2006

The economic burden of angina in women with suspected ischemic heart disease: results from the National Institutes of Health--National Heart, Lung, and Blood Institute--sponsored Women's Ischemia Syndrome Evaluation.

BACKGROUND: Coronary angiography is one of the most frequently performed procedures in women; however, nonobstructive (ie, < 50% stenosis) coronary artery disease (CAD) is frequently reported. Few data exist regarding the type and intensity of resource consumption in women with chest pain after coronary angiography. METHODS AND RESULTS: A total of 883 women referred for coronary angiography were prospectively enrolled in the National Institutes of Health--National Heart, Lung, and Blood Institute--sponsored Women's Ischemia Syndrome Evaluation (WISE). Cardiovascular prognosis and cost data were collected. Direct (hospitalizations, office visits, procedures, and drug utilization) and indirect (out-of-pocket, lost productivity, and travel) costs were estimated through 5 years of follow-up. Among 883 women, 62%, 17%, 11%, and 10% had nonobstructive and 1-vessel, 2-vessel, and 3-vessel CAD, respectively. Five-year cardiovascular death or myocardial infarction rates ranged from 4% to 38% for women with nonobstructive to 3-vessel CAD (P < 0.0001). Five-year rates of hospitalization for chest pain occurred in 20% of women with nonobstructive CAD, increasing to 38% to 55% for women with 1-vessel to 3-vessel CAD (P < 0.0001). The volume of repeat catheterizations or angina hospitalizations was 1.8-fold higher in women with nonobstructive versus 1-vessel CAD after 1 year of follow-up (P < 0.0001). Drug treatment was highest for those with nonobstructive or 1-vessel CAD (P < 0.0001). The proportion of costs for anti-ischemic therapy was higher for women with nonobstructive CAD (15% versus 12% for 1-vessel to 3-vessel CAD; P = 0.001). For women with nonobstructive CAD, average lifetime cost estimates were $767,288 (95% CI, $708,480 to $826,097) and ranged from $1,001,493 to $1,051,302 for women with 1-vessel to 3-vessel CAD (P = 0.0003). CONCLUSIONS: Symptom-driven care is costly even for women with nonobstructive CAD. Our lifetime estimates for costs of cardiovascular care identify a significant subset of women who are unaccounted for within current estimates of the economic burden of coronary heart disease.

Aged↗
PubMed2006

Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NHLBI-sponsored Women's Ischaemia Syndrome Evaluation (WISE) study.

AIMS: Women with chest pain but without obstructive coronary artery disease (CAD) are considered at low risk for cardiovascular (CV) events, but half continue to experience debilitating chest pain over many years. This study compared CV outcomes in women with persistent chest pain (PChP) vs. those without PChP. METHODS AND RESULTS: We studied 673 Women's Ischaemia Syndrome Evaluation (WISE) participants with chest pain undergoing coronary angiography for suspected myocardial ischaemia and at least 1 year of follow-up. PChP was defined as self-reported continuing chest pain after 1 year. Events occurring after that year were recorded for a median of 5.2 years. We compared CV event rates for women with and without PChP in subgroups with and without obstructive CAD. The median age was 58 years, 20% were racial minorities, 45% had PChP, 39% had obstructive CAD. Among women without CAD, those with PChP had more than twice the rate of composite CV events (P = 0.03), that included non-fatal myocardial infarctions (P = 0.11), strokes (P = 0.03), congestive heart failure (P = 0.38), and CV deaths (P = 0.73), compared with those without PChP. In women with CAD, there was no difference in composite CV events in those with and without PChP (P = 0.72). CONCLUSION: Among women undergoing coronary angiography for suspected myocardial ischaemia, PChP in women with no obstructive CAD predicted adverse CV outcomes. Such women might benefit from additional evaluation and aggressive risk factor modification therapy.

Aged↗
PubMed2006

Past oral contraceptive use and angiographic coronary artery disease in postmenopausal women: data from the National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation.

OBJECTIVE: To evaluate past oral contraceptive use and angiographic coronary artery disease in women. SETTING: Academic medical centers. PATIENT(S): Six hundred seventy-two postmenopausal women enrolled in the Women's Ischemia Syndrome Evaluation (WISE) with coronary risk factors undergoing coronary angiography for suspected myocardial ischemia. INTERVENTION(S): Past oral contraceptive use, assessed by reproductive questionnaire. MAIN OUTCOME MEASURE(S): Quantitative coronary artery disease, assessed by a core angiography laboratory. RESULT(S): Past oral contraceptive use was associated with a lower mean coronary artery disease severity index score (mean +/- SD: 11.8 +/- 10.3 vs. 18.7 +/- 17.3) compared with non-prior users, despite age adjustment. Past oral contraceptive use remained a significant independent negative predictor of coronary artery disease severity when adjusting for coronary risk factors, including age, diabetes mellitus, triglycerides, low-density lipoprotein cholesterol, smoking, aspirin use, and lipid-lowering medication (model R2 = 0.19). The modeling indicated that past oral contraceptive use was associated with a 2.44 lower coronary artery disease severity score index. There was no apparent relationship between duration of past oral contraceptive use and the coronary artery disease severity index score. CONCLUSION(S): Past oral contraceptive use is associated with less coronary artery disease, measured by quantitative coronary angiography, among postmenopausal women with suspected myocardial ischemia. These findings suggest that a prospective study should address the hypothesis that past oral contraceptive use during the premenopausal years might offer women protection from atherosclerotic coronary disease later in life.

Academies and Institutes↗
PubMed2006

Phytoestrogens and lipoproteins in women.

OBJECTIVES: We undertook a study to evaluate relationships among blood phytoestrogen levels, lipoprotein levels, estrogen levels, and angiographically defined coronary artery disease in women. BACKGROUND: Evidence for a beneficial role and the potential mechanism(s) of plant estrogens (phytoestrogens) on blood lipoproteins in humans is controversial. METHODS: We evaluated 483 women enrolled in the National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation with coronary risk factors undergoing coronary angiography for evaluation for suspected ischemia for blood phytoestrogen levels (daidzein and genistein), lipoprotein levels [total cholesterol, triglycerides, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol (HDL-C)], estrogen levels (estradiol, bioavailable estradiol, estrone), and angiographic coronary artery disease using core laboratories. RESULTS: Higher blood levels of the phytoestrogen daidzein were associated with lower triglycerides (P = 0.01), higher HDL-C (P = 0.05) levels, and a beneficial total cholesterol to HDL-C ratio (P = 0.02). This beneficial association was evident among the subgroup of women with low [<184 pmol/liter (<50 pg/ml)] blood estradiol levels, regardless of age and lipoprotein levels. The phytoestrogen associations with lipoproteins were incrementally related to the magnitude of daidzein level and independent of other lipoprotein modulators. There were no detectable relationships between the phytoestrogen levels and angiographic coronary artery disease. CONCLUSIONS: Higher blood phytoestrogen daidzein levels are associated with beneficial lipoprotein levels in women with low estrogen levels, possibly by an estrogen receptor mechanism. These results suggest a potential explanation for the variable lipoprotein results observed in prior randomized controlled trials and call for investigation regarding subgroups of subjects who may preferentially benefit from dietary intake of food products, such as soy.

Adult↗
PubMed2006

Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease.

Coronary heart disease is the leading cause of death and disability in the U.S., but recent advances have not led to declines in case fatality rates for women. The current review highlights gender-specific issues in ischemic heart disease (IHD) presentation, evaluation, and outcomes with a special focus on the results derived from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. In the second part of this review, we will assess new evidence on gender-based differences in vascular wall or metabolic alterations, atherosclerotic plaque deposition, and functional expression on worsening outcomes of women. Additionally, innovative cardiovascular imaging techniques will be discussed. Finally, we identify critical areas of further inquiry needed to advance this new gender-specific IHD understanding into improved outcomes for women.

Atherosclerosis↗
PubMed2006

Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies.

Despite a dramatic decline in mortality over the past three decades, coronary heart disease is the leading cause of death and disability in the U.S. Importantly, recent advances in the field of cardiovascular medicine have not led to significant declines in case fatality rates for women when compared to the dramatic declines realized for men. The current review highlights gender-specific issues in ischemic heart disease presentation, evaluation, and outcomes with a special focus on the results published from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. We will present recent evidence on traditional and novel risk markers (e.g., high sensitivity C-reactive protein) as well as gender-specific differences in symptoms and diagnostic approaches. An overview of currently available diagnostic test evidence (including exercise electrocardiography and stress echocardiography and single-photon emission computed tomographic imaging) in symptomatic women will be presented as well as data using innovative imaging techniques such as magnetic resonance subendocardial perfusion, and spectroscopic imaging will also be discussed.

Female↗
PubMed2006

Hypertension, menopause, and coronary artery disease risk in the Women's Ischemia Syndrome Evaluation (WISE) Study.

OBJECTIVES: We evaluated whether the relationship between hypertension, other cardiac risk factors, and coronary artery disease (CAD) is modulated by menopausal status and/or age. BACKGROUND: The relative contribution of age versus menopausal status in the development of CAD in women remains unclear. METHODS: We compared systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and traditional cardiac risk factors for CAD in premenopausal (n = 123) and postmenopausal (n = 482) women undergoing coronary angiography for suspected ischemia. To assess the relative contribution of age versus menopausal status, we fit a hypertension-menopausal status interaction term and adjusted for age. RESULTS: There were similar relationships with regard to traditional coronary risk factors and angiographic CAD in premenopausal versus postmenopausal women, with few exceptions. Twenty percent of premenopausal women had angiographic CAD versus 31% of postmenopausal women (p = 0.02). Premenopausal women had lower mean (standard deviation) SBP (132 [25] vs. 139 [20] mm Hg; p < 0.0001) and lower PP (54 [18] vs. 62 [18] mm Hg; p < 0.0001) compared to postmenopausal women; however, multivariable analyses revealed that SBP was a risk factor for CAD in premenopausal (p = 0.002) but not postmenopausal women (p = 0.13), and regression slopes were significantly different (p = 0.04). This interaction effect remained after age adjustment, suggesting independent risk contribution from both age and menopausal status. A similar slope difference was observed for PP (p = 0.03) but not for DBP. CONCLUSIONS: Among women undergoing angiography for suspected ischemia, elevated SBP and PP are potent risk factors in premenopausal women. The results suggest that identification of hypertension in premenopausal women dictates additional CAD risk factor assessment and management.

Adult↗
PubMed2006

Prediction of medical morbidity and mortality after acute myocardial infarction in patients at increased psychosocial risk in the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study.

BACKGROUND: Patients with myocardial infarction (MI) are at further increased risk for untoward events when patients also exhibit low social support and/or depression. The ENRICHD study was the largest controlled trial in post-MI patients attempting to treat these psychological comorbidities and provides an opportunity to examine the medical and psychological characteristics that may affect risk in this population. METHODS: We analyzed the baseline characteristics and their relationship to the primary end point of long-term mortality and recurrent infarction and to the secondary end points of overall mortality and cardiovascular mortality in 2481 post-MI patients. Cox proportional hazards models were used to predict the risk of these outcomes over a mean of 2.5 years of follow-up. RESULTS: Death or nonfatal MI occurred in 24.1%, all-cause mortality in 13.7%, and cardiovascular mortality in 8.4% of the sample (62% of the total). Age, heart failure, pulmonary disease, Killip class, ejection fraction, an elevated creatinine, the use of non-angiotensin-coverting enzyme asodilators, prior MI, diabetes, depression, and bypass surgery after acute MI were all significant multivariable predictors. CONCLUSIONS: The medical predictors of adverse events in post-MI patients with low social support and/or depression were similar to those of patients with MI in other clinical trials.

Area Under Curve↗
PubMed2006

Self-rated health among women with coronary disease: depression is as important as recent cardiovascular events.

BACKGROUND: Prior studies have shown an association between depression and self-rated health among patients with coronary disease. However, the magnitude of the effect of depression on self-rated health compared with that of major clinical events is unknown. Our main objective was to clarify the association between depression and self-rated health using longitudinal data. METHODS: We performed a prospective cohort study of 2675 postmenopausal women with coronary disease. The primary predictor variable was a 4-state categorical depression variable based on the Burnam depression screen assessed at sequential visits. The outcome variable was self-rated overall health (excellent, very good, or good vs fair or poor). RESULTS: After adjustment for age, comorbidities, prior self-rated health, and interim events, women with depression at both current and prior annual visits had a >5-fold increased odds of fair/poor self-rated health (odds ratio [OR] 5.1, 95% CI 3.8-6.8). New depression was associated with a >2-fold increased odds of fair/poor self-rated health (OR 2.6, 95% CI 2.0-3.4). Having a history of depression at the preceding annual visit but not at the current visit was associated with a slight increased odds of fair/poor self-rated health (OR 1.3, 95% CI 1.0-1.7). The magnitude of the impact of persistent or new depression was comparable to that of recent angina, myocardial infarction, angioplasty, heart failure, or bypass surgery. CONCLUSIONS: Women with persistent or new depression are more likely to report fair/poor self-rated health. The magnitude of the impact of persistent or new depression is comparable to that of major cardiac events.

Aged↗
PubMed2006

Migraines, angiographic coronary artery disease and cardiovascular outcomes in women.

PURPOSE: There are conflicting data regarding the association between migraines and cardiovascular events. We evaluated the relationship between migraine headaches, angiographic coronary artery disease, and cardiovascular events in women. SUBJECTS AND METHODS: The Women's Ischemia Syndrome Evaluation (WISE) study is a National Heart, Lung and Blood Institute (NHLBI)-sponsored prospective, multicenter study aiming to improve ischemia evaluation in women. A total of 944 women presenting with chest pain or symptoms suggestive of myocardial ischemia were enrolled and underwent complete demographic, medical, and psychosocial history, physical examination, and coronary angiography testing. A smaller subset of 905 women, representing a mean age of 58 years, answered questions regarding a history of migraines. We prospectively followed 873 women for 4.4 years for cardiovascular events and all-cause mortality. RESULTS: Women reporting a history of migraines (n=220) had lower angiographic coronary severity scores, and less severe (> or = 70% luminal stenosis) angiographic coronary artery disease compared to women without a history of migraines (n=685). These differences remained statistically significant after adjustment for age and other important cardiac risk factors. On prospective follow-up of a median of 4.4 years, women with a history of migraines were not more likely to have a cardiovascular event (hazard ratio [HR] 1.2; 95% confidence interval [CI], 0.93-1.58) and migraines did not predict all-cause mortality (HR 0.96; 95% CI, 0.49-1.99). CONCLUSION: Among women undergoing coronary angiography for suspected ischemia, those reporting migraines had less severe angiographic coronary artery disease. We could not support an association between migraines and cardiovascular events or death. Further research studying the common pathophysiology underlying migraines and cardiovascular disease is warranted.

Coronary Artery Disease↗
PubMed2006

Obesity distribution and reproductive hormone levels in women: a report from the NHLBI-sponsored WISE Study.

PURPOSE: Relationships between body weight and disease are not straightforward. Central obesity appears to be a relatively greater cardiovascular risk factor than generalized obesity. The purpose of this study was to evaluate body mass index (BMI) and waist circumference and the association of obesity distribution with blood estrogen levels (estradiol, bioavailable estradiol, and estrone). METHODS: The study cohort consisted of 207 postmenopausal women enrolled in the Women's Ischemia Syndrome Evaluation (WISE) undergoing angiography for evaluation of suspected ischemia. RESULTS: Both BMI and waist circumference were positively associated with all three blood estrogen levels (p < 0.01), with the highest estrogen levels found in the obese women with large waists (p < 0.01). Results from regression analyses confirmed significant associations of BMI and waist circumference with the estrogen levels. CONCLUSIONS: These results demonstrate differing relationships between blood estrogen levels and obesity distribution in a cohort of postmenopausal women with chest pain undergoing coronary angiography. The differing levels by general and central obesity may help explain in part observed epidemiological relationships between obesity and disease.

Adult↗
PubMed2006

Cardiac rehabilitation as secondary prevention center.

Coronary heart disease is the major cause of death in most industrialized countries and is increasing rapidly in many developing nations. Cardiac rehabilitation programs have evolved from predominantly exercise-based programs into comprehensive secondary prevention programs. Studies of efficacy and effectiveness of cardiac rehabilitation document reductions in mortality and improvements in clinical and behavioral outcomes beyond the improvements in morbidity and mortality already available through revascularization and effective pharmacotherapy, but cardiac rehabilitation, like many preventive measures, is under-utilized. Future research directions are outlined.

Coronary Disease↗
PubMed2006

Perspectives on dyslipidemia and coronary heart disease in women: an update.

PURPOSE OF REVIEW: Coronary heart disease remains the most common cause of death among women. This review summarizes observational studies of lipoproteins and coronary heart disease risk and randomized trials of lipid-lowering therapy among women and reviews progress in the implementation of proven therapies in clinical practice. RECENT FINDINGS: Recent studies confirm the strong relationship between lipoproteins and coronary heart disease development among women and extend these observations to more diverse populations. The apoprotein B/A-1 ratio is emerging as the strongest marker of coronary heart disease risk while enthusiasm for the importance of small dense LDL particles appears to be waning. International observational data re-affirm the importance of traditional risk factors in coronary heart disease development. Recent clinical trials suggest that intensive therapy with statins may provide incremental benefits. While there is progress in awareness, treatment and control of dyslipidemia, substantial proportions of women (and men) remain untreated or undertreated in the US and elsewhere. SUMMARY: Dyslipidemia and coronary heart disease risk among women are closely linked. The benefits of lipid-lowering treatment are well documented, but the full potential of such therapies has yet to be realized, in part due to delayed diagnosis of dyslipidemia, underutilization of therapy by providers, and poor adherence to treatment among patients.

Apolipoproteins↗
PubMed2005

Perspectives on dyslipidemia and coronary heart disease in women.

Coronary heart disease (CHD) remains the leading cause of death among American women. Numerous differences exist between younger and older women and between women and men with respect to the pathology of CHD and its incidence and prevalence over the life cycle. Differences in lipoprotein levels and lipid fractions play an important role in CHD risk. Hormonal influences on lipoprotein levels in women are complex, change throughout the life span, and are influenced by the administration of oral contraceptives and hormone replacement therapy. Women with obesity, metabolic syndrome, or diabetes have lipid profiles that adversely affect CHD risk. To date, no randomized trials testing the impact of lifestyle changes on lipoprotein levels and subsequent CHD events in non-institutionalized women have been performed, and women have not been well represented in clinical end point trials of pharmacologic lipid-lowering therapy. Available evidence suggests that lipid-lowering therapy with statins does provide benefit in reducing the risk of coronary events in women; however, women remain undertreated, and more data are needed to determine optimal cardiovascular prevention and treatment in this population.

Coronary Disease↗
PubMed2005

The relation of postmenopausal hormone therapy to serum uric acid and the risk of coronary heart disease events: the Heart and Estrogen-Progestin Replacement Study (HERS).

PURPOSE: To determine whether baseline serum uric acid (UA) levels and estrogen-progestin (E+P)-associated change in serum UA in postmenopausal women with coronary disease are associated with recurrent coronary heart disease (CHD) events. METHODS: 2763 postmenopausal women enrolled in the Heart and Estrogen-Progestin Replacement Study (HERS) were randomly assigned to take conjugated E+P or placebo in a secondary CHD prevention study. The primary outcome for these analyses was nonfatal myocardial infarction or CHD death during a mean follow up of 4.1 years. RESULTS: The baseline serum UA for the cohort was 5.4 mg/dl and, compared with placebo, E+P on average lowered serum UA levels slightly (0.2 mg/dl) at one year of follow up (p<0.0001). Baseline serum UA levels were associated in simple proportional hazards models with CHD events; each standard deviation increase (1.3 mg/dl) was associated with a 22% increased risk of primary CHD events (p=.0001). This association, however, was no longer statistically significant after multivariable adjustment (p=0.36). There was no association between on-study change in serum UA level and any CHD outcome. CONCLUSION: Treatment with E+P lowered serum UA levels slightly, but neither baseline UA nor change in UA affected CHD risk.

Aged↗
PubMed2005

Impaired fasting glucose and cardiovascular outcomes in postmenopausal women with coronary artery disease.

BACKGROUND: Type 2 diabetes increases risk for cardiovascular disease. Persons with impaired fasting glucose levels may also have increased risk. OBJECTIVE: To evaluate the association between glucose status and cardiovascular outcomes and the effect of lowering the fasting glucose level criterion for impaired fasting glucose from a lower limit of 6.1 mmol/L (110 mg/dL) to 5.6 mmol/L (100 mg/dL). DESIGN: Prospective cohort study. SETTING: 20 U.S. clinical centers. PATIENTS: 2763 postmenopausal women with established coronary heart disease (CHD) who were followed for 6.8 years. MEASUREMENTS: Any CHD event (nonfatal myocardial infarction or CHD death), stroke or transient ischemic attack (TIA), congestive heart failure (CHF) hospitalization, and any cardiovascular event. RESULTS: During follow-up, 583 women had a CHD event, 329 women had a stroke or TIA, and 348 women were hospitalized for CHF. Women with diabetes were at an approximately 75% increased risk for each outcome compared with normoglycemic women. The 218 women with impaired fasting glucose according to the 1997 definition (fasting glucose level, 6.1 to 6.9 mmol/L [110 to 125 mg/dL]) had increased risk for any CHD event (hazard ratio, 1.37 [95% CI, 1.08 to 1.74]), while the 698 women with impaired fasting glucose according to the 2003 definition (fasting glucose level, 5.6 to 6.9 mmol/L [100 to 125 mg/dL]) were not at increased risk (hazard ratio, 1.09 [CI, 0.90 to 1.34]). Most of the women (n = 480) with fasting glucose levels between 5.6 mmol/L (100 mg/dL) and 6.0 mmol/L (109 mg/dL) had no increased risk for CHD (hazard ratio, 0.90 [CI, 0.73 to 1.12]). Women with impaired fasting glucose according to either definition were not at increased risk for stroke or TIA or CHF. LIMITATIONS: These findings may not be generalizable to men or women without existing heart disease. CONCLUSIONS: Among postmenopausal women with coronary artery disease, the 2003 definition for impaired fasting glucose was not associated with increased risk for new CHD, stroke or TIA, or CHF.

Aged↗
PubMed2005

Depression and heart failure in patients with a new myocardial infarction.

BACKGROUND: Heart failure (HF) is a disabling chronic illness that is increasing in prevalence. Despite advances in its medical treatment, little is known about its psychosocial correlates. This investigation compared the prevalence of depression in patients with and without HF who were hospitalized with myocardial infarction (MI) and also at high psychosocial risk. METHODS: Baseline data from the 2444 participants in the ENRICHD clinical trial were used. Within 28 days of the MI, all patients were assessed for depression using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, for HF based upon left ventricular dysfunction or history of HF and for demographic and medical confounders. RESULTS: Eight hundred forty-seven patients (34.7%) met the criteria for HF. Major depression was observed in 43% in the HF group compared with 36% in the non-HF group (P < .001). Multivariate modeling showed a 38% increase in odds of HF for patients with major depression, after adjustment for sociodemographic factors and medical comorbidities (adjusted OR 1.38, 95% CI 1.09-1.76). CONCLUSIONS: These findings suggest that in patients with new MI who are at psychosocial risk, major depression is more prevalent in those who also have HF. Because major depression undermines adherence and lowers quality of life, special efforts to diagnose and treat it in post-MI patients with HF appear warranted.

Aged↗