In This Issue of Archives of Internal Medicine FREE

Ibrahim et al conducted an analysis of 15 116 patient discharges with a primary diagnosis of pulmonary embolism from 186 acute care hospitals in Pennsylvania (January 2000–November 2002). In this statewide sample, thrombolytic therapy was used infrequently and was associated with a higher risk of both 30-day and in-hospital mortality in the large subgroup of patients with relatively low predicted probability of receiving thrombolysis, based on characteristics at presentation. Major bleeding was an uncommon complication of thrombolytic therapy.

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To evaluate the association of depression and antidepressant therapy with long-term mortality, O’Connor et al studied 1006 patients 18 years or older with clinical heart failure (HF) and an ejection fraction of 35% or lower. They found that 30% of patients in the study were depressed (Beck Depression Inventory score ≥10), and 24.2% of these patients were taking antidepressants. During a mean (SD) follow-up of 972 (731) days, 42.7% of the study participants died. Overall, the use of antidepressants was associated with increased mortality (unadjusted hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.03-1.69). However, the association between antidepressants and increased mortality no longer existed after controlling for depression and other confounders (HR, 1.24; 95% CI, 0.94-1.64). Nonetheless, depression remained associated with increased mortality after adjustment for baseline confounders and antidepressant use (HR, 1.33; 95% CI, 1.07-1.66). Thus, this study suggests that depression, but not antidepressant use, is associated with increased mortality in patients with HF.

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A nested case-control study found that 12 of 23 inflammatory, lipid, and thrombotic biomarkers (and 1 genetic marker) were associated with risk of coronary heart disease (CHD) in the Women's Health Initiative trials of postmenopausal hormone therapy (HT) (estrogen and estrogen plus progestin compared with placebo). The associations tended to be stronger during the first 2 years of the trials. Several biomarkers changed in response to HT. However, with the exception of baseline low-density lipoprotein cholesterol level (and possibly high-density lipoprotein cholesterol level), the biomarkers did not identify a subset of women who were at higher risk of CHD due to HT. Women with higher levels of low-density lipoprotein cholesterol were at significantly higher risk of CHD due to estrogen plus progestin therapy during the first 4 years of the trial. The findings suggest that it may be useful to measure the lipid profile prior to initiating HT.

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Eguchi et al sought to examine if short sleep is associated with incident cardiovascular disease (CVD). Ambulatory blood pressure (BP) monitoring was performed at baseline in 1255 hypertensive subjects (mean [SD] age, 70.4 [9.9] years), who were followed up for 50 (23) months. The authors found that short duration of sleep (defined as <7.5 hours) was associated with an increased risk of CVD, and a synergistic interaction was observed between short sleep duration and the riser pattern (sleep BP > awake BP). Short duration of sleep is associated with incident CVD risk, and the combination of riser pattern and short duration of sleep is most strongly predictive of future CVD.

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Impaired kidney function is associated with increased mortality risk in older adults. It remains unknown, however, whether longitudinal declines in kidney function are independently associated with increased cardiovascular and all-cause mortality in this population. In an analysis from the Cardiovascular Health Study, Rifkin et al calculated change in estimated glomerular filtration rate over 7 years of follow-up, using both cystatin C and creatinine-based measures of kidney function. Then they examined the relationship between rapid declines in kidney function (>mL/min/1.73 m² per year) and mortality. Rapid decline by either measure of kidney function was associated with 50% to 70% increases in risk of cardiovascular and all-cause mortality in older adults, independent of baseline kidney function and other demographic variables. This result suggests that both the baseline level of kidney function and changes in kidney function over time should be considered risk factors for mortality in older adults.

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