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Vera Bittner

Publications and source records attributed to Vera Bittner.

52 records · Page 3Linked to original sources
PubMed2003

Women in cardiac rehabilitation.

Women have been underrepresented in both cardiac rehabilitation (CR) clinical care and research studies. This review summarizes the available data on women in CR, including referral and enrollment patterns, baseline characteristics, and sex-specific outcomes reported within each core component of care. Women in CR tend to be older than their male counterparts and to have a greater burden of comorbidities and coronary risk factors and lower functional status. Women and men seem to benefit equally from CR, with improvements in clinical, psychosocial, and behavioral outcomes, but sex-specific data are lacking for several of the core components of care. Future research needs to test single and multiple behavioral interventions in randomized controlled trials, paying particular attention to their sex specificity, feasibility, and cost-effectiveness within CR and secondary prevention programs.

Adult↗
PubMed2002

Cholesterol-lowering medication, cholesterol level, and reproductive hormones in women: the Women's Ischemia Syndrome Evaluation (WISE).

PURPOSE: Reproductive hormones such as estrogen, progesterone, and testosterone are synthesized from a common cholesterol precursor pathway. We hypothesized that use of statins and the resultant lower blood lipoprotein levels would be associated with lower reproductive hormone levels in women. We also sought to evaluate this association, independent of statin use, particularly among premenopausal women of childbearing age. METHODS: We enrolled 453 (114 pre-, 30 peri-, and 309 postmenopausal) women with coronary risk factors (mean [+/- SD] age, 58 +/- 13 years) who were undergoing coronary angiography for suspected ischemia at four academic medical centers. Blood lipoprotein levels (total cholesterol, triglycerides, low-density lipoprotein [LDL] cholesterol, high-density lipoprotein cholesterol) and serum reproductive hormone levels (estradiol, bioavailable estradiol, estrone, progesterone) were measured. RESULTS: Use of statins was associated with lower lipoprotein levels, but not lower reproductive hormone levels, in all women. Mean estradiol levels were not significantly lower among premenopausal women with very low LDL cholesterol levels compared with women with higher LDL cholesterol levels (estradiol: 71 +/- 52 pg/mL vs. 88 +/- 67 pg/mL, P = 0.32). CONCLUSION: Among women undergoing coronary angiography for suspected myocardial ischemia, the use of statins, or lower cholesterol levels, are not associated with significantly lower levels of reproductive hormones.

Adult↗
PubMed2002

Effects of hormone replacement therapy and antioxidant vitamin supplements on coronary atherosclerosis in postmenopausal women: a randomized controlled trial.

CONTEXT: Hormone replacement therapy (HRT) and antioxidant vitamins are widely used for secondary prevention in postmenopausal women with coronary disease, but no clinical trials have demonstrated benefit to support their use. OBJECTIVE: To determine whether HRT or antioxidant vitamin supplements, alone or in combination, influence the progression of coronary artery disease in postmenopausal women, as measured by serial quantitative coronary angiography. DESIGN, SETTING, AND PATIENTS: The Women's Angiographic Vitamin and Estrogen (WAVE) Trial, a randomized, double-blind trial of 423 postmenopausal women with at least one 15% to 75% coronary stenosis at baseline coronary angiography. The trial was conducted from July 1997 to January 2002 in 7 clinical centers in the United States and Canada. INTERVENTIONS: Patients were randomly assigned in a 2 x 2 factorial design to receive either 0.625 mg/d of conjugated equine estrogen (plus 2.5 mg/d of medroxyprogesterone acetate for women who had not had a hysterectomy), or matching placebo, and 400 IU of vitamin E twice daily plus 500 mg of vitamin C twice daily, or placebo. MAIN OUTCOME MEASURE: Annualized mean (SD) change in minimum lumen diameter (MLD) from baseline to concluding angiogram of all qualifying coronary lesions averaged for each patient. Patients with intercurrent death or myocardial infarction (MI) were imputed the worst rank of angiographic outcome. RESULTS: The mean (SD) interval between angiograms was 2.8 (0.9) years. Coronary progression, measured in mean (SD) change, worsened with HRT by 0.047 (0.15) mm/y and by 0.024 (0.15) mm/y with HRT placebo (P =.17); and for antioxidant vitamins by 0.044 (0.15) mm/y and with vitamin placebo by 0.028 (0.15) mm/y (P =.32). When patients with intercurrent death or MI were included, the primary outcome showed an increased risk for women in the active HRT group (P =.045), and suggested an increased risk in the active vitamin group (P =.09). Fourteen patients died in the HRT group and 8 in the HRT placebo group (hazard ratio [HR], 1.8; 95% confidence interval [CI], 0.75-4.3), and 16 in the vitamin group and 6 in the vitamin placebo group (HR, 2.8; 95% CI, 1.1-7.2). Death, nonfatal MI, or stroke occurred in 26 HRT patients vs 15 HRT controls (HR, 1.9; 95% CI, 0.97-3.6) and in 26 vitamin patients and 18 vitamin controls (HR, 1.5; 95% CI, 0.80-2.9). There was no interaction between the 2 treatment interventions. CONCLUSION: In postmenopausal women with coronary disease, neither HRT nor antioxidant vitamin supplements provide cardiovascular benefit. Instead, a potential for harm was suggested with each treatment.

Aged↗
PubMed2002

Non-high-density lipoprotein cholesterol levels predict five-year outcome in the Bypass Angioplasty Revascularization Investigation (BARI).

BACKGROUND: Current National Cholesterol Education Program guidelines recommend that non-high-density lipoprotein cholesterol (non-HDL-C) be considered a secondary target of therapy among individuals with triglycerides >2.26 mmol/L. It is not known whether non-HDL-C relates to prognosis among patients with coronary heart disease. METHODS AND RESULTS: Lipid levels were available at baseline among 1514 patients (73% men; mean age, 61 years) enrolled in the Bypass Angioplasty Revascularization Investigation (BARI); all had multivessel coronary artery disease. Patients were followed for 5 years. Outcomes of death, nonfatal myocardial infarction, and death or myocardial infarction were modeled using univariate and multivariate time-dependent proportional hazards methods; angina pectoris at 5 years was modeled using univariate and multivariate logistic regression. Non-HDL-C was a strong and independent predictor of nonfatal myocardial infarction (multivariate relative risk, 1.049 [95% confidence intervals, 1.006 to 1.093] for every 0.26 mmol/L increase) and angina pectoris (multivariate odds ratio, 1.049 [95% confidence intervals, 1.004 to 1.096] for every 0.26 mmol/L increase), but it did not relate to mortality. HDL-C and LDL-C did not predict events during follow-up. CONCLUSIONS: Among patients with lipid values in BARI, non-HDL-C is a strong and independent predictor of nonfatal myocardial infarction and angina pectoris at 5 years, even after consideration of powerful clinical variables. Our data suggest that non-HDL-C is an appropriate treatment target among patients with coronary heart disease.

Angina Pectoris↗
PubMed2002

Lipoprotein abnormalities related to women's health.

Although women have a greater life expectancy than men and tend to develop coronary artery disease (CAD) 10 to 20 years later than men, the burden of CAD in women is high, with a lifetime risk >20%. Beginning at puberty, women have more favorable lipoprotein profiles than men. High-density lipoprotein (HDL) cholesterol levels remain higher in women than men throughout their lifetime. Low-density lipoprotein (LDL) cholesterol levels in women exceed those in men after middle age, but despite a shift toward smaller, denser LDL particles at the time of menopause, LDL particle number remains lower in women than in men throughout the lifespan. Lipoprotein levels strongly predict incident and recurrent CAD events in both sexes, and LDL particle size may be a better predictor of premature CAD in women than of CAD associated with advanced age. The effects of postmenopausal hormonal therapy on lipoprotein levels are complex, and the benefits of such therapy are not established. In contrast, lifestyle changes and pharmacological lipid-lowering therapy have been shown to favorably influence the natural course of atherosclerotic disease and reduce cardiovascular events in men and women.

Adult↗
PubMed2002

Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II).

CONTEXT: The Heart and Estrogen/progestin Replacement Study (HERS) found no overall reduction in risk of coronary heart disease (CHD) events among postmenopausal women with CHD. However, in the hormone group, findings did suggest a higher risk of CHD events during the first year, and a decreased risk during years 3 to 5. OBJECTIVE: To determine if the risk reduction observed in the later years of HERS persisted and resulted in an overall reduced risk of CHD events with additional years of follow-up. DESIGN AND SETTING: Randomized, blinded, placebo-controlled trial of 4.1 years' duration (HERS) and subsequent unblinded follow-up for 2.7 years (HERS II) conducted at outpatient and community settings at 20 US clinical centers. PARTICIPANTS: A total of 2763 postmenopausal women with CHD and average age of 67 years at enrollment in HERS; 2321 women (93% of those surviving) consented to follow-up in HERS II. INTERVENTION: Participants were randomly assigned to receive 0.625 mg/d of conjugated estrogens and 2.5 mg of medroxyprogesterone acetate (n = 1380), or placebo (n = 1383) during HERS; open-label hormone therapy was prescribed at personal physicians' discretion during HERS II. The proportions with at least 80% adherence to hormones declined from 81% (year 1) to 45% (year 6) in the hormone group, and increased from 0% (year 1) to 8% (year 6) in the placebo group. MAIN OUTCOME MEASURES: The primary outcome was nonfatal myocardial infarction and CHD death. Secondary cardiovascular events were coronary revascularization, hospitalization for unstable angina or congestive heart failure, nonfatal ventricular arrhythmia, sudden death, stroke or transient ischemic attack, and peripheral arterial disease. RESULTS: There were no significant decreases in rates of primary CHD events or secondary cardiovascular events among women assigned to the hormone group compared with the placebo group in HERS, HERS II, or overall. The unadjusted relative hazard (RH) for CHD events in HERS was 0.99 (95% confidence interval [CI], 0.81-1.22); HERS II, 1.00 (95% CI, 0.77-1.29); and overall, 0.99 (0.84-1.17). The overall RHs were similar after adjustment for potential confounders and differential use of statins between treatment groups (RH, 0.97; 95% CI, 0.82-1.14), and in analyses restricted to women who were adherent to randomized treatment assignment (RH, 0.96; 95% CI, 0.77-1.19). CONCLUSIONS: Lower rates of CHD events among women in the hormone group in the final years of HERS did not persist during additional years of follow-up. After 6.8 years, hormone therapy did not reduce risk of cardiovascular events in women with CHD. Postmenopausal hormone therapy should not be used to reduce risk for CHD events in women with CHD.

Aged↗
PubMed2002

Statin therapy, cardiovascular events, and total mortality in the Heart and Estrogen/Progestin Replacement Study (HERS).

BACKGROUND: Although effects of statins on cardiovascular outcomes are well established in men, fewer data exist for women. Furthermore, the effects of statins plus hormone replacement therapy (HRT) on cardiovascular outcomes are uncertain. METHODS AND RESULTS: We examined statin use, cardiovascular events, and total mortality in the Heart and Estrogen/progestin Replacement Study (HERS), a randomized clinical trial of estrogen plus progestin versus placebo in postmenopausal women with heart disease (n=2763). A nonrandomized comparison of statin users and nonusers revealed lower rates of the primary outcome, nonfatal myocardial infarction or coronary heart disease death (relative hazard [RH]=0.79, 95% confidence intervals [CI] 0.63 to 0.99, P=0.04), and total mortality (RH=0.67, 95% CI 0.51 to 0.87, P=0.003). Rates of venous thromboembolic events were also lower among statin users (RH=0.45, 95% CI 0.23 to 0.88, P=0.02). HRT resulted in a significant increase in early risk for primary events in women who did not use statins (RH=1.75, 95% CI 1.02 to 3.03, P=0.04) but not in statin users (RH=1.34, 95% CI 0.63 to 2.86, P=0.45). Adjustment for postrandomization statin use showed no effect of HRT on risk for the primary outcome (RH=0.96, 95% CI 0.77 to 1.29; P=0.72). CONCLUSIONS: In HERS, statin use was associated with lower rates of cardiovascular events, venous thromboembolic events, and total mortality. These data provide strong support for statin use in eligible women with coronary disease.

Aged↗
PubMed2002

Factor V Leiden, hormone replacement therapy, and risk of venous thromboembolic events in women with coronary disease.

Oral contraceptive use in women with factor V Leiden is associated with increased rates of venous thromboembolic events (VTEs). However, the effects of hormone replacement therapy (HRT) in postmenopausal women with factor V Leiden are not known. A nested case-control study was conducted among women with established coronary disease enrolled in 2 randomized clinical trials of HRT, the Heart and Estrogen/Progestin Replacement Study (HERS) and the Estrogen Replacement and Atherosclerosis (ERA) trial. The Leiden mutation was present in 8 (16.7%) of 48 cases with VTE compared with only 7 (6.3%) of 112 controls (odds ratio [OR](Leiden) 3.3, 95% CI 1.1 to 9.8; P=0.03). In women without the factor V Leiden mutation, risk associated with HRT use was significantly increased (OR(HRT) 3.7, 95% CI 1.4 to 9.4; P<0.01). On the other hand, in women with the factor V Leiden mutation, the estimated risk associated with HRT was increased nearly 6-fold, although the CIs were wide and included unity (OR(HRT) 5.7, 95% CI 0.6 to 53.9; P=0.13). The OR for women with the Leiden mutation who were also assigned to HRT compared with wild-type women assigned to placebo was 14.1 (95% CI 2.7 to 72.4, P=0.0015). In women with the factor V Leiden mutation who were treated with HRT, the estimated absolute incidence of VTE was 15.4 of 1000 per year compared with 2.0 of 1000 per year in women without the mutation who were taking a placebo (P=0.0015). On the basis of these data, in women with coronary disease, the estimated number needed to screen for factor V Leiden to avoid an HRT-associated VTE during 5 years of treatment is 376. If factor V Leiden genotyping becomes less expensive, it could be cost effective to screen for the presence of the mutation before instituting HRT in women with coronary disease.

Aged↗
PubMed2002

Women's angiographic vitamin and estrogen trial: design and methods.

The Women's Angiographic Vitamin and Estrogen trial was a randomized, double-blind, placebo-controlled study designed to test the efficacy of estrogen replacement and antioxidant vitamins for preventing angiographic progression of coronary artery disease. Postmenopausal women with one or more angiographically documented coronary stenoses of 15-75% at baseline were assigned in a 2 x 2 factorial randomization to active hormone replacement therapy (conjugated estrogens for women who had had a hysterectomy or conjugated estrogens with medroxyprogesterone for women with intact uteri) or placebo and to active vitamins E and C or their placebos. Seven clinical centers, five in the United States and two in Canada, randomized 423 women between July 1997 and July 1999. Quantitative coronary angiography was performed at baseline and repeated after projected mean follow-up of 3 years.

Antioxidants↗
PubMed2002

Women and coronary heart disease risk factors.

The prevalence of cardiovascular risk factors among women is high and cardiovascular risk factors often occur in clusters. Strong relationships between exposure to cigarette smoke, physical inactivity, hypertension, and abnormal levels of lipoproteins and homocysteine and subsequent coronary heart disease (CHD) in women are evident from many studies, while the impact of menopause, psychosocial factors, and inflammatory markers is less clear and requires further study. Observational studies document that smoking cessation reduces CHD risk among persons with and without existing CHD, and that moderate levels of physical activity are associated with lower CHD risk. Clinical trials over the last decade have convincingly shown that treatment of hypertension and dyslipidemia reduces CHD risk in both genders, but many women (and men) with hypertension and dyslipidemia remain either untreated or under-treated.

Coronary Disease↗
PubMed2002

Prehospital delay in individuals with acute coronary disease: concordance of medical records and follow-up phone interviews.

Patient-associated delay in seeking medical care in persons with acute coronary disease is receiving increasing importance given the time-dependent benefits associated with myocardial reperfusion therapies. We examined the extent of concordance between self-reported information about prehospital delay provided by patients to hospital staff at the time of hospitalization for coronary disease compared with information obtained from a telephone interview approximately 2 months following hospital discharge. The sample included 316 patients with acute myocardial infarction or unstable angina at 43 hospitals who had delay time information available from both data sources. The extent of agreement between the medical record and telephone accounts of delay was 47% in the total study sample, 53% in patients with acute myocardial infarction, and 40% in patients with unstable angina. These results suggest that a telephone interview carried out several months following hospitalization for acute coronary disease may not provide sufficiently reliable information about prehospital delay.

Aged↗
PubMedDate not supplied

Validity and reliability of the NYHA classes for measuring research outcomes in patients with cardiac disease.

The New York Heart Association (NYHA) functional classification system was developed to help physicians in clinical practice evaluate the effect of cardiac symptoms on a patient's daily activities. Over time, the role of the NYHA classification system has expanded, and it is now frequently used in clinical research. This review of the literature was undertaken to explore whether the NYHA classes have sufficient validity and reliability to serve as a functional outcome measure in research studies. After exploring its strengths and limitations, we conclude that the NYHA classes are a valid measure of functional status, a concept that is distinct from functional capacity and functional performance. The reproducibility of the NYHA functional classification system has not been established in the literature. Researchers are urged to report the methods for determining NYHA class, the training of raters, and the intra-rater or inter-rater reliability in studies that have multiple raters or measurements. Until the reliability of the NYHA functional classification system is determined, it is prudent to refrain from using the NYHA classes as the sole outcome measure of change in function in research studies of cardiac patients.

Clinical Trials as Topic↗
PubMedDate not supplied

Factors associated with the failure of patients to complete cardiac rehabilitation for medical and nonmedical reasons.

PURPOSE: Cardiac rehabilitation (CR) provides effective secondary prevention services, but many patients fail to complete the recommended program. The purposes of this study were to describe completion rates in a hospital-based outpatient CR program, and to identify factors associated with patients failing to complete CR because of nonmedical and medical reasons. METHODS: Data used for the analyses were from a hospital-based CR program involving 526 discharged patients between January 1996 and February 2002. Patient discharge status was classified into three categories: complete, noncomplete-medical reasons, and noncomplete-nonmedical reasons. Logistic regression modeling identified factors associated with the groups failing to complete CR. RESULTS: The rate of CR completion was 58% (304/526). Among the 222 patients who did not complete CR, 139 (63%) had nonmedical reasons. As compared with the patients who completed CR, the adjusted odds ratio (AOR) for those who did not complete CR because of nonmedical reasons were more likely to be employed (AOR 2.2), to be obese (AOR 2.5), to be smokers (AOR 2.1), and to have shorter 6-minute walk distances (AOR 1.7). They were less likely to be women (AOR 0.6) or have diabetes (AOR 0.5). Patients not completing CR for medical reasons were more likely to be categorized as being at high clinical risk (AOR 4.2) and having shorter 6-minute walk distances (AOR 1.9). CONCLUSION: Except for low functional capacity, baseline factors associated with patients failing to complete CR differed on the basis of medical or nonmedical reasons. The development of interventions that address the special needs of patients with low functional capacity may be especially important in attempts to retain this high-risk group in CR therapy.

Aged↗
PubMedDate not supplied

Optimizing risk stratification in cardiac rehabilitation with inclusion of a comorbidity index.

PURPOSE: The risk stratification criteria of the American Association of Cardiovascular and Pulmonary Rehabilitation include guidelines to be used in stratifying cardiac rehabilitation (CR) patients for risk of disease progression (long term) and clinical events (short term). Noncardiac comorbidities are not included as indicators in these criteria. This study was designed to ascertain the prevalence of noncardiac comorbidities among CR patients, and to assess their relation to the current risk stratification algorithm for clinical events. METHODS: Patients were stratified into high-, intermediate-, and low-risk groups according to the American Association of Cardiovascular and Pulmonary Rehabilitation risk stratification criteria for clinical events (ARSE) at program entry. Within each risk group, age, gender, race, and noncardiac comorbidities were ascertained. Comorbidities were summarized in a comorbidity index (CMI). The relation between clinical events and risk status by ARSE and CMI was evaluated by logistic regression. RESULTS: Among 490 patients (age, 60 +/- 12 years; 35% women; 30% nonwhite) enrolled in CR with ischemic heart disease, the number of comorbidities ranged from 0 to 7 (median, 2; 75th percentile, 3). The patients categorized in the three ARSE groups differed significantly in age and comorbidities. Although ARSE tended to identify patients with a greater comorbidity burden, 38% of the patients with a comorbidity index exceeding the 75th percentile were not classified in the highest ARSE group. Clinical events increased across ARSE and CMI risk strata. Both ARSE and CMI were independent predictors of events in an age-, gender-, and race-adjusted logistic regression analysis (ARSE odds ratio [OR], 1.56; 95% confidence interval [CI], 1.14-2.12; CMI OR, 1.23, 95% CI, 1.03a-1.47). Events were predicted best when both classifications were combined. Exploratory gender-specific analyses suggested that ARSE performed better among men than among women, whereas CMI was a more important predictor among women. CONCLUSIONS: To appreciate more fully the overall complexity of disease among CR patients, ARSE should be supplemented not only with the inclusion of cardiac risk factors, as suggested in the current guidelines, but also with an assessment of noncardiac comorbidities.

Age Factors↗
PubMedDate not supplied

Physical activity patterns among women in rural Alabama.

OBJECTIVE: To explore factors associated with physically active women in a rural community. METHODS: Physical activity patterns were assessed in 585 women in rural Alabama. RESULTS: When combining leisure and nonleisure activities, 68% of women reported > or = 150 minutes per week. Active African American women tended to be younger (AOR 0.97), married (AOR 1.75), less likely to report arthritis (AOR 0.58), or give health (AOR 0.30) or motivational reasons (AOR 0.39) for not being more active; active white women were less likely to report lower health perception (AOR 0.51). CONCLUSION: Ethnic differences in factors associated with higher activity levels need to be considered in physical activity interventions.

Adult↗