Domburg, R.T. van

Feasibility and Observer Reproducibility of Speckle Tracking Echocardiography in Congenital Heart Disease Patients (Article)

2013-03-19T00:00:00Z

Aims: The twisting motion of the heart has an important role in the function of the left ventricle. Speckle tracking echocardiography is able to quantify left ventricular (LV) rotation and twist. So far this new technique has not been used in congenital heart disease patients. The aim of our study was to investigate the feasibility and the intra- and inter-observer reproducibility of LV rotation parameters in adult patients with congenital heart disease. Methods and Results: The study population consisted of 66 consecutive patients seen in the outpatient clinic (67% male, mean age 31 ± 7.7 years, NYHA class 1 ± 0.3) with a variety of congenital heart disease. First, feasibility was assessed in all patients. Intra- and inter-observer reproducibility was assessed for the patients in which speckle tracking echocardiography was feasible. Adequate image quality, for performing speckle echocardiography, was found in 80% of patients. The bias for the intra-observer reproducibility of the LV twist was 0.0°, with 95% limits of agreement of -2.5° and 2.5° and for interobserver reproducibility the bias was 0.0°, with 95% limits of agreement of -3.0° and 3.0°. Intra- and inter-observer measurements showed a strong correlation (0.86 and 0.79, respectively). Also a good repeatability was seen. The mean time to complete full analysis per subject for the first and second measurement was 9 and 5 minutes, respectively. Conclusion: Speckle tracking echocardiography is feasible in 80% of adult patients with congenital heart disease and shows excellent intra- and inter-observer reproducibility.

Health care utilisation after defibrillator implantation for primary prevention according to the guidelines in 2 Dutch academic medical centres (Article)

2011-12-14T00:00:00Z

Background The benefit of implantable defibrillators (ICDs) for primary prevention remains debated. We analysed the implications of prophylactic ICD implantation according to the guidelines in 2 tertiary hospitals, and made a healthcare utilisation inventory. Methods The cohort consisted of all consecutive patients with coronary artery disease (CAD) or dilated cardiomyopathy (DCM) receiving a primary prophylactic ICD in a contemporary setting (2004-2008). Follow-up was obtained from hospital databases, and mortality checked at the civil registry. Additional data came from questionnaires sent to general practitioners. Results There were no demographic differences between the 2 centres; one had proportionally more CAD patients and more resynchronisation therapy (CRT-D). The 587 patients were followed over a median of 28 months, and 50 (8.5%) patients died. Appropriate ICD intervention occurred in 123 patients (21%). There was a small difference in interventionfree survival between the 2 centres. The questionnaires revealed 338 hospital admissions in 52% of the responders. Device-related admissions happened on 68 occasions, in 49/ 276 responders. The most frequently reported ICD-related admission was due to shocks (20/49 patients); for other cardiac problems it was mainly heart failure (52/99). Additional outpatient visits occurred in 19%. Conclusion Over a median follow-up of 2 years, one fifth of prophylactic ICD patients receive appropriate interventions. A substantial group undergoes readmission and additional visits. The high number of admissions points to a very ill population. Overall mortality was 8.5%. The 2 centres employed a similar procedure with respect to patient selection. One centre used more CRT-D, and observed more appropriate ICD interventions.

Prognostic significance of baseline ST-T-wave abnormalities in diagnostic stress echocardiography (Article)

2011-12-01T00:00:00Z

Objective: The aim of this study was to determine whether resting ST-T wave abnormalities (ST-Ta) provide incremental prognostic information in patients with no history of coronary artery disease undergoing dobutamine stress echocardiography (DSE). Methods: We evaluated 1308 consecutive patients without previous myocardial infarction (MI) or revascularization who underwent DSE. Ischemia was defined as new or worsening wall motion abnormalities. End points during follow-up were all-cause death and cardiac death/nonfatal MI. Results: ST-Ta were detected in 162 (12%) patients. The incidence of ischemia was higher in patients with baseline ST-Ta than patients without [74 (46%) vs. 327 (28%), P=0.00001]. During a follow-up of 4.6±3 years, cardiac death/nonfatal MI occurred in 42 (26%) patients with resting ST-Ta and in 157 (14%) patients without resting ST-Ta (P<0.001). Patients with ST-Ta had a higher annual cardiac death/nonfatal MI rate compared with patients without, both in the presence of normal DSE (3.2 vs. 1.4%, P=0.01) as well as abnormal DSE (5.3 vs. 3%, P<0.001). In a Cox proportional modeling, resting ST-Ta added incremental value over clinical and stress echocardiographic data for the prediction of death (global χ 125, 140, 150, respectively; P<0.05) and cardiac death/nonfatal MI (global χ 79, 100, 111, respectively; P<0.05). Conclusion: Baseline ST-Ta are associated with an increased risk of cardiac death/nonfatal MI and all-cause mortality, incremental to clinical data and DSE results. The associated risk is persistent among patients with normal DSE.

Serial in vivo intravascular ultrasound-based echogenicity changes of everolimus-eluting bioresorbable vascular scaffold during the first 12 months after implantation: Insights from the ABSORB B trial (Article)

2011-12-01T00:00:00Z

Because the bioresorption of the ABSORB bioresorbable vascular scaffold (Abbott Vascular, Santa Clara, California) is characterized by a diminishing gray-level intensity of the struts over time, the evaluation of quantitative changes in hyperechogenicity can be useful to follow the in vivo degradation of the scaffold. Whereas the first ABSORB generation showed at 6 months a 50% reduction in hyperechogenicity, the second ABSORB generation (1.1), designed to prolong the duration of luminal scaffolding, showed a 15% and 20% reduction in hyperechogenicity at 6 and 12 months, respectively, compared with post-implantation. These findings confirm the value of the manufacturing changes and suggest a slower degradation rate of the scaffold. This study sought to investigate quantitative and homogeneity differential echogenicity changes of the ABSORB scaffold (1.1) during the first year after implantation. The imaging of the ABSORB bioresorbable vascular scaffold degradation by intravascular ultrasound (IVUS) has previously demonstrated diminishing gray-level intensity of the struts over time that can be evaluated by IVUS-based differential echogenicity. The first generation of ABSORB (1.0) showed a 50% reduction in hyperechogenicity at 6 months and restoration of the pre-ABSORB implantation values at 2 years. The second generation of ABSORB (1.1), investigated in the ABSORB B trial, was modified to prolong the duration of luminal scaffolding. A total of 63 patients were examined by IVUS immediately post-implantation and at 6-month (Cohort B1, n = 28) or 12-month (Cohort B2, n = 35) follow-up. IVUS-based tissue composition analysis software was used to quantify changes in hyperechogenicity over time in the scaffolded regions. Relative changes in hyperechogenicity were calculated as: 100 × (% hyperechogenicity at follow-up - % hyperechogenicity at baseline)/% hyperechogenicity at baseline. At 6- and 12-month follow-up, there was a 15% (from 22.58 ± 9.77% to 17.42 ± 6.69%, p = 0.001) and 20% (from 23.51 ± 8.57% to 18.25 ± 7.19%, p < 0.001) reduction in hyperechogenicity, respectively, compared with post-implantation values. No difference in hyperechogenicity changes were observed between the proximal, medial, or distal part of the scaffolded segment. Quantitative differential echogenicity changes of the ABSORB scaffold (1.1) during the first 12 months after implantation are lower compared with those previously observed with its first generation (1.0), confirming the value of the manufacturing changes and suggesting a slower degradation rate of the scaffold.

Changes in clinical profile, treatment, and mortality in patients hospitalised for acute myocardial infarction between 1985 and 2008 (Article)

2011-11-02T00:00:00Z

Objectives: To quantify the impact of the implementation of treatment modalities into clinical practice since 1985, on outcome of patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI). Methods: All consecutive patients admitted for STEMI or NSTEMI at the Thoraxcenter between 1985 and 2008 were included. Baseline characteristics, pharmacological and invasive treatment modalities, and survival status were collected. The study population was categorised in three groups of patients: those hospitalised between 1985-1990, 1990-2000, and 2000-2008. Results: We identified 14,434 patients hospitalised for myocardial infarction (MI). Both STEMI and NSTEMI patients were increasingly treated with the current guideline based therapy. In STEMI, at 30 days following admission, cumulative mortality rate decreased from 17% in 1985-1990 to 13% in 1990-2000, and to 6% in 2000-2008. Adjusted 30-day and three-year mortality in the last period was 80% and 68% lower than in 1985, respectively. In NSTEMI, at 30 days following admission, cumulative mortality rate decreased from 6% in 1985-1990 to 4% in 1990-2000, and to 2% in 2000-2008. Adjusted 30-day and three-year mortality in the last period was 78% and 49% lower than in 1985, respectively. For patients admitted between 2000 and 2008, 3 year survival of STEMI and NSTEMI patients was 87% and 88%, respectively. Conclusions: Our results indicate substantial improvements in acute- and long-term survival in patients hospitalised for MI, related to improved acute- as well as long-term treatment. Early medical evaluation in suspected MI and intensive early hospital treatment both remain warranted in the future.

Intra-individual changes in anxiety and depression during 12-month follow-up in percutaneous coronary intervention patients (Article)

2011-11-01T00:00:00Z

Background: Only a paucity of studies focused on intra-individual changes in anxiety and depression over time and its correlates in cardiac patients, which may contribute to the identification of high-risk patients and point to targets for intervention. We examined changes in anxiety and depression over a 12-month period and the demographic and clinical correlates of change scores using an intra-individual approach in patients treated with percutaneous coronary intervention (PCI). Methods: Consecutive PCI patients (N = 715) completed the Hospital Anxiety and Depression Scale (HADS) at baseline and at 12 months post-PCI. Individual change scores were calculated and in secondary analysis, three categories of change were identified (i.e., stable, improved, and deteriorated anxiety or depression). Results: The mean individual change was -.16 (± 3.0) for anxiety and -.02 (± 2.8) for depression. In linear regression analysis, baseline anxiety levels (B = -.25, 95%CI[-.30 to -.20], p = <.001) and baseline depression levels (B = -.28, 95%CI[-.33 to -.22], p = <.001) were significant correlates of individual change scores. Secondary analysis showed that anxiety remained stable in 76.4% (546/715) of patients, while depression remained stable in 81.4% (582/715) of patients. Conclusions: The findings of the current study showed that levels of anxiety and depression remained stable in the majority of PCI patients from the index PCI to 12 months post-PCI. Future studies using an intra-individual approach are warranted to further examine individual changes in anxiety and depression over time in CAD, and PCI in particular, as a means to bridge the gap between research and clinical practice.

Heart and mind: Are we closer to disentangling the relationship between emotions and poor prognosis in heart disease? (Article)

2011-10-01T00:00:00Z

Timing and potential mechanisms of new conduction abnormalities during the implantation of the Medtronic CoreValve System in patients with aortic stenosis (Article)

2011-08-01T00:00:00Z

AimsNew-onset left bundle branch block (LBBB) and complete atrioventricular block (AV3B) frequently occur following transcatheter aortic valve implantation (TAVI). We sought to determine the timing and potential mechanisms of new conduction abnormalities (CAs) during TAVI, using the Medtronic CoreValve System (MCS).Methods and resultsSixty-five consecutive patients underwent TAVI with continuous 12-lead ECG analysis. New CAs were defined by the occurrence of LBBB, RBBB, and/or AV3B after the following pre-defined time points: (i) crossing of valve with stiff wire, (ii) positioning of balloon catheter in the aortic annulus, (iii) balloon valvuloplasty, (iv) positioning of MCS in the left ventricular outflow tract (LVOT), (v) expansion of MCS, (vi) removal of all catheters. A new CA occurred during TAVI in 48 patients (74) and after TAVI in 5 (8). Of the 48 patients with procedural CAs, a single new CA occurred in 43 patients (90) and two types of CAs in 5 (10). A new LBBB was seen in 40 patients (83), AV3B in 9 (19), and RBBB in 4 (8). The new CA first occurredin descending order of frequencyafter balloon valvuloplasty in 22 patients (46), MCS expansion in 14 (29), MCS positioning in 6 (12), positioning of balloon catheter in 3 (6), wire-crossing of aortic valve in 2 (4), and after catheter removal in 1 patient (2). Patients who developed a new CA during balloon valvuloplasty had a significantly higher balloon/annulus ratio than those who did not (1.10 ± 0.10 vs. 1.03 ± 0.11, P 0.030). No such relationship was found with the valve/annulus ratio.ConclusionTranscatheter aortic valve implantation with the MCS was associated with new CAs in 82 of which more than half occurred before the actual valve implantation. It remains to be elucidated by dedicated studies whether new CAs can be reduced by appropriate balloon sizinga precept that also holds for valve size given the observed directional signal of the valve size/aortic annulus ratio.

Indications and outcome of implantable cardioverter-defibrillators for primary and secondary prophylaxis in patients with noncompaction cardiomyopathy (Article)

2011-08-01T00:00:00Z

Prophylactic ICDs for Noncompaction Cardiomyopathy. Background: Noncompaction cardiomyopathy (NCCM) is a rare, primary cardiomyopathy, with initial presentation of heart failure, emboli, or arrhythmias, including sudden cardiac death. Implantable cardioverter-defibrillators (ICDs) are frequently used for primary and secondary prevention in different cardiomyopathy patients, but data about ICD in NCCM are scarce. The aim of this study was, therefore, to investigate ICD indications and outcomes in NCCM patients. Methods and Results: We collected prospective data from our NCCM cohort (n = 77 pts, mean age: 40 ± 14 years). ICD was implanted in 44 (57%) patients with NCCM according to the current ICD guidelines for nonischemic cardiomyopathies: in 12 for secondary prevention (7 × ventricular fibrillation, 5 × sustained ventricular tachycardia [VT]) and in 32 patients for primary prevention (heart failure/severe LV dysfunction). During a mean follow-up of 33 ± 24 months, 8 patients presented with appropriate ICD shocks due to sustained VT after median 6.1 [1-16] months. This included 4 of 32 (13%) patients in the primary prevention group and 4 of 12 (33%) in the secondary prevention group (P = 0.04). 9 patients presented with inappropriate ICD therapy: 6 (19%) in the primary and 3 (25%) in the secondary prevention group, at a median follow-up of 4 (2-23) months. Conclusions: In our cohort of NCCM patients, an ICD was frequently implanted for primary or secondary prevention of sudden cardiac death. At follow-up, frequent appropriate ICD therapy was observed in both groups, supporting the application of current ICD guidelines for primary and secondary prevention of sudden cardiac death in NCCM.

Impact of body mass index on the five-year outcome of patients having percutaneous coronary interventions with drug-eluting stents (Article)

2011-07-15T00:00:00Z

The purpose of this study was to assess the impact of body mass index (BMI) on clinical outcome of patients treated by percutaneous coronary intervention (PCI) using drug-eluting stents. Patients were stratified according to BMI as normal (<25 kg/m2), overweight (25 to 30 kg/m2), or obese (>30 kg/m2). At 5-year follow-up all-cause death, myocardial infarction, clinically justified target vessel revascularization (TVR), and definite stent thrombosis were assessed. A complete dataset was available in 7,427 patients, of which 45%, 22%, and 33% were classified according to BMI as overweight, obese, and normal, respectively. Mean age of patients was significantly older in those with a normal BMI (p <0.05). Incidence of diabetes mellitus, hypertension, and dyslipidemia increased as BMI increased (p <0.05). Significantly higher rates of TVR (15.3% vs 12.8%, p = 0.02) and early stent thrombosis (1.5% vs 0.9%, p = 0.04) were observed in the obese compared to the normal BMI group. No significant difference among the 3 BMI groups was observed for the composite of death/myocardial infarction/TVR or for definite stent thrombosis at 5 years, whereas the normal BMI group was at higher risk for all-cause death at 5 years (obese vs normal BMI, hazard ratio 0.74, confidence interval 0.53 to 0.99, p = 0.05; overweight vs normal BMI, hazard ratio 0.73, confidence interval 0.59 to 0.94, p = 0.01) in the multivariate Cox proportional hazard model. Age resulted in a linearly dependent covariate with BMI in the all-cause 5-year mortality multivariate model (p = 0.001). In conclusion, the "obesity paradox" observed in 5-year all-cause mortality could be explained by the higher rate of elderly patients in the normal BMI group and the existence of colinearity between BMI and age. However, obese patients had a higher rate of TVR and early stent thrombosis and a higher rate of other risk factors such as diabetes mellitus, hypertension, and hypercholesterolemia.

First-line evaluation of coronary artery disease with coronary calcium scanning or exercise electrocardiography (Article)

2011-06-20T00:00:00Z

Background: Although conventional (CAG) and computed tomography angiography (CTA) are reliable diagnostic modalities for exclusion of obstructive coronary artery disease (CAD), they are costly and with considerable exposure to radiation and contrast media. We compared the accuracy of coronary calcium scanning (CCS) and exercise electrocardiography (X-ECG) as less expensive and non-invasive means to rule out obstructive CAD. Methods: In a rapid-access chest pain clinic, 791 consecutive patients with stable chest pain were planned to undergo X-ECG and dual-source CTA with CCS. According to the Duke pre-test probability of CAD patients were classified as low (< 30%), intermediate (30-70%) or high risk (> 70%). Angiographic obstructive CAD (> 50% stenosis by CAG or CTA) was found in 210/791 (27%) patients, CAG overruling any CTA results. Results: Obstructive CAD was found in 12/281 (4%) patients with no coronary calcium and in 73/319 (23%) with a normal X-ECG (p < 0.001). No coronary calcium was associated with a substantially lower likelihood ratio compared to X-ECG; 0.11, 0.13 and 0.13 vs. 0.93, 0.55 and 0.46 in the low, intermediate and high risk group. In low risk patients a negative calcium score reduced the likelihood of obstructive CAD to less than 5%, removing the need for further diagnostic work-up. CCS could be performed in 754/756 (100%) patients, while X-ECG was diagnostic in 448/756 (59%) patients (p < 0.001). Conclusions: In real-world patients with stable chest pain CCS is a reliable initial test to rule out obstructive CAD and can be performed in virtually all patients.

Anhedonia is associated with poor health status and more somatic and cognitive symptoms in patients with coronary artery disease (Article)

2011-06-01T00:00:00Z

Purpose: The effectiveness of cardiac rehabilitation (CR) in patients with coronary artery disease (CAD) is moderated by negative emotions and clinical factors, but no studies evaluated the role of positive emotions. This study examined whether anhedonia (i.e. the lack of positive affect) moderated the effectiveness of CR on health status and somatic and cognitive symptoms. Methods: CAD patients (n = 368) filled out the Hospital Anxiety and Depression Scale (HADS) to assess anhedonia at the start of CR, and the Short-Form Health Survey (SF-36) and the Health Complaints Scale (HCS) at the start of CR and at 3 months to assess health status and somatic and cognitive symptoms, respectively. Results: Adjusting for clinical and demographic factors, health status improved significantly during the follow-up (F(1,357) = 10.84, P = .001). Anhedonic patients reported poorer health status compared with non-anhedonic patients, with anhedonia exerting a stable effect over time (F(1,358) = 34.80, P < .001). Somatic and cognitive symptoms decreased over time (F(1,358) = 3.85, P = .05). Anhedonics experienced more benefits in terms of somatic and cognitive symptoms over time (F(1,358) = 13.00, P < .001). Conclusion: Anhedonic patients reported poorer health status and higher levels of somatic and cognitive symptoms prior to and after CR. Somatic and cognitive symptoms differed as a function of anhedonia over time, but health status did not. Anhedonia might provide a new avenue for secondary prevention in CAD.

Exercise ankle brachial index adds important prognostic information on long-term out-come only in patients with a normal resting ankle brachial index (Article)

2011-06-01T00:00:00Z

Background: The clinical value of exercise ankle brachial index (ABI) is still unclear, especially in patients with normal resting ABI. Method: 2164 patients performed a single-stage treadmill exercise test to diagnose or evaluate PAD. The population was divided into two groups: a normal resting ABI (resting ABI ≥ 0.90) and PAD (resting ABI < 0.90). Patients with a normal resting ABI were divided into 4 exercise ABI groups: exercise ABI < 0.90, 0.90-0.99, 1.00-1.09 and 1.10-1.29 (reference). Results: Mean follow-up was 5. years. Exercise ABI added significant prognostic information on all cause long-term mortality only in patients with normal resting ABI (p-value 0.014, HR 0.99 95% CI (0.98-0.99)), not in patients with PAD. Fifty years or older (OR 2.93 95% CI (1.65-5.20)) and resting systolic blood pressure > 140. mmHg (OR 2.18 95% CI (1.35-3.55)) were associated with an abnormal exercise ABI in patients with a normal resting ABI. Mortality rate increased when the exercise ABI became worse (p trend 0.0001) with a 2.5-fold increase mortality risk in patients with a normal resting ABI but exercise ABI <0.90 (HR 2.56, 95% CI (1.11-5.91)). Conclusion: In patients with a normal resting ABI, treadmill exercise ABI added important prognostic information on long-term mortality. Based on our results we recommend that at least all patients suspected for PAD, with a resting ABI ≥ 0.90, who are 50. years or older and having hypertension should undergo treadmill exercise testing.

EuroHeart score for the evaluation of in-hospital mortality in patients undergoing percutaneous coronary intervention (Article)

2011-06-01T00:00:00Z

AimsThe applicability of currently available risk prediction models for patients undergoing percutaneous coronary interventions (PCIs) is limited. We aimed to develop a model for the prediction of in-hospital mortality after PCI that is based on contemporary and representative data from a European perspective. Methods and resultsOur analyses are based on the Euro Heart Survey of PCIs, which contains information on 46 064 consecutive patients who underwent PCI for different indications in 176 participating European centres during 200508. Patients were randomly divided into a training (n = 23 032) and a validation (n = 23 032) set with similar characteristics. In these sets, 339 (1.5) and 305 (1.3) patients died during hospitalization, respectively. On the basis of the training set, a logistic model was constructed that related 16 independent patient or lesion characteristics with mortality, including PCI indication, advanced age, haemodynamic instability, multivessel disease, and proximal LAD disease. In both the training and validation data sets, the model had a good performance in terms of discrimination (C-index 0.91 and 0.90, respectively) and calibration (HosmerLemeshow P-value 0.39 and 0.18, respectively). Conclusion In-hospital mortality in PCI patients was well predicted by a risk score that contains 16 factors. The score has strong applicability for European practices.

Exercise blood pressure response and perioperative complications after major vascular surgery (Article)

2011-06-01T00:00:00Z

Objective: Earlier studies have shown that hypertensive or hypotensive blood pressure (BP) response during a preoperative treadmill exercise test in patients with peripheral arterial disease is associated with a two-fold increased risk of cardiovascular events and mortality. However, it is unknown if these patients also experience an increased perioperative complication risk at major vascular surgery. Methods: In total 665 consecutive patients with peripheral arterial disease underwent elective major vascular surgery (carotid endarterectomy, abdominal aorta repair, or lower extremity revascularization). Perioperative complications (infection, myocardial infarction, angina pectoris, cardiac arrhythmia, heart failure, cerebrovascular accident or spinal cord ischemia, dialyses, amputation, thrombectomy, reoperation or death) were defined as occurring within 30 days after surgery and were collected using medical records. Hypertensive BP response was defined as a difference between exercise systolic BP and resting systolic BP of more than 55 mmHg. Hypotensive BP response was defined as a drop in exercise systolic BP below resting systolic BP. Results: Patients with a hypertensive BP response during a preoperative exercise test (n=66) showed a higher risk of early perioperative thrombectomy [hazard ratio (HR) 2.80 95% CI (1.24-6.33)] compared with patients with a normal BP response (n=582). Patients with a hypotensive BP response (n=18) showed an increased risk of perioperative myocardial infarction [HR 3.69 95% CI (1.08-12.64)] and cardiac complications [HR 2.90 95% CI (1.02-8.19)] compared with patients with a normal BP response. Conclusion: Patients with an abnormal BP response have more cardiovascular complications at elective major vascular surgery.

Primary percutaneous coronary intervention by magnetic navigation compared with conventional wire technique (Article)

2011-06-01T00:00:00Z

AimsComparison of magnetic guidewire navigation in percutaneous coronary intervention (MPCI) vs. conventional percutaneous coronary intervention (CPCI) for the treatment of acute myocardial infarction.Methods and resultsWe compared 65 sequential patients (mean age 61 ± 15 years) undergoing primary MPCI with those of 405 patients undergoing CPCI (mean age 61 ± 13 years). The major endpoint was contrast media use. Technical success and procedural outcomes were evaluated. Clinical demographics and angiographic characteristics of the two groups were similar, except for fewer patients with previous coronary artery bypass grafting (CABG) and hypertension in the CPCI group and fewer patients with diabetes in the MPCI group. The technical success rate was high in both the MPCI and CPCI groups (95.4 vs. 98). There was significantly less contrast media usage in the MPCI compared with the CPCI group, median reduction of contrast media of 30 mL with an OR 0.41 (0.210.81). Fluoroscopy times were significantly reduced for MPCI compared with CPCI, median reduction of 7.2 min with an OR 0.42 (0.200.79).ConclusionThis comparison indicates the feasibility and non-inferiority of magnetic navigation in performing primary PCI and suggests the possibility of reductions in contrast media use and fluoroscopy time compared with CPCI.

In-hospital complications after transcatheter aortic valve implantation revisited according to the valve academic research consortium definitions (Article)

2011-05-13T00:00:00Z

Objectives: To determine the occurrence of in-hospital complications after transcatheter aortic valve implantation (TAVI) according to the Valve Academic Research Consortium (VARC) criteria in addition to the length of stay (LOS). Background: The absence of uniformity in endpoint definitions challenges the comparison between previously reported major adverse cerebro- and cardiovascular event rates after TAVI. To address this, in 2009, the VARC was established aiming to provide standardized endpoint definitions for TAVI clinical trials. Methods: Between November 2005 and September 2010, we prospectively enrolled 150 consecutive patients who underwent TAVI with the Medtronic CoreValve System in our institution. Complications, prosthetic valve associated endpoints, and therapy-specific endpoints were defined according to the definitions provided by the VARC. Results: The mean age (±SD) was 81 (±7) years and 55% were female. Thirty-day or in-hospital mortality was 11%, and the 30-day combined safety endpoint was 22%. Seventy-six patients (51%) had ≥1 cardiovascular and/or noncardiovascular complication of whom 16 also underwent a new permanent pacemaker implantation (PPI). In the 74 patients with uneventful TAVI, 12 patients (8%) underwent PPI. TAVI was truly uneventful in 62 patients (41%). Bleeding complications were observed most frequently (31%), followed by acute kidney injury (18%), vascular complications (16%), and stroke/TIA (11%). The median LOS in patients with a complicated and a truly uncomplicated TAVI was 14.0 (8.0-20.5) and 8.0 (7.0-10.8) days, respectively (P < 0.001). Conclusion: TAVI was associated with ≥1 cardiovascular and/or noncardiovascular event in 51% of the patients; new PPI was needed in another 8%, and TAVI was truly uncomplicated in 41%. Complications and need for new PPI significantly prolonged LOS.

Six-month clinical follow-up of the Tryton side branch stent for the treatment of bifurcation lesions: A two center registry analysis (Article)

2011-05-01T00:00:00Z

Background: Treatment of bifurcation lesions with the Tryton Sidebranch stent has been shown to be feasible with an acceptable clinical outcome and low side branch late loss in the first in man trial. Objective: To report acute procedural and six month clinical follow-up after the use of the Tryton Sidebranch stent in an "all comer" registry. Methods: The first 100 coronary bifurcation lesions assigned for treatment with the Tryton stent were included in a prospective registry. Procedural and angiographic success rates were determined from patient charts and pre- and postprocedural quantitative coronary angiography. Results: Totally, 96 patients with 100 lesions were included in the study. Seventy-two percent presented with stable angina, 25% with unstable angina/NSTEMI, and 3% STEMI. The bifurcation was located in the left main in 8%. Two lesions were chronic total occlusions. Sixty-nine percent were true bifurcation lesions. One failure of stent delivery occurred. Acute gain in SB was 0.76 ± 0.64mm and three patients had residual stenosis of >30%. Angiographic success rate was 95%; procedural success rate reached 94%. Peri-procedural MI occurred in two and there was one cardiac death during hospitalization. At a median six months follow-up, TLR rate was 4%, MI 3%, and cardiac death 1%. The percentage MACE-free survival at six months was 94%. No cases of definite stent thrombosis occurred. Conclusions: In a real world the use of the Tryton Sidebranch stent is associated with good procedural safety and angiographic success rate and acceptable outcome at six months of follow-up.

Contrast echocardiography improves interobserver agreement for wall motion score index and correlation with ejection fraction (Article)

2011-05-01T00:00:00Z

Background: The wall motion score index (WMSI) is a surrogate for left ventricular ejection fraction (LV-EF), which becomes unreliable in poor echo windows. The value of contrast LV opacification (LVO) for WMSI assessment is not well known. Objectives: We sought to compare interobserver agreement for WMSI and the correlation between the LVO-WMSI and LV-EF using two-dimensional second harmonic (SH) and LVO echocardiography. Methods: The study comprised 100 consecutive patients (57 ± 13 years, 85% males). Two independent physicians assessed LV segmental quality and wall motion for both the SH and LVO studies according to a 17-segment model. Systolic wall motion was defined as: normokinesia, hypokinesia (systolic inward endocardial motion <7 mm), akinesia, and dyskinesia. LV-EF was assessed from the LVO images according to the biplane modified Simpson's method. Results: Of the 1,700 analyzed segments, 453 (26.6%) were poorly visualized with SH imaging, and 173 (10.2%) with LVO (P < 0.0001). The two observers agreed on segmental wall motion score in 1,299 segments (agreement 76%, Kappa 0.60) with SH imaging and in 1,491 segments (agreement 88%, Kappa 0.78) with LVO. Interobserver correlation (r2) was 0.86 for the SH-WMSI and 0.93 for the LVO-WMSI. The limits-of-agreement for interobserver LVO-WMSI (mean difference -1.0%± 6.8%, agreement -14.6%, 12.6%) was lower than that for SH-WMSI (mean difference -2.3%± 10.1%, agreement -22.5, 17.9). The LVO-WMSI correlated well with LV-EF (r2= 0.71). LV-EF could be estimated according to the formula 1.01 - 0.32 × WMSI. Conclusion: Echo-contrast improves interobserver agreement for wall motion scoring and the WMSI. The LVO-imaged WMSI correlates well with LV-EF.

Frequency, determinants, and prognostic effects of acute kidney injury and red blood cell transfusion in patients undergoing transcatheter aortic valve implantation (Article)

2011-05-01T00:00:00Z

Objectives: To determine the frequency and independent predictors of acute kidney injury (AKI) in addition to the prognostic implications of both AKI and periprocedural red blood cell (RBC) transfusions on 30 day and cumulative late mortality in patients undergoing transcatheter aortic valve implantation (TAVI). Background: RBC transfusions have been reported to predict AKI following TAVI. Data on the prognostic implications of both factors, however, are lacking. Methods: 126 consecutive patients underwent TAVI with the Medtronic CoreValve Revalving System. AKI was defined according to the valve academic research consortium definitions as an absolute increase in serum creatinine ≥0.3 mg dL-1(≥26.4 μmol L-1) or a percentage increase ≥50% within 72 hr following TAVI. Results: Five patients on chronic haemodialysis and three intraprocedural deaths were excluded, leading to a final study population of 118 patients. AKI occurred in 19% of the patients necessitating temporary haemodialysis in 2%. Independent predictors of AKI included: previous myocardial infarction (OR: 5.72; 95% CI: 1.64-19.94), periprocedural (<24 hr) RBC transfusions (OR: 1.29; 95% CI: 1.01-1.70), postprocedural (<72 hr) leucocyte count (OR: 1.18; 95% CI: 1.02-1.37), and logistic EuroSCORE (OR: 1.08; 95% CI: 1.01-1.14). In patients with AKI, 30-day mortality was 23% and cumulative late mortality (median: 13 months) was 55%. AKI (OR: 5.47; 95% CI: 1.23-24.21) and postprocedural leucocyte count (OR: 1.20; 95% CI: 1.03-1.38) were independent predictors of 30-day mortality while AKI (HR: 2.79; 95% CI: 1.36-5.71) was the only independent predictor of late mortality. Conclusions: AKI following TAVI occurred in 19% of the patients. RBC transfusion was found to be an independent predictor of AKI, which in turn predicted both 30-day and cumulative late mortality.

Value of the SYNTAX score in patients treated by primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: The MI SYNTAXscore study (Article)

2011-04-01T00:00:00Z

Aims: The aims of this study were to evaluate the SYNTAX score (SXscore) calculated at 2 stages during a primary percutaneous intervention (PPCI), that is, SXscore I (diagnostic) and SXscore II (postwiring), and assess its additional value to standard clinical risk scores in acute myocardial infarction. Methods and Results: SXscores I and II were applied to 736 consecutive acute ST-elevation myocardial infarction patients referred for PPCI between November 2006 and February 2008. SXscore changed significantly before (I: 16, interquartile range 9.5-23) and after wiring (II: 11, interquartile range 6-19), P < .001. Kaplan-Meier methods were used to compare the primary end point major adverse coronary events (MACE; composite of repeat MI, target vessel revascularization [TVR], and mortality) and secondary end point mortality at 1.5 years in tertiles of SXscore I and SXscore II. Major adverse coronary event was highest in the higher SXscore I tertile (11% vs 15% vs 23%, log-rank <0.01), driven primarily by increased rate of mortality (9% vs 11% vs 17%, log-rank 0.02). Major adverse coronary event was also highest in SXscore II tertile, by a combination of increased mortality and also TVR (TVR rate 2% vs 3% vs 9%, log-rank <0.01). Predictive Cox regression models for mortality and MACE were significantly and similarly improved by the addition of either SXscore I or SXscore II (hazard ratio 1.63, 95% CI 1.18-2.26, P < .01 for MACE) with respective c indices of 0.61 and 0.63 for MACE and 0.60 and 0.61 for mortality. Conclusions: SXscore during PPCI is a useful tool that provides additional risk stratification to known risk factors of long-term mortality and MACE in patients with ST-elevation myocardial infarction.

Encouraging survival rates in patients with acute myocardial infarction treated with an intra-aortic balloon pump (Article)

2011-03-01T00:00:00Z

Objective To evaluate a 30-day and long-term outcome of patients with acute myocardial infarction (AMI) treated with intra-aortic balloon pump (IABP) counterpulsation and to identify predictors of a 30-day and long-term all-cause mortality. Methods Retrospective cohort study of 437 consecutive AMI patients treated with IABP between January 1990 and June 2004. A Cox proportional hazards model was used to identify predictors of a 30-day and long-term all-cause mortality. Results Mean age of the study population was 61±11 years, 80% of the patients were male, and 68% had cardiogenic shock. Survival until IABP removal after successful haemodynamic stabilisation was 78% (n=341). Cumulative 30-day survival was 68%. Median follow-up was 2.9 years (range, 6 months to 15 years). In patients who survived until IABP removal, cumulative 1-, 5-, and 10-year survival was 75%, 61%, and 39%, respectively. Independent predictors of higher long-term mortality were prior cerebrovascular accident (hazard ratio (HR), 1.8; 95% confidence interval (CI), 1.0-3.4), need for antiarrhythmic drugs (HR, 2.3; 95% CI, 1.5-3.3), and need for renal replacement therapy (HR, 2.3; 95% CI, 1.2-4.3). Independent predictors of lower long-term mortality were primary percutaneous coronary intervention (PCI; HR, 0.6; 95% CI, 0.4-1.0), failed thrombolysis with rescue PCI (HR, 0.5; 95% CI, 0.3-0.9), and coronary artery bypass grafting (HR, 0.3; 95% CI, 0.1-0.5). Conclusions Despite high in-hospital mortality in patients with AMI treated with IABP, a favourable number of patients survived in the long-term. These results underscore the value of aggressive haemodynamic support of patients throughout the acute phase of AMI.

Left ventricular mass regression one year after transcatheter aortic valve implantation (Article)

2011-03-01T00:00:00Z

Background: Left ventricular (LV) hypertrophy is associated with LV diastolic dysfunction and constitutes a risk factor for cardiac morbidity and mortality. The objective of this study was to investigate the degree of LV mass regression and the changes of LV diastolic function one year after transcatheter aortic valve implantation (TAVI). Methods Echocardiography was performed at baseline, before discharge, and at one-year follow-up in 63 consecutive patients with severe aortic stenosis who underwent TAVI with the Medtronic CoreValve System (Medtronic Inc, Minneapolis, MN). The LV mass was calculated using the Devereux formula and indexed to body surface area. Results One-year all-cause mortality was 29%. The LV mass index decreased from 126 ± 42 g/m2at baseline to 110 ± 30 g/m2at one-year follow-up (p < 0.001). Left ventricular ejection fraction and LV diastolic function did not change significantly. Mean transaortic gradient decreased from 47 ± 19 mm Hg at baseline to 9 ± 5 mm Hg at discharge and 9 ± 4 mm Hg at one year (p < 0.001), and was accompanied by significant clinical improvement. More than mild paravalvular aortic regurgitation was found in 24% and 15% of patients at discharge and one-year follow-up, respectively. Conclusions A significant regression in LV mass was found one year after TAVI. However, regression was incomplete and was not accompanied by an improvement in LV diastolic function.

Minor elevations in troponin i are associated with mortality and adverse cardiac events in patients with atrial fibrillation (Article)

2011-03-01T00:00:00Z

Aims In patients with atrial fibrillation, minor troponin I elevation is regularly detected; however, the prognostic significance of this finding is unknown. We therefore sought to examine the prognostic value of elevated troponin I in patients with atrial fibrillation. Methods and results A prospective study was conducted analysing all consecutive patients admitted with atrial fibrillation in a 2-year period. Patients with an ST-elevation myocardial infarction (MI) were excluded. Minor troponin elevation was defined as a troponin I level between 0.15 and 0.65 ng/mL, which is still below the 99th percentile of the upper reference limit. A positive troponin I was defined as >0.65 ng/mL. Study outcomes were all-cause mortality (death), death and myocardial infarction (death/MI), or all major adverse cardiac events (MACE: death, MI, or revascularization). A total of 407 patients were eligible for inclusion. The median duration of follow-up was 688 days. A minor elevation occurred in 81 (20) patients and 77 (19) had a positive troponin I. In a multivariate model, minor troponin I elevation and a positive troponin I were independently associated with death [hazard ratio (HR): 2.36, 95 confidence interval (CI): 1.174.73 for minor elevation and HR: 3.77, 95 CI: 1.4210.02 for positive troponin I]. Also, there was an independent correlation between the combined endpoints of death/MI and MACE and both a minor elevation and a positive troponin I. Conclusion Minor elevations in troponin I on hospital admission are associated with mortality and cardiac events in patients with atrial fibrillation and might be useful for risk stratification.

Late outcome after intracoronary beta radiation brachytherapy: A matched-propensity controlled ten-year follow-up study (Article)

2011-01-01T00:00:00Z

Aims: Increased major adverse cardiac events (MACE) beyond six months after intracoronary β radiation brachytherapy (IRBT) are a major concern. The aim of this study was to evaluate the 10-year clinical outcome after IRBT. Methods and results: From 1997 to 2002, 301 consecutive patients treated with IRBT were included prospectively, whereafter 602 control patients treated with conventional percutaneous coronary intervention (PCI) were matched by propensity score methodology. MACE was defined as all-cause death, any myocardial infarction or any revascularisation. Median follow-up duration was 9.7 years. Mortality rates in both groups were similar. Cumulative 5-month, 2-, and 10- year MACE-free survival rates of IRBT patients were 89%, 56% and 29%, respectively, while those of the control patients were 90%, 76% and 52%, respectively (p<0.001). The difference in the MACE rate was mainly driven by target vessel revascularisation (TVR) (p<0.001). Furthermore, two or more repeat TVRs were needed in 12% of IRBT patients and in only 6% of control patients (p<0.01). Adjusted hazard ratios for IRBT-associated all-cause mortality and MACE were 1.0 (95% CI 0.7-1.5) and 1.8 (95% CI 1.5-2.2), respectively. Conclusion: IRBT was associated with increased MACE between five months and two years of follow-up, mainly driven by repeat revascularisations. Similar event rate after two years indicate that there were no very late adverse effects related to IRBT.

Comparison of five-year outcome of octogenarians undergoing percutaneous coronary intervention with drug-eluting versus bare-metal stents (from the RESEARCH and T-SEARCH Registries) (Article)

2010-11-15T00:00:00Z

Although octogenarians are increasingly referred for percutaneous coronary intervention (PCI), data are lacking on long-term safety and efficacy of drug-eluting stents in this high-risk subpopulation. The aim of this study was to evaluate 5-year clinical outcome of octogenarians who underwent PCI using sirolimus-eluting stents (SESs) or paclitaxel-eluting stents (PESs) compared to bare-metal stents (BMSs). From January 2000 to December 2005, 319 consecutive octogenarian patients who underwent PCI with BMSs (n = 93, January 2000 to April 2002), SESs (n = 52, April 2002 to February 2003), or PESs (n = 174, February 2003 to December 2005) were included prospectively. Primary study end points were all-cause mortality and major adverse cardiac events (MACEs), defined as all-cause death, any myocardial infarction, or any revascularization. Mean age of the study population was 83 ± 2 years and 51% of patients were men. Median follow-up duration was 5.4 years (range 3 to 9). Five-year mortality rates in the BMS, SES, and PES cohorts were similar (41%, 42%, and 41%, respectively). Cumulative 5-year MACE-free survival in the BMS, SES, and PES cohorts were 44%, 52%, and 48%, respectively. Compared to the BMS cohort, adjusted hazard ratios for MACEs in the SES and PES cohorts were 0.5 (95% confidence interval [CI] 0.3 to 0.9, p <0.05) and 0.5 (95% CI 0.2 to 1.4, p = 0.2), respectively. Overall, use of drug-eluting stents was associated with fewer MACEs (adjusted hazard ratio 0.5, 95% CI 0.3 to 0.9, p <0.05) and a trend toward less target vessel revascularization (adjusted hazard ratio 0.5, 95% CI 0.2 to 1.2, p = 0.1). In conclusion, PCI with drug-eluting stents in octogenarians was found to be safe and more effective compared to PCI with BMSs.

Patient-rated health status predicts prognosis following percutaneous coronary intervention with drug-eluting stenting (Article)

2010-10-27T00:00:00Z

Purpose: In patients treated with percutaneous coronary intervention (PCI) with the paclitaxel-eluting stent, we examined whether patient-rated health status predicts adverse clinical events. Methods: Consecutive PCI patients treated with drug-eluting stenting (N = 870; 72.2% men; mean age = 62.6 ± 11.5) completed the EQ-5D post-PCI. The EQ-5D levels were dichotomized into 'no problems' (level 1) versus 'problems' (levels 2, 3); the visual analogue scale (VAS) was dichotomized using the 25th percentile (cut-off ≤60) indicating poor health status. Patients were followed up for 1-year clinical events (death or non-fatal myocardial infarction (MI)). Results: There were 53 deaths/MIs at follow-up. The EQ-5D health status dimensions mobility (HR:2.23; 95% CI:1.25-3.97), self-care (HR:3.09; 95% CI:1.54-6.20), and self-reported health status as measured with the EQ-VAS (HR:2.94; 95% CI:1.65-5.25) were independent predictors of death/MI and added to the predictive value of a model comprised of demographic and clinical characteristics. The EQ-5D dimensions usual activities, pain/discomfort, and anxiety/depression were not associated with adverse clinical events in adjusted analysis. Conclusions: Patient-rated health status predicted adverse clinical events at 1-year follow-up in PCI patients treated with drug-eluting stenting, with the risk being more than 2-fold independent of disease severity and other demographic and clinical characteristics. It may be timely to adopt standard assessment of health status in clinical practice.

The unrestricted use of sirolimus- and paclitaxel-eluting stents results in better clinical outcomes during 6-year follow-up than bare-metal stents: An analysis of the RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital) and T-SEARCH (TaxusStent Evaluated at Rotterdam Cardiology Hospital) registries (Article)

2010-10-01T00:00:00Z

Objectives The aim of this study was to assess the 6-year clinical outcome after unrestricted use of sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) as compared with bare-metal stents (BMS) in consecutive de novo patients undergoing percutaneous coronary intervention (PCI). Background SES and PES have been shown to significantly decrease target vessel revascularization (TVR) rates compared with BMS in "real-world" registries. However, possible higher rates of very-late stent thrombosis and a restenosis "catch-up" trend might jeopardize the benefit. Methods Three PCI cohorts, each with exclusive use of 1 stent type (BMS = 450; SES = 508; PES = 576), were systematically followed for the occurrence of major adverse cardiac events (MACE). Results Very-late stent thrombosis was more common in SES and PES patients than BMS patients (2.4% vs. 0.9% vs. 0.4%, respectively; p = 0.02); however, there were no significant differences between the stent types for all-cause mortality and all-cause mortality/myocardial infarction at 6-year follow-up. Sixty-nine SES patients (Kaplan-Meier estimate 14%) and 72 PES patients (14%) had a TVR, as compared with 79 BMS patients (18%; log-rank p = 0.02), which maintained significance after adjustment for (potential) confounders. Multivariate analysis showed that DES implantation is associated with lower incidence of TVR and MACE than BMS implantation (hazard ratio: 0.65, 95% confidence interval: 0.49 to 0.86; p = 0.003; hazard ratio: 0.79, 95% confidence interval: 0.65 to 0.97; p = 0.02, respectively). Incidence of MACE was also lower in SES and PES patients (30% and 30%, respectively) than in BMS patients (34%); however, significance was borderline. Conclusions The unrestricted use of both DES resulted in a sustained advantage in decreasing TVR and, to a lesser extent, MACE compared with BMS at 6 years. The SES and PES are equally safe and effective in the treatment of coronary lesions.

Four-year clinical outcome of sirolimus- and paclitaxel-eluting stents compared to bare-metal stents for the percutaneous treatment of stable coronary artery disease (Article)

2010-07-01T00:00:00Z

Background: There are limited data on the long-term safety and efficacy profile of coronary stent implantation in patients with stable coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). Objective: We aimed to assess the 4-year clinical outcome in patients who received a bare-metal stent (BMS), sirolimus-eluting stent (SES), or a paclitaxel-eluting stent (PES) for the percutaneous treatment of stable angina in our center during 2000-2005. Methods: In the study period, a total of 2,449 consecutive patients (BMS = 1,005; SES = 373; and PES = 1071) underwent a PCI as part of three historical PCI-cohorts for stable angina and were routinely followed for the occurrence of major adverse cardiac events (MACE). Results: At 4 years follow-up, 264 BMS patients (26.8%) had a MACE, compared to 75 SES patients (20.9%) and 199 PES patients (23.9%). Multivariate analysis showed that SES and PES were superior to BMS with respect to MACE [hazard ratio (HR) = 0.62, 95% confidence interval (CI): 0.47-0.81; HR = 0.67, 95% CI: 0.55-0.82, respectively]. The occurrence of MACE was significantly lower in the SES and PES population, primarily due to less target-vessel revascularization (TVR) procedures (HR = 0.53, 95% CI: 0.37-0.75; HR = 0.71, 95% CI: 0.62-0.81, respectively). The occurrence of early, late, and very late stent thrombosis was equally rare with each stent type. There were no significant differences between SES and PES on death, myocardial infarction, TVR, and MACE. Conclusion: These findings suggest that SES and PES result in decreased TVR procedures and MACE compared to BMS at 4 years follow-up. SES or PES implantation should be the preferred choice over BMS for patients with stable CAD undergoing PCI.

Statin treatment after a recent TIA or stroke: Is effectiveness shown in randomized clinical trials also observed in everyday clinical practice? (Article)

2010-07-01T00:00:00Z

Aim and background - The benefit of statin treatment in patients with a previous ischemic stroke or transient ischemic attack (TIA) has been demonstrated in randomized clinical trials (RCT). However, the effectiveness in everyday clinical practice may be decreased because of a different patient population and less controlled setting. We aim to describe statin use in an unselected cohort of patients, identify factors related to statin use and test whether the effect of statins on recurrent vascular events and mortality observed in RCTs is also observed in everyday clinical practice. Methods - In 10 centers in the Netherlands, patients admitted to the hospital or visiting the outpatient clinic with a recent TIA or ischemic stroke were prospectively and consecutively enrolled between October 2002 and May 2003. Statin use was determined at discharge and during follow-up. We used logistic regression models to estimate the effect of statins on the occurrence of vascular events (stroke or myocardial infarction) and mortality within 3 years. We adjusted for confounders with a propensity score that relates patient characteristics to the probability of using statins. Results - Of the 751 patients in the study, 252 (34%) experienced a vascular event within 3 years. Age, elevated cholesterol levels and other cardiovascular risk factors were associated with statin use at discharge. After 3 years, 109 of 280 (39%) of the users at discharge had stopped using statins. Propensity score adjusted analyses showed a beneficial effect of statins on the occurrence of the primary outcome (odds ratio 0.8, 95% CI: 0.6-1.2). Conclusion - In our study, we found poor treatment adherence to statins. Nevertheless, after adjustment for the differences between statin users and non-statin users, the observed beneficial effect of statins on the occurrence of vascular events within 3 years, although not statistically significant, is compatible with the effect observed in clinical trials. Copyright

A decline in walking distance predicts long-term outcome in patients with known or suspected peripheral artery disease (Article)

2010-06-01T00:00:00Z

AIM: To assess the predictive value of a decline in total walking distance and ankle brachial index (ABI) on all-cause mortality and cardiac death in patients with known or suspected peripheral artery disease. METHODS: Two hundred and sixty-one patients, who performed single-stage treadmill walking test twice to evaluate their peripheral artery disease, were enrolled in an observational study. Patients who underwent surgery during follow-up were excluded. Delta total walking distance and delta resting and exercise ABI consisted of the difference between the first and the second test. All three variables were categorized into two groups: stable/improvement or a decline. RESULTS: The mean follow-up period was 6 years. At both 5 years and total follow-up, a decline in total walking distance was independent and highly associated with an increased mortality risk and cardiac death [hazard ratio: 2.31 (95% confidence interval 1.35-3.96); hazard ratio: 3.55 (95% confidence interval: 1.53-8.21), respectively]. A decline in resting or exercise ABI after adjustment for delta walking distance was not significantly associated with all-cause mortality or cardiac death. CONCLUSION: A decline in total walking distance in single-stage treadmill exercise tests is a strong prognostic predictor of all-cause mortality and cardiac death in the short term and long term.

Contractile reserve in segments with nontransmural infarction in chronic dysfunctional myocardium using low-dose dobutamine CMR (Article)

2010-06-01T00:00:00Z

Objectives: This study sought to quantify contractile reserve of chronic dysfunctional myocardium, in particular in segments with intermediate transmural extent of infarction (TEI), using low-dose dobutamine cardiac magnetic resonance (CMR) in patients with a chronic total coronary occlusion (CTO). Background: Recovery of dysfunctional segments with intermediate TEI after percutaneous coronary intervention is variable and difficult to predict, and may be related to contractility of the unenhanced rim. Methods: Fifty-one patients (mean age 60 ± 9 years, 76% male) with a CTO underwent CMR at baseline and 35 patients underwent CMR at follow-up to quantify segmental wall thickening (SWT) at rest during 5 and 10 μg/kg/min dobutamine, and at follow-up. Delayed-enhancement CMR was performed to quantify TEI. Dysfunctional segments were stratified according to TEI, end-diastolic wall thickness (EDWT), or unenhanced rim thickness, and SWT was quantified. Segments with an intermediate TEI (25% to 75%) were further stratified according to baseline SWT of the unenhanced rim (SWTUR) (<45% and >45%), and SWT was quantified. For each parameter, odds ratio (OR) and diagnostic performance for the prediction of contractile reserve were calculated. Results: Significant contractile reserve was present in dysfunctional segments with EDWT >6 mm, unenhanced rim thickness >3 mm, or TEI of <25%; only TEI had significant relation with contractile reserve (OR: 0.98; 95% confidence interval [CI]: 0.96 to 0.99; p = 0.02). In segments with intermediate TEI (n = 58), mean SWT did not improve significantly. However, segments with SWTUR<45% showed contractile reserve and improved at follow-up, whereas segments with SWTUR>45% were unchanged. SWTURhad a significant relation with contractile reserve (OR: 0.98; 95% CI: 0.97 to 0.99; p = 0.02). Conclusions: CMR quantification of transmurality of infarcted myocardium allows the assessment of the potential of dysfunctional segments to improve in function during dobutamine of most segments. However, in segments with intermediate TEI, measurement of baseline contractility of the epicardial rim better identifies which segments maintain contractile reserve.

Long-term clinical results following stenting of the left main stem: Insights from RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital) and T-SEARCH (Taxus-Stent Evaluated at Rotterdam Cardiology Hospital) registries (Article)

2010-06-01T00:00:00Z

Objectives We investigated the long-term clinical outcomes and independent predictors of major cardiac events in unprotected left main coronary artery disease (ULMCA) patients treated by percutaneous coronary intervention with drug-eluting stent (DES). Background There is limited information on long-term (3 years) outcomes after DES implantation for ULMCA. Furthermore, bifurcation angle and SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score are emerging as parameters for patient risk stratification, and their prognostic implications have still to be elucidated. Methods One hundred forty-eight patients with ULMCA treated with DES were analyzed and compared with a historical cohort of 79 patients who received bare-metal stents for the treatment of ULMCA. Patient-oriented composite end point was defined as the occurrence of all-cause death, any myocardial infarction, or any revascularization. Results The 4-year cumulative incidence of all-cause death, any myocardial infarction, any revascularization, and patient-oriented composite were 35.6%, 3.8%, 25.2%, and 54.4%, respectively. These end points had relatively increased from 1 year to 4 years by Δ70%, Δ5%, Δ50%, and Δ68%, respectively. When compared with a historical cohort who received bare-metal stents for ULMCA treatment, landmark analysis performed after the first 2 years of follow-up demonstrated that the DES cohort had significantly higher patient-oriented composite end point over the last 2 years of follow-up (26% vs. 8%, p = 0.02). EuroSCORE (European System for Cardiac Operative Risk Evaluation), cardiogenic shock, and SYNTAX score were identified as independent predictors for the 4-year patient-oriented composite, whereas bifurcation angle was not. Conclusions Late increase in patient-oriented composite end points after DES implantation for ULMCA warrants careful and long-term follow-up. SYNTAX score and EuroSCORE appear to have a significant prognostic value in long-term patient risk.

Predictive value of NT-proBNP in vascular surgery patients with COPD and normal left ventricular systolic function (Article)

2010-03-19T00:00:00Z

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is commonly used to identify a cardiac cause of dyspnoea. However, patients with chronic obstructive pulmonary disease (COPD) may also have increased plasma NT-proBNP levels because of right-sided myocardial stress caused by pulmonary hypertension. We investigated the relationship between COPD and elevated NT-proBNP levels as well as the impact of elevated NT-proBNP levels on mortality in vascular surgery patients with normal left ventricular systolic function. Prior to vascular surgery, NT-proBNP levels, pulmonary function and left ventricular ejection fraction (LVEF) were assessed in 376 patients. Only patients with a LVEF > 40 were included; n 261. Elevated NT-proBNP levels were defined as ≥500 pg/ml. Firstly, we assessed the relationship between COPD and NT-proBNP levels. Secondly, we investigated the association between elevated NT-proBNP levels and one-year mortality. COPD was independently associated with elevated NT-proBNP levels (OR 3.36, 95CI 1.308.65) with significant associations found for mild and severe COPD. Elevated NT-proBNP levels were associated with increased one-year mortality in patients with (HR 7.73, 95CI 1.6037.43) and without COPD (HR 3.44, 95CI 1.1010.73). COPD was associated with elevated NT-proBNP levels in patients with a normal LVEF undergoing vascular surgery. Elevated NT-proBNP levels independent of other well-established risk factors were associated with increased one-year mortality. NT-proBNP may be useful biomarker to risk stratify patients with COPD. © Copyright

Health-related quality of life and long-term mortality in patients treated with percutaneous coronary intervention (Article)

2010-03-01T00:00:00Z

Background: Health status has become increasingly important as an outcome measure in patients with cardiovascular disease. Poor patient-rated health status has been shown to predict mortality in patients with coronary artery disease and heart failure. In patients treated with percutaneous coronary intervention (PCI), we examined whether poor health status predicts 6-year mortality and whether a decline in health status is associated with adverse clinical outcome. Methods: Consecutive patients (N = 872) treated with PCI as part of the RESEARCH registry, completed the 36-item Short-Form Health Survey (SF-36) at 1 and 12 months post-PCI. Results: The SF-36 domains physical functioning (hazard ratio [HR] 2.59, 95% CI 1.61-4.16), social functioning (HR 2.76, 95% CI 1.74-4.37), role limitations due to physical functioning (HR 2.45, CI 1.52-3.92), mental health (HR 2.12, 95% CI 1.35-3.31), vitality (HR 1.73, 95% CI 1.09-2.74), bodily pain (HR 2.25, 95% CI 1.43-3.54), and general health (HR 2.46, 95% CI 1.57-3.87) were associated with 6-year mortality. A decline in health status was not related with higher 6-year mortality. Conclusions: Health status domains as measured with the SF-36 predicted death at 6-year follow-up in PCI patients treated with drug-eluting stenting, independent of demographic and clinical characteristics. In contrast, a decline in health status between 1 and 12 months post index procedure, as measured with the SF-36, was not associated with 6-year mortality in PCI patients treated with drug-eluting stenting.

Monitoring in vivo absorption of a drug-eluting bioabsorbable stent with intravascular ultrasound-derived parameters: A feasibility study (Article)

2010-03-01T00:00:00Z

Objectives: The aim of this study was to investigate the feasibility of using quantitative differential echogenicity to monitor the in vivo absorption process of a drug-eluting poly-l-lactic-acid (PLLA) bioabsorbable stent (BVS, Abbott Vascular, Santa Clara, CA). Background: A new bioabsorbable, balloon-expanded coronary stent was recently evaluated in a first-in-man study. Little is known about the absorption process in vivo in diseased human coronary arteries. Methods: In the ABSORB (Clinical Evaluation of the BVS everolimus eluting stent system) study, 30 patients underwent treatment with the BVS coronary stent system and were examined with intracoronary ultrasound (ICUS) after implantation, at 6 months and at 2-year follow-up. Quantitative ICUS was used to measure dimensional changes, and automated ICUS-based tissue composition software (differential echogenicity) was used to quantify plaque compositional changes over time in the treated regions. Results: The BVS struts appeared as bright hyperechogenic structures and showed a continuous decrease of their echogenicity over time, most likely due to the polymer degradation process. In 12 patients in whom pre-implantation ICUS was available, at 2 years the percentage-hyperechogenic tissue was close to pre-implantation values, indicating that the absorption process was either completed or the remaining material was no longer differentially echogenic from surrounding tissues. Conclusions: Quantitative differential echogenicity is a useful plaque compositional measurement tool. Furthermore, it seems to be valuable for monitoring the absorption process of bioabsorbable coronary stents made of semi-crystalline polymers.

Abnormal spatial QRS-T angle predicts mortality in patients undergoing dobutamine stress echocardiography for suspected coronary artery disease (Article)

2010-01-01T00:00:00Z

Objective: To investigate the association between (cardiac) mortality and spatial QRS-T angle in patients undergoing dobutamine - atropine stress echocardiography (DSE) for evaluation of known or suspected coronary disease. Methods: Between 1990 and 2003, 2347 patients underwent DSE for evaluation of coronary disease at the Erasmus Medical Center. Echocardiographic images were analyzed offline using a 16-segment, 5-point scoring model for regional function. Twelve-lead resting ECGs were analyzed and patients were grouped in three categories according to their spatial QRS-T angle: normal (0-105°), borderline (105-135°), and abnormal (135-180°). Results: Mean age was 61±13 years, 66% were male, 32% had hypertension, 26% had hypercholesterolemia, 28% were smokers, and 12% were diabetic. During a mean follow-up of 7±3.4 years, 26.5% (623) of the patients died; 15.3% (359) died due to a cardiac cause. Abnormal QRS-T angle (135-180°) was present in 21% of the patients.Abnormal QRS-T angle was a predictor of cardiac death [hazard ratio: 3.2 (2.6-4.1)] and all-cause mortality [hazard ratio: 2.2 (1.8-2.6)]. After multivariate analysis abnormal and borderline QRS-T angle, peak wall motion score, age, male sex, history of diabetes, history of heart failure, smoking, and hypertension were independent predictors of (cardiac) death. Conclusion: Abnormal QRS-T angle is an independent predictor of (cardiac) death in patients undergoing DSE. Abnormal QRS-T angle should be considered as a risk factor in stable patients evaluated for coronary disease.

Five-year clinical outcomes after coronary stenting of chronic total occlusion using sirolimus-eluting stents: Insights from the rapamycin-eluting stent evaluated at Rotterdam Cardiology Hospital - (Research) Registry (Article)

2009-12-01T00:00:00Z

Background: The use of drug eluting stents (DES) in patients with a successfully recanalized chronic total occlusion (CTO) has been associated with a significant decrease in the need for repeat revascularization, and a favorable short-term clinical outcome when compared with the use of bare metal stents (BMS). Our group, however, has previously reported similar rates of target lesion revascularisation (TLR) and major adverse cardiovascular events (MACE) at 3 years follow-up in patients with a successfully opened CTO who were treated with either a sirolimus eluting stent (SES) or a BMS. The objective of this report was to evaluate the outcomes of these patients at 5-years clinical follow-up. Methods and Results: A total of 140 (BMS 64, SES 76) patients with successfully opened CTOs were included. Seven patients died in the BMS group whilst nine patients died in the SES group (P = 0.90). Noncardiac death was the major component of all-cause mortality (11 noncardiac deaths vs. 5 cardiac). There were two and three myocardial infarctions (MI) in the BMS and SES group, respectively (P = 1.0). The composite of death and MI occurred in seven (10.9%) and eleven (14.5%) patients in the BMS and SES group, respectively (P = 0.53). Clinically driven TLR was performed in eight patients (12.5%) in the BMS group, and five (6.6%) in the SES group (P = 0.26). Non-TLR target vessel revascularization was performed in one patient in the BMS group, and four in the SES group (P = 0.37). The 5-year device-oriented cumulative MACE rate was 15.6% and 11.8% in the BMS and SES group, respectively (P = 0.56). Conclusion: In patients with a successfully treated CTO, clinical outcome after 5 years was similar between SES and BMS, however, clinically driven TLR was slightly higher in the BMS group.

Prognostic Significance of QRS Duration in Patients With Suspected Coronary Artery Disease Referred for Noninvasive Evaluation of Myocardial Ischemia (Article)

2009-12-01T00:00:00Z

The purpose of this study was to evaluate the prognostic significance of QRS duration in patients with suspected coronary artery disease (CAD) referred for noninvasive evaluation of myocardial ischemia by dobutamine stress echocardiography. QRS duration is a prognostic marker in patients with previous myocardial infarction and/or heart failure. The relation between QRS duration and outcome of patients without known heart disease has not been evaluated. A total of 1,227 patients (707 men, mean age 61 ± 14 years) with suspected CAD underwent dobutamine stress echocardiography for evaluation of myocardial ischemia. Patients were followed to determine predictors of cardiac events and to assess the incremental significance of QRS duration compared to clinical and dobutamine stress echocardiographic data. During a mean follow-up of 4.2 ± 2.4 years, 280 patients (23%) died (129 cardiac deaths), and 60 (5%) had a nonfatal infarction. Annualized cardiac death rates were 2.0% in patients with QRS duration <120 ms and 4.4% in patients with QRS duration ≥120 ms, respectively (p <0.0001). Annualized event rates for cardiac death/nonfatal infarction were 2.8% in patients with QRS duration <120 ms and 4.8% in patients with QRS duration ≥120 ms (p = 0.0001). Multivariate models identified age, male gender, smoking, QRS duration ≥120 ms, and an abnormal dobutamine stress echocardiogram as independent predictors of cardiac death and the combined end point cardiac death/nonfatal infarction. In conclusion, QRS duration is an independent predictor of cardiac death and cardiac death/nonfatal infarction in patients with suspected CAD. This risk is persistent after adjustment for clinical variables, left ventricular function, and myocardial ischemia.

Timing of Noncardiac Surgery After Coronary Artery Stenting With Bare Metal or Drug-Eluting Stents (Article)

2009-11-01T00:00:00Z

The current guidelines have recommended postponing noncardiac surgery (NCS) for ≥6 weeks after bare metal stent (BMS) placement and for ≥1 year after drug-eluting stent (DES) placement. However, much debate has ensued about these intervals. The aim of the present study was to assess the influence of different intervals between stenting and NCS and the use of dual antiplatelet therapy on the occurrence of perioperative major adverse cardiac events (MACEs). We identified 550 patients (376 with a DES and 174 with a BMS) by cross-matching the Erasmus Medical Center percutaneous coronary intervention (PCI) database with the NCS database. The following intervals between PCI-BMS (<30 days, <3 months, and >3 months) or PCI-DES (<30 days, <3 months, 3 to 6 months, 6 to 12 months, and >12 months) and NCS were studied. MACEs included death, myocardial infarction, and repeated revascularization. In the PCI-BMS group, the rate of MACEs during the intervals of <30 days, 30 days to 3 months, and >3 months was 50%, 14%, and 4%, respectively (overall p <0.001). In the PCI-DES group, the rate of MACE changed significantly with the interval after PCI (35%, 13%, 15%, 6%, and 9% for patients undergoing NCS <30 days, 30 days to 3 months, 3 to 6 months, 6 to 12 months, and >12 months, respectively, overall p <0.001). Of the patients who experienced a MACE, 45% and 55% were receiving single and dual antiplatelet therapy at NCS, respectively (p = 0.92). The risk of severe bleeding in patients with single and dual therapy at NCS was 4% and 21%, respectively (p <0.001). In conclusion, we found an inverse relation between the interval from PCI to NCS and perioperative MACEs. Continuation of dual antiplatelet therapy until NCS did not provide complete protection against MACEs.

COPD and cancer mortality: The influence of statins (Article)

2009-11-01T00:00:00Z

Background: Chronic obstructive pulmonary disease (COPD) is associated with an increased risk of lung cancer, independently of smoking. However, the relationship between COPD and total cancer mortality is less certain. A study was undertaken to investigate the association between COPD and total cancer mortality and to determine whether the use of statins, which have been associated with cancer risk in other settings, modified this relationship. Methods: The study included 3371 patients with peripheral arterial disease who underwent vascular surgery between 1990 and 2006; 1310 (39%) had COPD and the rest did not. The primary end point was cancer mortality (lung and extrapulmonary) over a median follow-up of 5 years. Results: COPD was associated with an increased risk of both lung cancer mortality (hazard ratio (HR) 2.06; 95% CI 1.32 to 3.20) and extrapulmonary cancer mortality (HR 1.43; 95% CI 1.06 to 1.94). The excess risk was mostly driven by patients with moderate and severe COPD. There was a trend towards a lower risk of cancer mortality among patients with COPD who used statins compared with patients with COPD who did not use statins (HR 0.57; 95% CI 0.32 to 1.01). Interestingly, the risk of extrapulmonary cancer mortality was lower among statin users with COPD (HR 0.49; 95% CI 0.24 to 0.99). Conclusions: COPD was associated with increased lung and extrapulmonary cancer mortality in this large cohort of patients with peripheral arterial disease undergoing vascular surgery. The risk of lung cancer mortality increased with progression of COPD. Statins were associated with a reduced risk of extrapulmonary cancer mortality in patients with COPD.

Lower-leg symptoms in peripheral arterial disease are associated with anxiety, depression, and anhedonia (Article)

2009-10-22T00:00:00Z

Patients with peripheral arterial disease (PAD) report diverse clinical manifestations that are not always consistent with classic intermittent claudication. We examined the degree to which atypical exertional leg symptoms, intermittent claudication, and exertional leg symptoms that begin at rest were associated with mood states such as anxiety, depressive symptoms, and anhedonia (i.e. lack of positive affect). A cohort of consecutive PAD patients (n = 628) from the Erasmus Medical Center, Rotterdam, The Netherlands, completed the Hospital Anxiety and Depression Scale and the San Diego Claudication questionnaire. The ankle-brachial index and clinical factors were assessed in all patients at baseline. Anxiety was present in 29%, depressive symptoms in 30%, and anhedonia in 28% of patients. Pain at rest was independently associated with anxiety, depressive symptoms, and anhedonia (ORs between 2.5 and 4.0, p < 0.001), while there was no relationship between intermittent claudication and mood states. Patients with atypical leg symptoms had a twofold risk of anxiety (OR = 1.9, 95% CI 1.1-3.5, p < 0.05). Adjusting for sex, age, ankle-brachial index, cardiovascular history, time since ankle-brachial index screening, clinical factors, and medication use, both pain at rest (OR = 3.4, 95% CI 1.6-7.0, p = 0.001) and atypical leg symptoms (OR = 2.3, 95% CI 1.1-4.9, p < 0.05) were associated with comorbid mood problems. In conclusion, PAD patients with atypical leg symptoms or pain at rest reported more impaired mood than patients without those symptoms. These patients should be monitored closely in clinical practice, as previous research in cardiovascular patients has shown that mood disorders and sub-threshold symptoms predict poor prognosis.

Negative and positive affect are independently associated with patient-reported health status following percutaneous coronary intervention (Article)

2009-10-01T00:00:00Z

Purpose: We examined the association between negative and positive affect and 12-month health status in patients treated with percutaneous coronary intervention (PCI) with drug-eluting stents. Methods: Consecutive PCI patients (n = 562) completed the Global Mood Scale at baseline to assess affect and the EuroQoL-5D (EQ-5D) at baseline and 12-month follow-up to assess health status. Results: Negative affect [F(1, 522) = 17.14, P < .001] and positive affect [F(1, 522) = 5.11, P = .02] at baseline were independent associates of overall health status at 12-month follow-up, adjusting for demographic and clinical factors. Moreover, there was a significant interaction for negative by positive affect [F(1, 522) = 6.11, P = .01]. In domain-specific analyses, high negative affect was associated with problems in mobility, self-care, usual activities, pain/discomfort, and anxiety/depression with the risk being two to fivefold. Low positive affect was only associated with problems in self-care (OR: 8.14; 95% CI: 1.85-35.9; P = .006) and usual activities (OR: 1.87; 95% CI: 1.17-3.00; P = .009). Conclusions: Baseline negative and positive affect contribute independently to patient-reported health status 12 months post PCI. Positive affect moderated the detrimental effects of negative affect on overall health status. Enhancing positive affect might be an important target to improve patient-centered outcomes in coronary artery disease.

The Prognostic Value of Impaired Walking Distance on Long-term Outcome in Patients with Known or Suspected Peripheral Arterial Disease (Article)

2009-10-01T00:00:00Z

Objectives: To assess the predictive value of walking distance after an exercise test on long-term outcome in patients with normal and impaired ankle-brachial index (ABI). Design: A total of 2191 patients with known or suspected peripheral arterial disease (PAD), who were referred for a single-stage treadmill exercise test to diagnose or evaluate their PAD, were enrolled in an observational study between 1993 and 2006. Materials and methods: They were divided into two groups: normal ABI (≥0.90) and impaired ABI (<0.90). Walking distance was divided into quartiles (no (reference), mild, moderate or severe impairment). Results: In patients with normal ABI, severe walking distance was, after adjustment, associated with higher mortality risk (hazard ratio (HR): 2.60 (range: 1.16-5.78)). In patients with impaired ABI, all walking distance impairment quartiles were associated with higher mortality (mild HR: 1.26 (range: 0.95-1.67), moderate HR: 1.52 (range: 1.13-2.05) and severe HR: 1.69 (range: 1.26-2.27)). Furthermore, comparable associations were observed between all walking distance quartiles, cardiac death or major adverse cerebrovascular and cardiac events. Conclusions: Our study illustrated that walking impairment is a strong prognostic indicator of long-term outcome in patients with impaired and normal ABI, which should be a warning sign to physicians to monitor these patients carefully and to provide them optimal treatment.

Impact of drug-eluting stent selection on long-term clinical outcomes in patients treated for unprotected left main coronary artery disease: The sirolimus vs paclitaxel drug-eluting stent for left main registry (SP-DELFT) (Article)

2009-09-01T00:00:00Z

Aim: To compare the long-term relative efficacy and safety of SES and PES in patients undergoing percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) disease and to evaluate the role of lesion location and stenting technique in determining outcomes. Methods and results: From April 2002 to April 2004, 288 consecutive patients who underwent elective PCI with DES implantation for de novo lesions on ULMCA have been retrospectively selected and analyzed in seven European and US tertiary care centers. All patients had a minimum follow-up of 3 years. SES was used in 152 patients while 136 received PES. Isolated ostial-shaft disease was present in 27% of patients. Distal LM disease (73%) was treated with single and double stent approach in 29.5% and 43.4% of patients respectively. After 3 years, rates of survival free from any of the events investigated, were independent from lesion location and stenting approach and did not differ significantly between SES and PES groups. Freedom from MACE (SES vs. PES) was 76.3% vs. 83.1% in the ostial/shaft group, 80.3% vs. 72.8% in the distal-single stent group and 67.1% vs. 66.2% in the distal-double stent group. Definite stent thrombosis occurred only in 1(0.3%) patient at 439 days. Conclusions: In elective patients who underwent PCI for de novo lesions in the ostium, shaft or distal ULMCA, long-term clinical outcomes with SES and PES use were similar independently of lesion location and stenting technique.

Brief depression screening with the PHQ-2 associated with prognosis following percutaneous coronary intervention with paclitaxel-eluting stenting (Article)

2009-09-01T00:00:00Z

BACKGROUND: Depression is associated with adverse prognosis in cardiac patients, warranting the availability of brief and valid instruments to identify depressed patients in clinical practice. OBJECTIVES: We examined whether the two-item Patient Health Questionnaire (PHQ-2) was associated with adverse events in percutaneous coronary intervention (PCI) patients treated with paclitaxel-eluting stenting (using the continuous score and various cutoffs), overall and by gender. DESIGN: Prospective follow-up study. PARTICIPANTS: Consecutive PCI patients (n = 796) seen at a university medical centre. MEASUREMENTS: PHQ-2 at baseline. The study endpoint was an adverse event, defined as a combination of death or non-fatal myocardial infarction (MI) at follow-up (mean of 1.4 years). RESULTS: At follow-up, 47 patients had experienced an adverse event. Using the continuous score of the PHQ-2 and the recommended cutoff ≥3, depressive symptoms were not associated with adverse events (ps > 0.05). Using a cutoff ≥2, depressive symptoms were significantly associated with adverse events (HR: 1.89; 95% CI: 1.06-3.35) and remained significant in adjusted analysis (HR: 1.90; 95% CI: 1.05-3.44). Depressive symptoms were associated with an increased risk of adverse events in men (HR: 2.69; 95% CI: 1.36-5.32) but not in women (HR: 0.76; 95% CI: 0.24-2.43); these results remained in adjusted analysis. CONCLUSIONS: Depression screening with a two-item scale and a cutoff score of ≥2 was independently associated with adverse events at follow-up. The PHQ-2 is a brief and valid measure that can easily be used post PCI to identify patients at risk for adverse health outcomes.

Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: A meta-analysis of controlled trials (Article)

2009-09-01T00:00:00Z

Aims Studies have compared safety and efficacy of percutaneous left ventricular assist devices (LVADs) with intra-aortic balloon pump (IABP) counterpulsation in patients with cardiogenic shock. We performed a meta-analysis of controlled trials to evaluate potential benefits of percutaneous LVAD on haemodynamics and 30-day survival.Methods and resultsTwo independent investigators searched Medline, Embase, and Cochrane Central Register of Controlled Trials for all controlled trials using percutaneous LVAD in patients with cardiogenic shock, where after data were extracted using standardized forms. Weighted mean differences (MDs) were calculated for cardiac index (CI), mean arterial pressure (MAP), and pulmonary capillary wedge pressure (PCWP). Relative risks (RRs) were calculated for 30-day mortality, leg ischaemia, bleeding, and sepsis. In main analysis, trials were combined using inverse-variance random effects approach. Two trials evaluated the TandemHeart and a recent trial used the Impella device. After device implantation, percutaneous LVAD patients had higher CI (MD 0.35 L/min/m2, 95 CI 0.09-0.61), higher MAP (MD 12.8 mmHg, 95 CI 3.6-22.0), and lower PCWP (MD -5.3 mm Hg, 95 CI -9.4 to -1.2) compared with IABP patients. Similar 30-day mortality (RR 1.06, 95 CI 0.68-1.66) was observed using percutaneous LVAD compared with IABP. No significant difference was observed in incidence of leg ischaemia (RR 2.59, 95 CI 0.75-8.97) in percutaneous LVAD patients compared with IABP patients. Bleeding (RR 2.35, 95 CI 1.40-3.93) was significantly more observed in TandemHeart patients compared with patients treated with IABP. ConclusionAlthough percutaneous LVAD provides superior haemodynamic support in patients with cardiogenic shock compared with IABP, the use of these more powerful devices did not improve early survival. These results do not yet support percutaneous LVAD as first-choice approach in the mechanical management of cardiogenic shock.

Association between chronic obstructive pulmonary disease and chronic kidney disease in vascular surgery patients (Article)

2009-09-01T00:00:00Z

Background. Chronic obstructive pulmonary disease (COPD) is recognized as a source of systemic inflammation and is associated with the development of cardiovascular disease. However, little is known about the association between COPD and chronic kidney disease (CKD). Therefore, we investigated the relationship between COPD and CKD and the association between COPD and mortality in patients with CKD.Methods. We conducted a cohort study of 3358 vascular surgery patients between 1990 and 2006. CKD was defined according to the Modification of Diet in Renal Disease equation as an estimated glomerular filtration rate (GFR) <60 mLmin1.73 m2. In addition, the patients were divided into three categories based on the baseline estimated GFR: ≥90 mLmin1.73 m2; 60-89 mLmin1.73 m2and <60 mLmin1.73 m2. Multivariable logistic regression analysis was used to evaluate the independent association between prevalent COPD and CKD.Results. The prevalence of COPD was inversely related to kidney function. COPD was present in 47, 38 and 32 of patients with an estimated GFR <60, 60-89 and ≥90 mLmin1.73 m2, respectively. COPD was independently associated with CKD (OR 1.22; 95 CI 1.03-1.44; P = 0.03). This association was strongest in patients with moderate COPD (OR 1.33; 95 CI 1.07-1.65; P = 0.01). Both moderate and severe COPD were associated with increased long-term mortality in patients with CKD (HR 1.27; 95 CI 1.03-1.56; P = 0.03 and HR 1.61; 95 CI 1.10-2.35; P = 0.01, respectively), compared to patients without COPD.Conclusions. Our findings indicate that COPD is moderately associated with CKD in a large cohort of vascular surgery patients. In addition, moderate and severe COPD are related to increased long-term mortality in patients with CKD.

Coronary calcium significantly affects quantitative analysis of coronary ultrasound: Importance for atherosclerosis progression/regression studies (Article)

2009-09-01T00:00:00Z

BACKGROUND: Coronary atherosclerosis is a dynamic process, which progresses differently in coronary segments containing noncalcified or calcified plaques. This may have implications for the study of the effects of therapy on progression/regression. OBJECTIVE: To test this hypothesis, we performed a post-hoc analysis on data of a randomized trial in which perindopril treatment was compared with placebo on progression/regression of atherosclerosis with regard to the degree of calcification. METHODS AND RESULTS: The intracoronary ultrasound data of 118 patients, who were enrolled in the multicentre, double-blinded randomized trial (PERSPECTIVE), were analysed. Vessel, lumen and plaque areas were measured in 711 5-mm-long matched coronary segments (perindopril 360, placebo 351). Each individual intracoronary ultrasound cross-section was binary labelled for the presence of calcium (yes/no), and the degree of calcium was assessed as a percentage of length. The segments were classified into three groups: 0-25, 25-50 and 50-100% (percentage of length) calcification. Coronary plaques with no or little calcium (0-25%) regressed on perindopril and did not change on placebo (-0.33±1.74 vs. -0.03±1.66, respectively; P=0.04). Plaques containing moderate calcium (group 25-50%) did not change and plaques with severe amounts of calcification (group 50-100%) equally progressed. CONCLUSION: Noncalcified plaques may be amenable to regression with ACE inhibitor treatment. The method, which considers the amount of calcium content in a plaque, may lead to new insights for quantitative analysis of the effects of therapy in progression/regression studies of atherosclerosis.

Assisted circulation using the tandemheart® during very high-risk PCI of the unprotected left main coronary artery in patients declined for CABG (Article)

2009-08-01T00:00:00Z

Objectives: In a single center experience, we retrospectively evaluated the short-term safety and efficacy of the TandemHeart® percutaneous transseptal left ventricular assist (PTVA®) system to deliver extracorporeal circulatory support during catheter based treatment of the unprotected left main coronary artery (ULMCA). Background: Percutaneous Coronary Intervention (PCI) of the ULMCA usually has been restricted to patients who are hemodynamically unstable or ineligible for coronary artery bypass grafting (CABG). High-risk patients for CABG should be considered at increased risk for PCI as well. In these patients the TandemHeart PTVA System (p-LVAD) may provide a valuable safeguard to reduce procedural risks. Methods and Results: Between July 2002 and May 2008 the TandemHeart was used in 9 very high risk patients (Logistic Euro score: 13.64 (7.46-29.67); Syntax score:43 (41-50); Mayo Clinic Risk score (MCRS) 7 (6-8); age: median 65 (range 55-71) undergoing elective PCI for the novo lesions on the ULMCA. All patients were declined for CABG by a heart team. A "true" percutaneous insertion technique was used in all patients, technical success rate was 100%. The median (range) time for implementation of circulatory support was 27 min (24-30). A median (range) pump flow up to 4.36 (3.40-5.54) L/min was achieved with significant reduction of left ventricular filling pressures, pulmonary capillary wedge pressure and a small increase of systemic arterial pressures. Median (range) duration of support was 93 min (50.4-102). Successful weaning was achieved in all patients. There was no in hospital death, survival at 6 months was (89%), whereas vascular access site complications were seen in 4 patients (44.4%). Conclusions: In very high risk PCI, assisted circulation using the TandemHeart-PTVA provides effective, total left ventricular support and may contribute to a reduced procedural risk and improved survival. The rate of device related cardiac and vascular complications was acceptable.

Usefulness of Intra-Aortic Balloon Pump Counterpulsation in Patients With Cardiogenic Shock from Acute Myocardial Infarction (Article)

2009-08-01T00:00:00Z

Although intra-aortic balloon pump (IABP) counterpulsation is increasingly being used for the treatment of patients with cardiogenic shock from acute myocardial infarction, data on the long-term outcomes are lacking. The aim of the present study was to evaluate the 30-day and long-term mortality and to identify predictors for 30-day and long-term all-cause mortality of patients with acute myocardial infarction complicated by cardiogenic shock who were treated with IABP. From January 1990 to June 2004, 300 consecutive patients treated with IABP were included. The mean age of the study population was 61 ± 11 years, and 79% of the patients were men. The survival rate until IABP removal after successful hemodynamic stabilization was 70% (n = 211). The overall cumulative 30-day survival rate was 58%. The 30-day mortality rate decreased over time from 52% in 1990 to 1994 to 36% in 2000 to 2004 (p for trend <0.05). Follow-up ranged from 0 to 15 years. In patients who survived until IABP removal, the cumulative 1-, 5-, and 10-year survival rate was 69%, 58%, and 36%, respectively. The adjusted predictors of long-term mortality were arrhythmias during the intensive cardiac care unit stay (hazard ratio [HR] 1.8, 95% confidence interval [CI] 1.2 to 2.9) and renal failure during the intensive cardiac care unit stay (HR 2.5, 95% CI 1.3 to 5.1). After adjustment, treatment with primary percutaneous coronary intervention (HR 0.5, 95% CI 0.3 to 0.9) and coronary artery bypass grafting (HR 0.4, 95% CI 0.2 to 0.8) were associated with lower long-term mortality. In conclusion, in patients with acute myocardial infarction complicated by cardiogenic shock treated with IABP, the 30-day survival improved with time and an encouraging number of patients survived in the long term.

Effect of Chronic Beta-Blocker Use on Stroke After Noncardiac Surgery (Article)

2009-08-01T00:00:00Z

The incidence of postoperative stroke ranges from 0.08% to 0.7% in noncardiac surgery. Recently, the PeriOperative ISchemic Evaluation (POISE) study reported an incidence of postoperative stroke of 1% in patients scheduled for noncardiac surgery when β blockers were initiated immediately before surgery. To assess the association between chronic β-blocker use and postoperative stroke in noncardiac surgery, we undertook a case-control study among 186,779 patients who underwent noncardiac surgery from 2000 to 2008 at the Erasmus Medical Centre. Patients who were undergoing intracerebral surgery or carotid surgery or who had head and/or carotid trauma were excluded. The case subjects were 34 patients (0.02%) who had experienced a stroke within 30 days after surgery. Of the remaining patients, 2 controls were selected for each case and were stratified according to calendar year, type of surgery, and age. For cases and controls, information was obtained regarding β-blocker use before surgery, the presence of cardiac risk factors, and the use of other cardiovascular medication. The use of β blockers was as common in the cases as in the controls (29% vs 29%; p = 1.0). The adjusted odds ratio for postoperative stroke among β-blocker users compared with nonusers was 0.4 (95% confidence interval 0.1 to 1.5). Similar results were obtained in the subgroups of patients stratified according to the use of cardiovascular therapy and the presence of cardiac risk factors. In conclusion, the present case-control study has shown no increased risk of postoperative stroke in patients taking chronic β-blocker therapy.

Prognosis of patients undergoing cardiac surgery and treated with intra-aortic balloon pump counterpulsation prior to surgery: A long-term follow-up study (Article)

2009-08-01T00:00:00Z

The aim of this study was to evaluate short- and long-term outcome in patients undergoing coronary artery bypass grafting (CABG), who received an intra-aortic balloon pump (IABP) prior to surgery. Between January 1990 and June 2004, all patients (n=154) who received an IABP prior to on-pump CABG in our center were included. Patients received the IABP for vital indications (i.e. either unstable angina refractory to medical therapy or cardiogenic shock; group 1: n=99) or for prophylactic reasons (group 2: n=55). A Cox proportional hazards model was used to identify predictors of long-term all-cause mortality. Compared with the EuroSCORE predictive model, observed 30-day mortality in group 1 (15.2%) was slightly higher than predicted (10.3%). A decrease in 30-day mortality occurred in group 2 (median predicted mortality was 7.2% and observed was 0%). Cumulative 1-, 5-, and 6-year survival was 82.8±3.8%, 70.1±4.9%, and 67.3±5.1% for group 1 vs. 98.2±1.8%, 84.0±5.6% and 84.0±5.6% for group 2 (Log-rank: P=0.02). Logistic EuroSCORE (HR 1.03 w1.01-1.05x, Ps0.007) was an independent predictor of long-term all-cause mortality.

The benefits of statins in people without established cardiovascular disease but with cardiovascular risk factors: meta-analysis of randomised controlled trials. (Article)

2009-07-20T00:00:00Z

OBJECTIVES: To investigate whether statins reduce all cause mortality and major coronary and cerebrovascular events in people without established cardiovascular disease but with cardiovascular risk factors, and whether these effects are similar in men and women, in young and older (>65 years) people, and in people with diabetes mellitus. DESIGN: Meta-analysis of randomised trials. DATA SOURCES: Cochrane controlled trials register, Embase, and Medline. Data abstraction Two independent investigators identified studies on the clinical effects of statins compared with a placebo or control group and with follow-up of at least one year, at least 80% or more participants without established cardiovascular disease, and outcome data on mortality and major cardiovascular disease events. Heterogeneity was assessed using the Q and I(2) statistics. Publication bias was assessed by visual examination of funnel plots and the Egger regression test. RESULTS: 10 trials enrolled a total of 70 388 people, of whom 23 681 (34%) were women and 16 078 (23%) had diabetes mellitus. Mean follow-up was 4.1 years. Treatment with statins significantly reduced the risk of all cause mortality (odds ratio 0.88, 95% confidence interval 0.81 to 0.96), major coronary events (0.70, 0.61 to 0.81), and major cerebrovascular events (0.81, 0.71 to 0.93). No evidence of an increased risk of cancer was observed. There was no significant heterogeneity of the treatment effect in clinical subgroups. CONCLUSION: In patients without established cardiovascular disease but with cardiovascular risk factors, statin use was associated with significantly improved survival and large reductions in the risk of major cardiovascular events.

The Everolimus-Eluting Stent in Real-World Patients. 6-Month Follow-Up of the X-SEARCH (Xience V Stent Evaluated at Rotterdam Cardiac Hospital) Registry (Article)

2009-07-14T00:00:00Z

Objectives: The purpose of this study was to investigate the impact of everolimus-eluting stents (EES) in comparison with bare-metal stents (BMS), sirolimus-eluting stents (SES), and paclitaxel-eluting stents (PES) on the 6-month clinical outcomes in an all-comer population. Background: EES have been shown to be effective in the context of randomized trials with selected patients. The effect of EES implantation in more complex, unselected patients cannot be directly extrapolated from these findings. Methods: In total, 649 consecutive unselected patients treated exclusively with EES were enrolled. Six-month clinical end points were compared with 3 historical cohorts (BMS, n = 450; SES, n = 508; and PES, n = 576). Major adverse cardiac events (MACE) were defined as a composite of all-cause mortality, myocardial infarction, or target vessel revascularization (TVR). Results: The patients treated with EES were older, presented more frequently with acute myocardial infarction, and had more complicated lesions than the other groups. The EES group demonstrated a higher incidence of all-cause mortality than the SES group and a lower incidence of TVR than the BMS group. Multivariate adjustment demonstrated that BMS was associated with higher TVR and MACE risk than EES (adjusted hazard ratio [HR] for TVR: 2.02 [95% confidence interval (CI): 1.11 to 3.67]; adjusted HR for MACE: 2.15 [95% CI: 1.36 to 3.42]); that SES had a clinical outcome similar to that of EES, and that PES had a higher risk of MACE than did EES (adjusted HR: 1.57 [95% CI: 1.02 to 2.44]). Conclusions: This study suggests that the use of EES in an unselected population may be as safe as and more effective than BMS, may be as safe and effective as SES, may be as safe as PES, and may be more effective than PES.

Impact of Sex on 3-Year Outcome After Percutaneous Coronary Intervention Using Bare-Metal and Drug-Eluting Stents in Previously Untreated Coronary Artery Disease. Insights From the RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital) and T-SEARCH (Taxus-Stent Evaluated at Rotterdam Cardiology Hospital) Registries (Article)

2009-07-01T00:00:00Z

Objectives: We investigated the impact of sex on outcomes after percutaneous coronary intervention (PCI) with drug-eluting stent (DES). Background: Women have a higher risk of adverse outcomes after PCI than do men. However, long-term outcomes of women after contemporary PCI with DES have not been fully investigated. Methods: We performed a retrospective cohort study of 4,936 consecutive patients (28.2% women) who underwent PCIs between 2000 and 2004, before and after introduction of DES (bare-metal stent [BMS] group: n = 2,131, DES group: n = 2,805), to assess the impact of sex on long-term PCI outcomes and to compare outcome after PCI of women between the DES and BMS eras. Results: Compared with men, women undergoing PCIs were 5 years older and more frequently have comorbidities such as diabetes mellitus and hypertension. In patients treated throughout the BMS and DES eras, there were no differences by sex for risk of all-cause death, myocardial infarction, or target vessel revascularization 3 years after procedure. The procedural complexity was higher in the DES era, nevertheless, risk for target vessel revascularization and major adverse cardiac event at 3 years were significantly lower in women treated with DES than in women treated with BMS (adjusted hazard ratio [HR] for target vessel revascularization: 0.52 [95% confidence interval (CI): 0.36 to 0.75], adjusted HR for major adverse cardiac event: 0.63 [95% CI: 0.48 to 0.83]). Conclusions: Although women had worse baseline characteristics, no differences in 3-year outcomes were observed between men and women. Compared with BMS use, DES use has decreased revascularization rate equally in women and men.

Feelings of being disabled as a prognostic factor for mortality in the drug-eluting stent era (Article)

2009-07-01T00:00:00Z

Objective: It remains unclear whether feelings of being disabled are a relevant psychological factor that determines outcome after percutaneous coronary intervention (PCI). Therefore, we evaluated "feelings of being disabled" as an independent risk factor for mortality 4 years post-PCI. Methods: As part of the Taxus-Stent Evaluated At Rotterdam Cardiology Hospital (T-SEARCH) Registry, 658 consecutive patients (age 63 years, 75% male) completed the subscale "feelings of being disabled" of the Heart Patients Psychological Questionnaire (HPPQ), within the first month after PCI. Results: At 4-year follow-up, 8% of the patients (n=55) had died, 2% (n=16) underwent a myocardial infarction (MI), 13% (n=90) had a target-vessel revascularization (TVR), and 21% (n=137) had one or more major adverse cardiac events (MACE). One-third of the patients (32%) had high scores on "feelings of being disabled" at baseline. After adjusting for baseline characteristics, including symptoms of anxiety and depression, patients with a high score on "feelings of being disabled" had an increased risk for all cause mortality (HR=2.9, 95% CI=1.5-5.6), the composite end point mortality/MI (HR=2.4, 95% CI=1.3-4.4), and the occurrence of MACE (HR=1.7, 95% CI=1.1-2.7). Conclusion: Feelings of being disabled were an independent predictor of all-cause mortality, mortality/MI, and MACE 4 years post-PCI. These patients should be identified in clinical practice, as they warrant additional treatment, e.g., of a psychosocial nature, in addition to the standard medical treatment.

Co-occurrence of diabetes and hopelessness predicts adverse prognosis following percutaneous coronary intervention (Article)

2009-06-01T00:00:00Z

We examined the impact of co-occurring diabetes and hopelessness on 3-year prognosis in percutaneous coronary intervention patients. Consecutive patients (n = 534) treated with the paclitaxel-eluting stent completed a set of questionnaires at baseline and were followed up for 3-year adverse clinical events. The incidence of 3-year death/non-fatal myocardial infarction was 3.5% in patients with no risk factors (neither hopelessness nor diabetes), 8.2% in patients with diabetes, 11.2% in patients with high hopelessness, and 15.9% in patients with both factors (p = 0.001). Patients with hopelessness (HR: 3.28; 95% CI: 1.49-7.23) and co-occurring diabetes and hopelessness (HR: 4.89; 95% CI: 1.86-12.85) were at increased risk of 3-year adverse clinical events compared to patients with no risk factors, whereas patients with diabetes were at a clinically relevant but not statistically significant risk (HR: 2.40; 95% CI: 0.82-7.01). These results remained, adjusting for baseline characteristics and depressive symptoms. These findings testify to the importance of identifying patients with co-occurring risk factors, as they likely require special management in clinical practice in addition to standard medical treatment.

Preoperative Cardiac Risk Index Predicts Long-term Mortality and Health Status (Article)

2009-06-01T00:00:00Z

Objectives: Peripheral arterial disease patients undergoing vascular surgery are known to be at risk for the occurrence of (late) cardiovascular events. Before surgery, the perioperative cardiac risk is commonly assessed using the Lee Risk Index score, a combination of 6 cardiac risk factors. This study assessed the predictive value of the Lee Risk Index for late mortality and long-term health status in patients after vascular surgery. Methods: Between May and December 2004, data on 711 consecutive peripheral arterial disease patients undergoing vascular surgery were collected from 11 hospitals in the Netherlands. Before surgery, the Lee Risk Index was assessed in all patients. At 3-year follow-up, 149 patients died (21%) and the disease-specific Peripheral Artery Questionnaire (PAQ) was completed in 84% (n = 465) of the survivors. Impaired health status according to the PAQ was defined by the lowest tertile of the PAQ summary score. Multivariable regression analyses were performed to investigate the prognostic ability of the Lee Index for mortality and impaired health status at 3-year follow-up. Results: The Lee Risk Index proved to be an independent prognostic factor for both late mortality (1 risk factor hazard ratio (HR) = 2.1; 95% confidence interval [CI], 1.2-3.6; 2 risk factors HR = 2.4; 95% CI, 1.4-4.0 and ≥3 risk factors HR = 3.2; 95% CI, 1.7-6.2) and impaired health status at 3-year follow-up (1 risk factor odds ratio [OR] = 2.0; 95% CI, 1.1-3.5; 2 risk factors OR = 2.9; 95% CI, 1.6-5.2 and ≥3 risk factors OR = 3.2; 95% CI, 1.3-7.5). The predominant contributing factors associated with late mortality were cerebrovascular disease, insulin-dependent diabetes, and renal insufficiency. For impaired health status, ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, and renal insufficiency were the prognostic factors. Conclusions: The preoperative Lee Risk Index is not only an important prognostic factor for in-hospital outcome but also for late mortality and impaired health status in patients with peripheral arterial disease.

The Risk of Stent Thrombosis in Patients With Acute Coronary Syndromes Treated With Bare-Metal and Drug-Eluting Stents (Article)

2009-06-01T00:00:00Z

Objectives: We aimed to evaluate the risk of definite stent thrombosis with bare-metal stents (BMS) and drug-eluting stents (DES) in patients treated for acute coronary syndromes. Background: Acute coronary syndromes (ACS) have been reported as increasing the risk for stent thrombosis. Methods: Between January 2000 and December 2005, 5,816 consecutive patients underwent percutaneous coronary intervention for de novo lesions with a single stent type. These patients consisted of 3 sequential groups of BMS (n = 2,248), sirolimus-eluting stents (n = 822) and paclitaxel-eluting stents (n = 2,746). In total, 3,485 patients presented with an ACS. Results: After a median follow-up of 1,394 days, patients with ACS had a definite stent thrombosis rate of 2.5% versus 1.0% in patients with stable angina (propensity score-adjusted hazard ratio [HR]: 2.80, 95% confidence interval [CI]: 1.72 to 4.56). ACS patients had a higher risk of early and late stent thrombosis, although the increased risk of very late stent thrombosis was only present in ACS patients treated with DES. In stable patients, any stent thrombosis resulted in a significant increase in mortality (adjusted HR: 4.0, 95% CI: 1.7 to 9.3), although this was particularly evident for late or very late stent thrombosis; in contrast only early stent thrombosis significantly increased mortality in patients with acute coronary syndrome patients (adjusted HR: 2.0, 95% CI: 1.0 to 4.1). Conclusions: Patients with acute coronary syndromes are at higher risk of early and late stent thrombosis with either BMS or DES, although very late stent thrombosis seems to be uniquely associated with DES. The clinical sequelae of late and very late stent thrombosis are more pronounced in stable patients.

Preoperative oral glucose tolerance testing in vascular surgery patients: Long-term cardiovascular outcome (Article)

2009-05-01T00:00:00Z

Background: Diabetes mellitus (DM) is an important risk factor in vascular surgery patients, influencing late outcome. Screening for diabetes is recommended by fasting glucose measurement. Oral glucose tolerance testing (OGTT) could enhance the detection of patients with impaired glucose tolerance (IGT) and DM. Aim: To assess the additional value of OGTT on top of fasting glucose levels in vascular surgery patients to predict long-term cardiovascular outcome. Methods: A total of 404 patients without signs or histories of IGT (plasma glucose 7.8-11.1 mmol/L) or DM (glucose ≥11.1 mmol/L) were prospectively included and subjected to OGTT. Cardiac risk factors were noted. Primary outcome was the occurrence of late cardiovascular events (composite of cardiovascular death, angina pectoris, myocardial infarction, percutaneous coronary intervention/coronary artery bypass grafting, or cerebral vascular accident/transient ischemic attack), and secondary outcome included all-cause and cardiovascular mortality rates, in survivors of vascular surgery. Median follow-up was 3.0 (interquartile range 2.4-3.8) years. Results: Impaired glucose tolerance (n = 104) and DM (n = 43) were detected by fasting glucose levels in 26 (25%) and 12 (28%) patients, and by OGTT in 78 (75%) and 31 (72%) patients, respectively. During follow-up, 131 patients experienced a cardiovascular event. With multivariable analysis, patients with IGT showed a significant increased risk for cardiovascular events (hazard ratio 2.77, 95% CI 1.83-4.20) and mortality (hazard ratio 2.06, 95% CI 1.03-4.12). Patients with DM showed a nonsignificant increased risk for cardiovascular events. Conclusion: Vascular surgery patients with IGT or DM detected by preoperative OGTT have an increased risk of developing cardiovascular events and mortality during long-term follow-up. It is recommended that nondiabetic vascular surgery patients should be tested for glucose regulation disorders before surgery.

The clinical outcome after coronary bypass surgery: A 30-year follow-up study (Article)

2009-02-01T00:00:00Z

Aims: To investigate the long-term clinical outcome (up to 30 years) after coronary artery bypass graft (CABG) surgery and to assess the life expectancy (LE) among subgroups of patients. Methods and results: We analysed the 30-year outcome of the first 1041 consecutive patients in our institution (age at operation 53 years, 88% male) who underwent venous CABG between 1971 and 1980. During follow-up, every 5-7 years follow-up status was obtained by reviewing the hospital records and from general practitioners and civil registries. Data were collected on death and repeat coronary revascularization procedures. Follow-up was complete in 98%. Median follow-up was 29 years (26-36 years). The cumulative 10-, 20-, and 30-year survival rates were 77%, 40%, and 15%, respectively. Overall, 623 coronary re-interventions were performed in 373 patients (36%). The cumulative 10-, 20-, and 30-year freedom from death and coronary re-intervention rates were 60%, 20%, and 6%, respectively. Age [hazard ratio (HR) 1.04/year], extent of vessel disease (VD) (two-VD HR 1.4; three-VD HR 1.9), left main disease (HR 1.6) and impaired left ventricular ejection fraction (LVEF) (HR 1.8) were independent predictors of mortality. We were able to assess the exact LE by calculating the area under the Kaplan-Meier curves. Overall LE after first CABG was 17.6 years. LE in patients with one-, two-, and three-VD was 21.4, 18.8, and 15.4 years, respectively (P < 0.0001). Patients with impaired LVEF had a significant shorter LE than patients with normal LVEF (13.9% vs. 19.3%; P < 0.0001). Conclusion: This 30-year follow-up study comprises the almost complete life cycle after CABG surgery. Overall median LE was 17.6 years. As the majority of the patients (94%) needed a repeat intervention, we conclude that the classic venous bypass technique is a useful but palliative treatment of a progressive disease.

Three-Year Survival Following Multivessel Percutaneous Coronary Intervention With Bare-Metal or Drug-Eluting Stents in Unselected Patients (Article)

2009-01-15T00:00:00Z

Drug-eluting stents (DESs) have been shown to reduce the rate of repeat revascularization compared with bare-metal stents (BMSs) after multivessel percutaneous coronary intervention in carefully selected patients. However, the long-term safety and efficacy of DESs in patients with multivessel disease outside the setting of randomized trials was unknown. Therefore, all patients undergoing multivessel percutaneous coronary intervention with BMSs, sirolimus-eluting stents (SESs), or paclitaxel-eluting stents (PESs) from January 2000 to December 2005 were investigated. The primary end point was all-cause mortality. A total of 1,720 patients were recruited in 3 consecutive sequential groups of BMS (n = 701; January 2000 to April 2002), SES (n = 293; April 2002 to February 2003), and PES (n = 726; February 2003 to December 2005). Overall median follow-up was 1,440 days. There was improved 3-year survival in the SES group (93.7%) compared with both the BMS (86.1%) and PES groups (87.3%), which remained significant after propensity score adjustment for differences in baseline and procedural characteristics (SES vs BMS, adjusted hazard ratio 0.53, 95% confidence interval 0.30 to 0.94; SES vs PES, adjusted hazard ratio 0.49, 95% confidence interval 0.28 to 0.87). There was no difference in mortality between the PES and BMS groups. Both DES types significantly reduced the need for clinically driven target-vessel and target-lesion revascularization without an excess in myocardial infarction or stent thrombosis. In conclusion, both SESs and PESs significantly reduced the need for repeated revascularization in these patients with no excess in mortality. SESs might reduce mortality in patients undergoing multivessel percutaneous coronary intervention.

Elderly patients undergoing major vascular surgery: Risk factors and medication associated with risk reduction (Article)

2009-01-01T00:00:00Z

This study assesses risk factors in elderly vascular surgery patients and to evaluate whether perioperative cardiac medication can reduce postoperative mortality rate. In a cohort study, 1693 consecutive patients ≥65 years undergoing major non-cardiac vascular surgery were preoperatively screened for cardiac risk factors and medication. During follow-up (median: 8.2 years), mortality was noted. Hospital mortality occurred in 8.1% and long-term mortality in 28.5%. In multivariate analysis, age, coronary artery disease, heart failure, cerebrovascular disease, renal failure and diabetes were significantly associated with increased hospital and long-term mortality. Perioperative aspirin (OR: 0.53, 95% confidence interval: 0.34-0.83), β-blockers (OR: 0.32, 95% CI: 0.19-0.54) and statins (OR: 0.35, 95% CI: 0.18-0.68) were significantly associated with reduced hospital mortality. In addition, aspirin (HR: 0.65, 95% CI: 0.53-0.81), angiotensin-converting enzyme (ACE)-inhibitors (HR: 0.74, 95% CI: 0.59-0.92), β-blockers (HR: 0.61, 95% CI: 0.48-0.76) and statins (HR: 0.65, 95% CI: 0.49-0.87) were significantly associated with reduced long-term mortality. Heterogeneity tests revealed a gradient decrease of mortality risk in patients from low to high age using statins (p = 0.03). In conclusion, age is an independent predictor of hospital and long-term mortality in elderly patients undergoing major vascular surgery. Aspirin, ACE-inhibitors, β-blockers and statins reduce long-term mortality risk. Especially the very elderly may benefit from statin therapy.

Methionine loading does not enhance the predictive value of homocysteine serum testing for all-cause mortality or major adverse cardiac events (Article)

2009-01-01T00:00:00Z

Background: Hyperhomocysteinaemia is independently associated with atherosclerotic disease. Methionine loading could improve the predictive value of hyperhomocysteinaemia by detecting mild disturbances in enzyme activity. The aims of this study were to determine the beneficial effect of methionine loading on the predictive value of homocysteine testing for long-term mortality and major adverse cardiac events (MACE). Methods: In an observational study, 1122 patients with suspected or known vascular disease, underwent homocysteine testing, which was measured fasting and again 6 h after methionine loading. Hyperhomocysteinaemia was defined as a fasting level ≥15 μmol/L and post-methionine loading level ≥45 μmol/L or an increase of ≥30 μmol/L above fasting levels. Primary end-points were death and MACE. Multivariate Cox regression analysis was used, adjusting for all cardiac risk factors. Results: During follow up (mean 8.9 ± 3.4 years), 98 patients died (8.7%), 86 had a MACE (7.7%), 579 patients had normal tests, 134 patients had only fasting hyperhomocysteinaemia, 226 only post-methionine hyperhomocysteinaemia and 183 patients had both. In multivariate analysis, overall survival and MACE-free survival were significantly worse for those with fasting hyperhomocysteinaemia, with hazard ratios of 1.86 (95% confidence interval (CI) 1.20-2.87) and 2.24 (95%CI 1.41-3.53), respectively. The addition of hyperhomocysteinaemia after methionine loading did not significantly increase the risk of death or MACE, with hazard ratios of 0.97 (95%CI 0.52-1.81) and 0.89 (95%CI 0.47-1.69), respectively. Conclusion: The presence of post-methionine hyperhomocysteinaemia did not significantly alter risk of death or MACE in patients with normal or increased fasting homocysteine levels, respectively. In conclusion, methionine loading does not improve the predictive value of homocysteine testing with regard to long-term mortality or MACE.

Comparison of outcome after myocardial infarction in patients with and without abnormalities on previous stress Tc-99m tetrofosmin myocardial perfusion imaging (Article)

2008-12-01T00:00:00Z

BACKGROUND: Acute myocardial infarction (MI) can occur in patients with previously normal stress myocardial perfusion imaging (MPI). It is not known whether the prognosis of these patients differ from those with MI who had an abnormal MPI on an earlier testing. The aim of this study was to compare the outcome of patients who sustained a MI during follow-up after stress MPI based on the presence or absence of perfusion abnormalities on the earlier test. METHODS: We studied 109 patients (age 62 ± 11 years, 73 men) who developed MI 2.1 ± 2.7 years after exercise or dobutamine stress Tc-99m tetrofosmin MPI. Subsequently, a follow-up was done for the occurrence of death during or after the acute event. RESULTS: Myocardial perfusion was normal in 31 patients and was abnormal in 78 (45 had reversible defects). During a mean follow-up of 3.1 ± 2.4 years after MI, death occurred in 35 (32%) patients. The death rate was 19% in patients with previously normal versus 33% in patients with abnormal perfusion (P < 0.01). In a Cox model, independent predictors of death were age (risk ratio (RR) 1.06, 95% CI: 1.02-1.10), heart failure (RR 2.7, CI: 1.3-5.5), and abnormal MPI (RR 2.5, CI: 1.3-4.5). CONCLUSION: Patients with a previously normal stress MPI are less likely to die after acute MI than patients who had an abnormal MPI.

Statin use is associated with early recovery of kidney injury after vascular surgery and improved long-term outcome (Article)

2008-12-01T00:00:00Z

Background. Acute kidney injury (AKI) after major vascular surgery is an important risk factor for adverse long-term outcomes. The pleiotropic effects of statins may reduce kidney injury caused by perioperative episodes of hypotension and/or suprarenal clamping and improve long-term outcomes. Methods. Of 2170 consecutive patients undergoing lower extremity bypass or abdominal aortic surgery from 1995 to 2006, cardiac risk factors and medication were noted. A total of 515/1944 (27%) patients were statin users. Creatinine clearance (CrCl) was assessed preoperatively at 1, 2 and 3 days after surgery. Outcome measures were postoperative AKI and long-term mortality. Postoperative kidney injury was defined as a >10% decrease in CrCl on Day 1 or 2, compared to the baseline. Recovery of kidney function was defined as a CrCl >90% of the baseline value at Day 3 after surgery. Multivariable Cox regression analysis, including baseline cardiovascular risk factors, baseline CrCl and propensity score for statin use, was applied to evaluate the influence of statins on early postoperative kidney injury and long-term survival. Results. AKI occurred in 664 (34%) patients [median -25% CrCl, range (-10% to -71%)]. Of these 664 patients, 313 (47%) had a complete recovery of kidney function at Day 3 after surgery. Age, hypertension, suprarenal cross-clamping and baseline CrCl predicted the development of kidney injury during the postoperative period. The incidence of kidney injury was similar among statin users and non-users (29% versus 25%, OR 1.15, 95% CI 0.9-1.5). However, if kidney function deteriorated, statin use was associated with increased odds of complete kidney function recovery (OR 2.0, 95% CI 1.0-3.8). During a mean follow-up of 6.24 years, half of the patients died (55%). Importantly, statin use was also associated with an improved long-term survival, irrespective of kidney function change (HR 0.60, 95% CI 0.48-0.75). Conclusion. Statin use is associated with improved recovery from AKI after major surgery and has a beneficial effect on long-term survival.

Prognostic value of hypotensive blood pressure response during single-stage exercise test on long-term outcome in patients with known or suspected peripheral arterial disease (Article)

2008-12-01T00:00:00Z

Objective: A decline in systolic blood pressure during exercise is thought to be a sign of severe coronary artery disease. However, no studies have yet examined this effect in patients with known or suspected peripheral arterial disease. Therefore, we investigated the prognostic value of hypotensive blood pressure response after single-stage exercise test on long-term mortality, major adverse cerebrovascular and cardiac events (MACCE) and the effects of statin, β-blocker and aspirin use in patients with known or suspected peripheral arterial disease. Methods: A total of 2022 patients were enroled in an observational study with a mean follow-up of 5 years. Hypotensive blood pressure response, 4.6% of the total population, was defined as a drop in exercise systolic blood pressure below resting systolic blood pressure. Results: Our study showed that hypotensive blood pressure response was associated with an increased risk of all-cause mortality [hazard ratio (HR): 1.74, 95% confidence interval (CI): 1.10-2.73] and MACCE (HR: 1.85, 95% CI: 1.14-3.00), independent of other clinical variables. Additionally, after adjustments for clinical risk factors and propensity score, baseline statin use was associated with a reduced risk of all-cause mortality (HR: 0.60, 95% CI: 0.44-0.80). Besides, statin and aspirin use were both also associated with a reduced risk of MACCE (HR: 0.65, 95% CI: 0.47-0.89 and HR: 0.69, 95% CI: 0.53-0.88, respectively). Conclusion: Hypotensive blood pressure response after single-stage treadmill exercise tests in patients with known or suspected peripheral arterial disease was associated with a higher risk for all-cause long-term mortality and MACCE, which might be reduced by statin and aspirin use.

Long-Term Cardiac Outcome in High-Risk Patients Undergoing Elective Endovascular or Open Infrarenal Abdominal Aortic Aneurysm Repair (Article)

2008-12-01T00:00:00Z

Objectives: To assess long-term outcome of patients at high cardiac risk undergoing endovascular or open AAA repair. Methods: Patients undergoing open or endovascular infrarenal AAA repair with ≥3 cardiac risk factors and preoperative cardiac stress testing (DSE) at 2 university hospitals were studied. Main outcome was cardiac event free and overall survival. Multivariate Cox regression analysis was used to evaluate the influence of type of AAA repair on long-term outcome. Results: In 124 patients (55 endovascular, 69 open) the number and type of cardiac risk factors, medication use and DSE results were similar in both groups. In multivariable analysis, adjusting for cardiac risk factors, stress test results, medication use, and propensity score endovascular repair was associated with improved cardiac event free survival (HR 0.54; 95% CI 0.30-0.98) but not with an overall survival benefit (HR 0.73; 95% CI 0.37-1.46). Importantly, statin therapy was associated with both improved overall survival (HR 0.42; 95% CI 0.21-0.83) and cardiac event free survival (HR 0.45; 95% CI 0.23-0.86). Conclusions: The perioperative cardiac benefit of endovascular AAA repair in high cardiac risk patients is sustained during long-term follow-up provided patients are on optimal medical therapy but it is not associated with improved overall long-term survival.

A randomized comparison of the magnetic navigation system versus conventional percutaneous coronary intervention (Article)

2008-11-15T00:00:00Z

Objective: A randomized comparison of the magnetic navigation system (MNS) to conventional guidewire techniques in percutaneous coronary interventions. Background: The MNS precisely directs a magnetized guidewire in vivo through two permanent external magnets. Methods: A total of 111 consecutive patients were enrolled. Crossing success, crossing-/fluoroscopy times, and contrast usage were directly compared. Lesions were classified according to the AHA/ACC criteria. Three tertiles of vessel/lesion complexity [low (<5), medium (6-10) and high (>10)] were defined using 3D reconstructions and angiographic information. Results: The crossing success for magnetic and the conventional wires were 93.3and 95.6%, respectively. Crossing and fluoroscopy times were longer with the magnetic wires (72.9 ± 50.3 sec vs. 58.1 ± 47.2 sec, P < 0.001 and 66.2 ± 44.1 sec vs. 55.2 ± 44.4 sec, P 5 0.03, respectively). In vessels with low and medium complexity the magnetic wires had significantly longer times (P < 0.001) but for those with high scores (>10) a trend towards shorter times was observed. The MNS resulted in a small but significant reduction in contrast usage (2.3 ± 3.5 ml vs. 4.5 ± 4.4 ml, P < 0.001). Moreover by superimposing a virtual roadmap of the vessel on the live fluoroscopy image 48% of the lesions were crossed without requiring contrast agents with the MNS. Conclusion: The MNS has comparable crossing success to conventional PCI. It is relatively slower but there is a trend to support a potential advantage in more complex vessels. By simultaneously employing a virtual roadmap there is a small but significant reduction in contrast usage.

Late Stent Recoil of the Bioabsorbable Everolimus-Eluting Coronary Stent and its Relationship With Plaque Morphology (Article)

2008-11-11T00:00:00Z

Objectives: This study sought to evaluate late recoil of a novel bioabsorbable everolimus-eluting coronary stent (BVS), which is composed of a poly-L-lactic acid backbone, coated with a bioabsorbable polymer containing everolimus. Background: Little is known about the mechanical behavior of bioabsorbable polymer stents after deployment in diseased human coronary arteries. Methods: The study population consisted of 16 patients, who were treated with elective BVS implantation for single de novo native coronary artery lesions and were followed at 6 months. All patients underwent an intravascular ultrasound examination at post-procedure and follow-up. A total of 484 paired cross-sectional areas (CSAs) were acquired and analyzed. Late absolute stent recoil was defined as stent area at post-procedure (X) - stent area at follow-up (Y). Late percent stent recoil was defined as (X - Y)/X × 100. In each CSA, plaque morphology was assessed qualitatively and classified as calcific, fibronecrotic, or fibrocellular plaque. Results: Late absolute and percent recoil of the BVS was 0.65 ± 1.71 mm2(95% confidence interval [CI]: 0.49 to 0.80 mm2) and 7.60 ± 23.3% (95% CI: 5.52% to 9.68%). Calcified plaques resulted in significantly less late recoil (0.20 ± 1.54 mm2and 1.97 ± 22.2%) than fibronecrotic plaques (1.03 ± 2.12 mm2and 12.4 ± 28.0%, p = 0.001 and p = 0.001, respectively) or fibrocellular plaque (0.74 ± 1.48 mm2and 8.90 ± 19.8%, p = 0.001 and p = 0.001, respectively). Conclusions: The BVS shrank in size during the follow-up period. The lesion morphology of stented segments might affect the degree of late recoil of the BVS. (ABSORB Everolimus Eluting Coronary Stent System First in Man Clinical Investigation; NCT00300131).

Prognostic Significance of Myocardial Ischemia by Dobutamine Stress Echocardiography in Patients Without Angina Pectoris After Coronary Revascularization (Article)

2008-11-01T00:00:00Z

The clinical utility of stress testing in patients without angina pectoris after revascularization has been questioned. Dobutamine stress echocardiography (DSE) is an established technique for detection of myocardial ischemia and cardiac risk stratification. We studied the prognostic value of DSE in 393 patients without typical angina pectoris after coronary revascularization. Ischemia was incremental to clinical data in predicting all-cause death (hazard ratio 3.5, 95% confidence interval 1.8 to 6.7) and cardiac death (hazard ratio 4.2, 95% confidence interval 1.8 to 9.8). In conclusion, myocardial ischemia during DSE is independently associated with an increased risk of all-cause mortality and cardiac death in these patients after adjustment for clinical data.

The obesity paradox in patients with peripheral arterial disease (Article)

2008-11-01T00:00:00Z

Background: Cardiac events are the predominant cause of late mortality in patients with peripheral arterial disease (PAD). In these patients, mortality decreases with increasing body mass index (BMI). COPD is identified as a cardiac risk factor, which preferentially affects underweight individuals. Whether or not COPD explains the obesity paradox in PAD patients is unknown. Methods: We studied 2,392 patients who underwent major vascular surgery at one teaching institution. Patients were classified according to COPD status and BMIs (ie, underweight, normal, overweight, and obese), and the relationship between these variables and all-cause mortality was determined using a Cox regression analysis. The median follow-up period was 4.37 years (interquartile range, 1.98 to 8.47 years). Results: The overall mortality rates among underweight, normal, overweight, and obese patients were 54%, 50%, 40%, and 31%, respectively (p < 0.001). The distribution of COPD severity classes showed an increased prevalence of moderate-to-severe COPD in underweight patients. In the entire population, BMI (continuous) was associated with increased mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94 to 0.98). In addition, patients who were classified as being underweight were at increased risk for mortality (HR, 1.42; 95% CI, 1.00 to 2.01). However, after adjusting for COPD severity the relationship was no longer significant (HR, 1.29; 95% CI, 0.91 to 1.93). Conclusions: The excess mortality among underweight patients was largely explained by the overrepresentation of individuals with moderate-to-severe COPD. COPD may in part explain the "obesity paradox" in the PAD population. Copyright

Two-year outcome of the use of paclitaxel-eluting stents in aorto-ostial lesions (Article)

2008-10-13T00:00:00Z

Background: Percutaneous treatment of stenoses involving aorto-ostial lesions is technically demanding and has been associated with lower procedural success and poorer clinical and angiographic outcomes when compared with non-ostial lesions. This study evaluated the immediate and long-term (2-year) outcome of aorto-ostial stenoses treated with paclitaxel-eluting stents (PES). Methods: From February 2003 to December 2004, a total of 76 consecutive patients with 76 lesions underwent percutaneous intervention with PES for aorto-ostial lesions (right coronary artery, 37; left main, 26; saphenous vein graft, 13). All patients were clinically followed for the occurrence of major adverse cardiac events (MACE), defined as cardiac death, non-fatal myocardial infarction (MI), target lesion revascularization (TLR) or target vessel revascularization (TVR). Results: All stents (1.7/lesion) were successfully deployed. Three lesions (3.9%) were pre-treated with debulking devices. Thirty-seven lesions (48.7%) were post-dilated with non-compliant balloons (balloon/artery ratio, 1.2). Stents were positioned protruding into the aortic lumen in 29 lesions (38.2%). Cumulative 2-year event-free survival was 68.4%. There was one angiographically-proven stent thrombosis occurring 427 days after TLR for restenosis after the index procedure. The restenosis rate at 7 months (median) was 20.0% and in-stent late lumen loss was 0.48 mm in 40 patients with angiographic follow-up. Conclusions: Utilization of PES in this complex lesion subset is feasible and associated with favorable angiographic results at 7 months. However, the gradual increase in later events up to 2 years suggests that aorto-ostial disease remains problematic even in the era of drug-eluting stents.

Impact of cardioselective β-blockers on mortality in patients with chronic obstructive pulmonary disease and atherosclerosis (Article)

2008-10-01T00:00:00Z

Rationale: β-Blocker use is associated with improved health outcomes in patients with cardiovascular disease. There is a general reluctance to prescribe β-blockers in patients with chronic obstructive pulmonary disease (COPD) because they may worsen symptoms. Objectives: We investigated the relationship between cardioselective β-blockers and mortality in patients with COPD undergoing major vascular surgery. Methods: We evaluated 3,371 consecutive patients who underwent major vascular surgery at one academic institution between 1990 and 2006. The patients were divided into those with and without COPD on the basis of symptoms and spirometry. The major endpoints were 30-day and long-term mortality after vascular surgery. Patients were defined as receiving low-dose therapy if the dosage was less than 25% of the maximum recommended therapeutic dose; dosages higher than this were defined as intensified dose. Measurements and Main Results: There were 1,205 (39%) patients with COPD of whom 462 (37%) received cardioselective β-blocking agents. β-Blocker use was associated independently with lower 30-day (odds ratio, 0.37; 95% confidence interval, 0.19-0.72) and long-term mortality in patients with COPD (hazards ratio, 0.73; 95% confidence interval, 0.60-0.88). Intensified dose was associated with both reduced 30-day and long-term mortality in patients with COPD, whereas low dose was not. Conclusions: Cardioselective β-blockers were associated with reduced mortality in patients with COPD undergoing vascular surgery. In carefully selected patients with COPD, the use of cardioselective β-blockers appears to be safe and associated with reduced mortality.

Usefulness of Hypertensive Blood Pressure Response During a Single-Stage Exercise Test to Predict Long-Term Outcome in Patients With Peripheral Arterial Disease (Article)

2008-10-01T00:00:00Z

The prognostic value of a hypertensive blood pressure (BP) response is still unclear. Therefore, the prognostic value of a hypertensive BP response in patients during single-stage exercise testing for peripheral arterial disease (PAD) on long-term mortality and major adverse cerebrovascular and cardiac events (MACCEs) was investigated. In addition, effects of statin, β-blocker, and aspirin use in patients with known or suspected PAD were studied. A total of 2,109 patients were enrolled in an observational prospective study from 1993 to 2005. Hypertensive BP response was defined as an increase in systolic BP ≥55 mm Hg (95thpercentile within our population) after a single-stage treadmill exercise test. The outcome was obtained by using the civil registries, and a questionnaire about cardiac events was sent to all survivals. Hypertensive BP response was associated with increased risk of long-term mortality (hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.12 to 1.80) and MACCEs (HR 1.47, 95% CI 1.09 to 1.97). After adjustments for clinical risk factors and propensity score, baseline statin use was associated with reduced risk of long-term mortality (HR 0.59, 95% CI 0.44 to 0.79), and statin, β-blocker, and aspirin use were associated with reduced risk of MACCEs (HR 0.59, 95% CI 0.43 to 0.81; HR 0.75, 95% CI 0.60 to 0.95; HR 0.73, 95% CI, 0.57 to 0.92, respectively). In conclusion, hypertensive BP response at exercise in patients with known or suspected PAD is an important independent risk factor for all-cause long-term mortality and MACCEs, whereas statin, β-blocker, and aspirin use were associated with an improved outcome.

Association Between Serum Uric Acid and Perioperative and Late Cardiovascular Outcome in Patients With Suspected or Definite Coronary Artery Disease Undergoing Elective Vascular Surgery (Article)

2008-10-01T00:00:00Z

The role of uric acid as an independent marker of cardiovascular risk is unclear. Therefore, our aim was to assess the independent contribution of preoperative serum uric acid levels to the risk of 30-day and late mortality and major adverse cardiac event (MACE) in patients scheduled for open vascular surgery. In total, 936 patients (76% male, age 68 ± 11 years) were enrolled. Hyperuricemia was defined as serum uric acid >0.42 mmol/l for men and >0.36 mmol/l for women, as defined by large epidemiological studies. Outcome measures were 30-day and late mortality and MACE (cardiac death or myocardial infarction). Multivariable logistic and Cox regression analysis were used, adjusting for age, gender, and all cardiac risk factors. Data are presented as odds ratios or hazard ratios, with 95% confidence intervals. Hyperuricemia was present in 299 patients (32%). The presence of hyperuricemia was associated with heart failure, chronic kidney disease, and the use of diuretics. Perioperatively, 46 patients (5%) died and 61 patients (7%) experienced a MACE. Mean follow-up was 3.7 years (range: 0 to 17 years). During follow-up, 282 patients (30%) died and 170 patients (18%) experienced a MACE. After adjustment for all clinical risk factors, the presence of hyperuricemia was not significantly associated with an increased risk of 30-day mortality or MACE, odds ratios of 1.5 (0.8 to 2.8) and 1.7 (0.9 to 3.0), respectively. However, the presence of hyperuricemia was associated with an increased risk of late mortality and MACE, with hazard ratios of 1.4 (1.1 to 1.7) and 1.7 (1.3 to 2.3), respectively. In conclusion, the presence of preoperative hyperuricemia in vascular patients is a significant predictor of late mortality and MACE.

Type D patients report poorer health status prior to and after cardiac rehabilitation compared to non-type D patients (Article)

2008-10-01T00:00:00Z

Background: Type D personality is an emerging risk factor in coronary artery disease (CAD). Cardiac rehabilitation (CR) improves outcomes, but little is known about the effects of CR on Type D patients. Purpose: We examined (1) variability in Type D caseness following CR, (2) Type D as a determinant of health status, and (3) the clinical relevance of Type D as a determinant of health status compared to cardiac history. Methods: CAD patients (n = 368) participating in CR completed the Type D Scale, the Short-Form Health Survey 36 pre- and post-CR, and the Hospital Anxiety and Depression Scale pre-CR, to assess health status and depressive and anxious symptomatology, respectively. Results: The prevalence of Type D decreased from 26.6% to 20.7% (p = 0.012) following CR, but Type D caseness remained stable in 81% of patients. Health status significantly improved following CR [F(1,359) = 17.48, p < 0.001], adjusting for demographic and clinical factors and anxious and depressive symptoms. Type D patients reported poorer health status [F(1,359) = 10.40, p = 0.001], with the effect of Type D being stable over time [F(1,359) = 0.49, p = 0.48]. Patients with a cardiac history benefited less from CR [F(1,359) = 5.76, p = 0.02]. The influence of Type D on health status was larger compared to that for cardiac history, as indicated by Cohen's effect size index. Conclusions: Type D patients reported poorer health status compared to non-Type D patients pre- and post-CR. In the majority of patients, CR did not change Type D caseness, with Type D being associated with a stable and clinically relevant effect on outcome. These high-risk patients should be identified in clinical practice and may require adjunctive interventions.

Symptoms of fatigue and depression in ischemic heart disease are driven by personality characteristics rather than disease stage: A comparison of CAD and CHF patients (Article)

2008-10-01T00:00:00Z

BACKGROUND: Symptoms of fatigue and depression are prevalent across stages of ischemic heart disease (IHD). We examined (i) the effect of both the IHD stage and type-D personality on fatigue and depressive symptoms at 12-month follow-up, and (ii) whether the effect of type-D personality on these symptoms is moderated by IHD stage. METHODS: Two different samples of patients were included to represent IHD stage: 401 percutaneous coronary intervention patients (early-stage IHD) and 105 ischemic chronic heart failure patients (end-stage IHD) completed the DS14 Type-D Scale at baseline. Logistic regression analysis was used to examine the impact of IHD stage and type-D personality on fatigue and depression at follow-up. RESULTS: Disease stage was neither associated with symptoms of fatigue (P=0.99) nor depression (P=0.29) at 12 months. In contrast, type-D personality was shown to predict both symptoms of fatigue [odds ratio (OR)=2.96; 95% confidence interval (CI): 1.92-4.58, P<0.001] and depression (OR=4.91; 95% CI: 3.16-7.65, P<0.001) at follow-up; the effect of type-D personality on these symptoms was not moderated by disease stage. In multivariable analysis, type-D remained a significant predictor of symptoms of fatigue (OR=3.14; 95% CI: 1.98-4.99, P<0.001) and depression (OR=5.90; 95% CI: 3.60-9.67, P<0.001), also after controlling for symptom levels at baseline. CONCLUSION: Type-D personality but not disease stage predicted symptoms of fatigue and depression at 12-month follow-up.

Incidence and Correlates of Drug-Eluting Stent Thrombosis in Routine Clinical Practice. 4-Year Results From a Large 2-Institutional Cohort Study (Article)

2008-09-30T00:00:00Z

Objectives: We sought to determine the risk of late stent thrombosis (ST) during long-term follow-up beyond 3 years, searched for predictors, and assessed the impact of ST on overall mortality. Background: Late ST was reported to occur at an annual rate of 0.6% up to 3 years after drug-eluting stent (DES) implantation. Methods: A total of 8,146 patients underwent percutaneous coronary intervention with a sirolimus-eluting stent (SES) (n = 3,823) or paclitaxel-eluting stent (PES) (n = 4,323) and were followed up to 4 years after stent implantation. Dual antiplatelet treatment was prescribed for 6 to 12 months. Results: Definite ST occurred in 192 of 8,146 patients with an incidence density of 1.0/100 patient-years and a cumulative incidence of 3.3% at 4 years. The hazard of ST continued at a steady rate of 0.53% (95% confidence interval [CI]: 0.44 to 0.64) between 30 days and 4 years. Diabetes was an independent predictor of early ST (hazard ratio [HR]: 1.96; 95% CI: 1.18 to 3.28), and acute coronary syndrome (HR: 2.21; 95% CI: 1.39 to 3.51), younger age (HR: 0.97; 95% CI: 0.95 to 0.99), and use of PES (HR: 1.67; 95% CI: 1.08 to 2.56) were independent predictors of late ST. Rates of death and myocardial infarction at 4 years were 10.6% and 4.6%, respectively. Conclusions: Late ST occurs steadily at an annual rate of 0.4% to 0.6% for up to 4 years. Diabetes is an independent predictor of early ST, whereas acute coronary syndrome, younger age, and PES implantation are associated with late ST.

Three life-years gained from smoking cessation after coronary artery bypass surgery: A 30-year follow-up study (Article)

2008-09-01T00:00:00Z

Background: Previous studies have shown that smoking cessation after a cardiac event reduces the risk of subsequent mortality in patients, but the effect of smoking cessation in terms of prolonged life-years is not yet known. Methods: We analyzed the 30-year clinical outcome of the first 1,041 consecutive patients (age at operation 51 years, 92% male) who successfully underwent isolated venous coronary artery bypass surgery between 1971 and 1980. All 551 smokers (53%) were included in this study. Of these, 43% stopped smoking throughout the first year whereas 57% persisted smoking. Results: The median follow-up was 29 years (range 26-36 years). The cumulative 10-, 20-, and 30-year survival rates were 88%, 49%, and 19%, respectively, in the group of patients who quit smoking, and only 77%, 36%, and 11%, respectively, in the persistent smokers (P < .0001). After adjusting for all baseline characteristics, smoking cessation remained an independent predictor of lower mortality (hazard ratio 0.60, 95% CI 0.48-0.72). We were able to assess the exact life expectancy by calculating the area under the Kaplan-Meier curves. Life expectancy in the quitters was 20.0 years and 17.0 years in the persistent smokers (P < .0001). Conclusions: Using 30-year follow-up data, we estimated that self-reported smoking cessation after coronary artery bypass surgery was associated with a life expectancy gain of 3 years. Smoking cessation turned out to have a greater effect on reducing the risk of mortality than the effect of any other intervention or treatment.

Follow-up outcomes 10 years after arterial switch operation for transposition of the great arteries: Comparison of cardiological health status and health-related quality of life to those of the a normal reference population (Article)

2008-09-01T00:00:00Z

The purpose of this study was to investigate the cardiological health status and health-related quality of life after the arterial switch operation (ASO) for transposition of the great arteries (TGA) in comparison with a normative reference group. Chart review and cross-sectional systematic follow-up, including echocardiography, exercise testing, and electrocardiography, were performed on all survivors of ASO for TGA between 1990 and 1995. Health-related quality of life (HRQOL) was assessed using a standardized questionnaire. A normative reference group was included. Forty-nine survivors [median age at operation 13 days, mean age at follow-up 11±2 years (37/49 with intact ventricular septum] were identified. Thirty-three of 49 patients (67%) [22/33 TGA with intact ventricular septum (IVS)] participated in cross-sectional follow-up. Cumulative 10-year event-free survival was 88% and the re-intervention rate 6%. Aortic root dilatation occurred in 70% of patients; none had severe aortic regurgitation. Left ventricular function was normal. Exercise performance (85% of reference capacity, p=0.02), maximal oxygen uptake (85%, p<0.01) and peak heart rate (95%, p<0.01) were decreased. Exercise electrocardiogram was normal as was rhythm status. Unfavourable outcomes on HRQOL were found for motor functioning and positive emotional functioning. Overall there were no significant differences between TGA/IVS and TGA/VSD. We conclude that at mid- to long-term follow-up after ASO, major events and re-interventions (6%) occur infrequently. Exercise capacity and maximal oxygen uptake are lower than those in a reference population, which could not be related to diminished ventricular function. Aortic root dilatation is frequent, irrespective of the anatomical subgroup. Severe aortic regurgitation or left ventricular dilatation was not found. The unfavourable health-related quality of life deserves further attention.

Effect of Statin Therapy on Mortality in Patients With Peripheral Arterial Disease and Comparison of Those With Versus Without Associated Chronic Obstructive Pulmonary Disease (Article)

2008-07-15T00:00:00Z

Chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD) are both inflammatory conditions. Statins are commonly used in patients with PAD and have anti-inflammatory properties, which may have beneficial effects in patients with COPD. The relation between statin use and mortality was investigated in patients with PAD with and without COPD. From 1990 to 2006, we studied 3,371 vascular surgery patients. Statin use was noted at baseline and, if prescribed, converted to <25% (low dose) and ≥25% (intensified dose) of the maximum recommended therapeutic dose. The diagnosis of COPD was based on the Global Initiative for Chronic Obstructive Lung Disease guidelines using pulmonary function test. End points were short- (30-day) and long-term (10-year) mortality. A total of 330 patients with COPD (25%) used statins, and 480 patients (23%) without COPD. Statin use was independently associated with improved short- and long-term survival in patients with COPD (odds ratio 0.48, 95% confidence interval [CI] 0.23 to 1.00; hazard ratio 0.67, 95% CI 0.52 to 0.86, respectively). In patients without COPD, statins were also associated with improved short- and long-term survival (odds ratio 0.42, 95% CI 0.20 to 0.87; hazard ratio 0.76, 95% CI 0.60 to 0.95, respectively). In patients with COPD, only an intensified dose of statins was associated with improved short-term survival. However, for the long term, both low-dose and intensive statin therapy were beneficial. In conclusion, statin use was associated with improved short- and long-term survival in patients with PAD with and without COPD. Patients with COPD should be treated with an intensified dose of statins to achieve an optimal effect on both the short and long term.

Impaired sublingual microvascular perfusion during surgery with cardiopulmonary bypass: A pilot study (Article)

2008-07-01T00:00:00Z

Objective: Complications after cardiac surgery may involve multiple organ failure, which carries a high mortality. Development of multiple organ failure may be related to impaired microcirculatory perfusion as a result of systemic inflammation. Microcirculatory blood flow alterations have been associated with impaired outcome. We investigated whether these alterations occurred before, during, and after coronary artery bypass grafting. Methods: We observed 25 consecutive patients who underwent elective coronary artery bypass grafting with cardiopulmonary bypass. The sublingual microcirculation was investigated using side-stream dark-field imaging. Side-stream dark-field imaging was performed before (baseline), during, and after surgery. Microvascular blood flow was estimated with a semiquantitative microvascular flow index in small, medium, and large microvessels. Changes in microvascular flow were tested with Wilcoxon signed rank test. Results: Median microvascular flow index of medium blood vessels decreased after starting cardiopulmonary bypass relative to that after anesthetic induction (2.6, interquartile range 1.6-3.0, vs 3.0, interquartile range 2.8-3.0, P = .02). There was a trend toward decreased microvascular flow index of small and large vessels relative to baseline (P = .08 and P = .05, respectively). Decreases in microvascular flow index occurred irrespective of changes in systemic blood pressure. After each patient's return to the intensive care unit, microvascular flow index increased and normalized in all microvessels. Conclusion: For the first time, sublingual microvascular blood flow alterations have been observed during cardiopulmonary bypass-assisted coronary artery bypass grafting.

Longest Available Clinical Outcomes After Drug-Eluting Stent Implantation for Unprotected Left Main Coronary Artery Disease. The DELFT (Drug Eluting stent for LeFT main) Registry (Article)

2008-06-10T00:00:00Z

Objectives: The purpose of this study was to investigate the long-term safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation for unprotected left main coronary artery (ULMCA) disease. Background: Long-term clinical outcomes after DES implantation for ULMCA disease have not yet been ascertained. Methods: From April 2002 to April 2004, 358 consecutive patients who underwent PCI with DES implantation for de novo lesions on ULMCA were retrospectively selected and analyzed in 7 European and U.S. tertiary care centers. No patients were excluded from the analysis, and all patients had a minimum follow-up of 3 years. Results: Technical success rate was 100%. Procedural success rate was 89.6%. After 3 years, major adverse cardiovascular events (MACE)-free survival in the whole population was 73.5%. According to the Academic Research Consortium definitions, cardiac death occurred in 9.2% of patients, and reinfarction, target lesion revascularization (TLR), and target vessel revascularization (TVR) occurred in 8.6%, 5.8%, and 14.2% of patients, respectively. Definite stent thrombosis occurred in 2 patients (specifically at 0 and 439 days). In elective patients, the 3-year MACE-free survival was 74.2%, with mortality, reinfarction, TLR, and TVR rates of 6.2%, 8.3%, 6.6%, and 16%, respectively. In the emergent group the 3-year MACE-free survival was 68.2%, with mortality, reinfarction, TLR, and TVR rates of 21.4%, 10%, 2.8%, and 7.1%, respectively. Conclusions: Routine DES implantation in ULMCA disease seems encouraging, with favorable long-term clinical results.

Four-year follow-up of treatment with intramyocardial skeletal myoblasts injection in patients with ischaemic cardiomyopathy (Article)

2008-06-01T00:00:00Z

Aims: Studies reporting improved left ventricular (LV) function of percutaneous skeletal myoblast (SkM) injection in patients with ischaemic cardiomyopathy had follow-up not exceeding 12 months, and did not include a control group. Our group has reported evidence for myoblast efficacy in the first five out of the 14 treated patients. The objective of the present evaluation was to assess if these effects were sustained at long-term follow-up. We compared function of patients treated with SkM 4 years earlier with a matched control group. Secondary endpoints included mortality, NYHA class, N-terminal pro-B-natriuretic peptide levels, incidence of arrhythmias, and quality of life. Methods and results: Fourteen patients with ischaemic cardiomyopathy who underwent SkM injection were compared with 28 non-randomized control patients matched for age, sex, location, and extent of myocardial infarction. Contrast echocardiography and tissue Doppler imaging (TDI) was performed to compare global and regional LV function. At 4-year follow-up, three patients (21%) had died in the treated group and 11 patients (39%) in the control group (P = 0.8). In the survivors, LV ejection fraction (EF) was 35 ± 10% and 37 ± 9% in the SkM group and 36 ± 8% and 36 ± 6% in the controls at baseline and 4 years follow-up, respectively (P = 0.96 between groups at follow-up). TDI-derived systolic velocity in the injected sites was 5.4 ± 1.8 cm/s in the SkM group when compared with 5.1 ± 1.6 cm/s in corresponding sites in the control group (P = 0.47). None of the secondary endpoints showed a difference between the groups. However, in the patients fitted with an internal cardioverter defibrillator, more arrhythmias leading to interventions occurred in the treated group than in the control group, 87% and 13%, respectively (P = 0.015). Conclusion: Percutaneous intramyocardial SkM injection in ischaemic cardiomyopathy has no sustained positive effect on resting global or regional LV function, respectively, at 4-year follow-up. Moreover, the procedure may induce a higher risk of developing serious arrhythmias, but larger patient series are required before more precise characterization of the safety and efficacy profile of the procedure is possible.

Usefulness of Clinical, Echocardiographic, and Procedural Characteristics to Predict Outcome After Percutaneous Transluminal Septal Myocardial Ablation (Article)

2008-05-01T00:00:00Z

This study was conducted to assess outcomes after percutaneous transluminal septal myocardial ablation (PTSMA) treatment in 131 patients (mean age 56 ± 16 years) with obstructive hypertrophic cardiomyopathy. In-hospital and follow-up complications as well as late PTSMA failure (defined as unsatisfactory clinical outcome and a significant residual outflow tract gradient, necessitating reintervention) were noted. Baseline clinical, echocardiographic, and PTSMA characteristics were examined as determinants of outcomes. Also, the effect of ethanol volume and the role of a learning curve were investigated. PTSMA was successful in 90% of the patients. In-hospital and follow-up cardiac events were noted in 20 patients, including cardiac death (in-hospital n = 4, follow-up n = 1), acute myocardial infarction due to ethanol leakage (n = 1), coronary dissection (n = 2), nonfatal cardiac tamponade (n = 1), and permanent pacemaker (n = 6) or cardiac defibrillator (in-hospital n = 4, follow-up n = 1) implantation. Late PTSMA failure was noted in 12 patients. All baseline characteristics were comparable between successful and failed PTSMA. Ethanol volume was related to peak creatinine kinase value (p <0.0001) but not to late PTSMA failure or greater need for pacemaker implantation. Late PTSMA failure occurred more frequently in PTSMA procedures performed in the early, less experienced time period (p <0.001). In conclusion, this study confirms that PTSMA, although effective, has a relatively high complication rate. Late PTSMA failure could not be predicted by baseline characteristics but could partially be explained by a learning-curve effect. This finding implies that PTSMA procedures should be restricted to experienced centers.

Quantification of coronary plaque by 64-slice computed tomography: A comparison with quantitative intracoronary ultrasound (Article)

2008-05-01T00:00:00Z

BACKGROUND: Noninvasive assessment of coronary atherosclerotic plaque may be useful for risk stratification and treatment of atherosclerosis. MATERIALS AND METHODS: We studied 47 patients to investigate the accuracy of coronary plaque volume measurement acquired with 64-slice multislice computed tomography (MSCT), using newly developed quantification software, when compared with quantitative intracoronary ultrasound (QCU). Quantitative MSCT coronary angiography (QMSCT-CA) was performed to determine plaque volume for a matched region of interest (regional plaque burden) and in significant plaque defined as a plaque with ≥50% area obstruction in QCU, and compared with QCU. Dataset with image blurring and heavy calcification were excluded from analysis. RESULTS: In 100 comparable regions of interest, regional plaque burden was highly correlated (coefficient r = 0.96; P < 0.001) between QCU and QMSCT-CA, but QMSCT-CA overestimated the plaque burden by a mean difference of 7 ± 33 mm (P = 0.03). In 76 significant plaques detected within the regions of interest, plaque volume determined by QMSCT-CA was highly correlated (r = 0.98; P < 0.001) with a slight underestimation of 2 ± 17 mm (P = not significant) when compared with QCU. Calcified and mixed plaque volume was slightly overestimated by 4 ± 19 mm (P = ns) and noncalcified plaque volume was significantly underestimated by 9 ± 11 mm (P < 0.001) with QMSCT-CA. Overall, the limits of agreement for plaque burden/volume measurement between QCU and QMSCT-CA were relatively large. Reproducibility for the measurements of regional plaque burden with QMSCT-CA was good, with a mean intraobserver and interobserver variability of 0% ± 16% and 4% ± 24%, respectively. CONCLUSIONS: Quantification of coronary plaque within selected proximal or middle coronary segments without image blurring and heavy calcification with 64-slice CT was moderately accurate with respect to intravascular ultrasound and demonstrated good reproducibility. Further improvement in CT resolution is required for more reliable measurement of coronary plaques using quantification software.

Significance of hypotensive response during dobutamine stress echocardiography (Article)

2008-04-25T00:00:00Z

Background: In patients undergoing exercise testing a hypotensive response is associated with a poor prognosis. There is limited information regarding the prognostic significance of hypotension during dobutamine stress test. This study investigates the association between a severe hypotensive response during DSE and long-term prognosis. Methods: Patients (3381) underwent dobutamine stress echocardiography (DSE). Blood pressure was measured automatically at rest and at the end of every dose-step. Wall motion was scored using a 16-segement, 5-point score. Ischemia was defined by the presence of new wall motion abnormalities. Hypotensive response during DSE was defined as mild (MHR) when systolic blood pressure (SBP) dropped < 20 mmHg between rest and peak stress, and severe (SHR) when SBP dropped < 20 mmHg. During follow-up all cause mortality and MACE (cardiac death or non-fatal myocardial infarction) were noted. Results: MHR and SHR occurred in 936 (28%) and 521 (15%) patients, respectively. Independent predictors of SHR were older age, new or worsening wall motion abnormalities and history of hypertension. During follow-up of 4.5 (± 3.3) years, 920 patients died, of which 555 due to cardiac causes, and 713 patients experienced a MACE. After adjustment for baseline characteristics and DSE results SHR during DSE was independently associated with increased long-term cardiac death (HR: 1.3, 95% CI: 1.03-1.6) and MACE (HR: 1.34, 95% CI: 1.1-1.6), while MHR was not associated with a worse outcome. Conclusions: Severe hypotensive response during DSE independently predicts cardiac death and MACE in patients with known or suspected coronary artery disease.

Long-Term Prognosis of Patients With Peripheral Arterial Disease. A Comparison in Patients With Coronary Artery Disease (Article)

2008-04-22T00:00:00Z

Objectives: This study was designed to compare the long-term outcomes of patients with peripheral arterial disease (PAD) with a risk factor matched population of coronary artery disease (CAD) patients, but without PAD. Background: The PAD is considered to be a risk factor for adverse late outcome. Methods: A total of 2,730 PAD patients undergoing vascular surgery were categorized into groups: 1) carotid endarterectomy (n = 560); 2) elective abdominal aortic surgery (AAA) (n = 923); 3) acute AAA surgery (r-AAA) (n = 200), and 4) lower limb reconstruction procedures (n = 1,047). All patients were matched using the propensity score, with 2,730 CAD patients who underwent coronary angioplasty. Survival status of all patients was obtained. In addition, the cause of death and complications after surgery in PAD patients were noted. The Kaplan-Meier method was used to compare survival between the matched PAD and CAD population and the different operation groups. Prognostic risk factors and perioperative complications were identified with the Cox proportional hazards regression model. Results: The PAD patients had a worse long-term prognosis (hazard ratio 2.40, 95% confidence interval 2.18 to 2.65) and received less medication (beta-blockers, statins, angiotensin-converting enzyme inhibitors, aspirin, nitrates, and calcium antagonists) than CAD patients did (p < 0.001). Cerebro-cardiovascular complications were the major cause of long-term death (46%). Importantly, no significant difference in long-term survival was observed between the AAA and lower limb reconstruction groups (log rank p = 0.70). After vascular surgery, perioperative cardiac complications were associated with long-term cardiac death, and noncardiac complications were associated with all-cause death. Conclusions: Long-term prognosis of vascular surgery patients is significantly worse than for patients with CAD. The vascular surgery patients receive less cardiac medication than CAD patients do, and cerebro-cardiovascular events are the major cause of late death.

Four-Year Clinical Follow-Up of the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital Registry (Article)

2008-04-15T00:00:00Z

Although the safety of drug-eluting stents has been under considerable scrutiny, limited real-world follow-up data extending up to 4 years are available. The randomized clinical trials carefully selected patients and are not reflective of everyday practice. From April to October 2002, 508 consecutive patients treated with sirolimus-eluting stents (SES) were enrolled. The control group consisted of 450 patients treated with bare-metal stents during the preceding 6 months. After 4 years of follow-up, the incidence of composite major adverse clinical events (all-cause death, myocardial infarction, or target vessel revascularization) was found to be significantly lower in the SES group (23.0% vs 28.7%, adjusted hazard ratio 0.66, 95% confidence interval 0.51 to 0.86), as were rates of target vessel revascularization (12.2% vs 17.8%, adjusted hazard ratio 0.57, 95% confidence interval 0.39 to 0.83). There were no differences in all-cause mortality (10.5% for SES vs 10.6% for bare-metal stents, p = 0.9) or in the rates of cardiac death (4.5% vs 6.9%, p = 0.1). Although there was no difference in overall stent thrombosis (2.3% vs 2.2%, p = 1.0), SES had a higher rate of very late stent thrombosis (1.4% vs 0%, p = 0.02), balanced by a lower rate of early stent thrombosis (0.4% vs 1.8%, p = 0.05). In conclusion, after 4 years, SES were found to remain safe and effective compared with bare-metal stents. Nevertheless, the higher rate of very late stent thrombosis remains a concern. Longer term follow-up will be required to determine the extent of this problem.

Anemia as an Independent Predictor of Perioperative and Long-Term Cardiovascular Outcome in Patients Scheduled for Elective Vascular Surgery (Article)

2008-04-15T00:00:00Z

Anemia is common in patients scheduled for vascular surgery and is a risk factor for adverse cardiac outcome. However, it is unclear whether this is an independent risk factor or an expression of underlying co-morbidities. In total, 1,211 patients (77% men, 68 ± 11 years of age) were enrolled. Anemia was defined as serum hemoglobin levels <13 g/dl for men and <12 g/dl for women and was divided into tertiles to compare mild (men 12.2 to 13.0, women 11.2 to 12.0), moderate (men 11.0 to 12.1, women 10.2 to 11.1), and severe (men 7.2 to 11.0, women 7.5 to 10.1) anemia with nonanemia. Outcome measurements were 30-day and 5-year major adverse cardiac events (MACEs; cardiac death or myocardial infarction). All risk factors were noted. Multivariable logistic and Cox regression analyses were used, adjusting for all cardiac risk factors, including heart failure and renal disease. Data are presented as hazard ratios with 95% confidence intervals. In total, 74 patients (6%) had 30-day MACEs and 199 (17%) had 5-year MACEs. Anemia was present in 399 patients (33%), 133 of whom had mild anemia, 133 had moderate anemia, and 133 had severe anemia. Presence of anemia was associated with renal dysfunction, diabetes, and heart failure. After adjustment for all clinical risk factors, 30-day hazard ratios for a MACE per anemia group were 1.8 for mild (0.8 to 4.1), 2.3 for moderate (1.1 to 5.4), and 4.7 for severe (2.6 to 10.9) anemia, and 5-year hazard ratios for MACE per anemia group were 2.4 for mild (1.5 to 4.2), 3.6 for moderate (2.4 to 5.6), and 6.1 for severe (4.1 to 9.1) anemia. In conclusion, the presence and severity of preoperative anemia in vascular patients are significant predictors of 30-day and 5-year cardiac events, regardless of underlying heart failure or renal disease.

Clustering of psychosocial risk factors enhances the risk of depressive symptoms 12-months post percutaneous coronary intervention (Article)

2008-04-01T00:00:00Z

BACKGROUND: Psychosocial risk factors cluster together, but generally a single factor approach has been adopted when studying their influence on health outcomes in cardiac patients. We examined the impact of clustering (i.e. type D personality and anxiety) on depressive symptoms 12 months post percutaneous coronary intervention (PCI). DESIGN: Prospective study. METHODS: Consecutive patients (n=416), treated with PCI with drug-eluting stents, completed the type D Scale and the Hospital Anxiety and Depression Scale anxiety subscale at baseline, and the depression subscale at 12 months. RESULTS: Of all patients, 27% experienced depressive symptoms at 12 months. Depressive symptoms could not be attributed to cardiac events occurring during follow-up (P=0.76). The prevalence of depressive symptoms at 12 months was highest in patients with clustering (64%), followed by the single risk factors type D (45%) and anxiety (38%), with the lowest prevalence in the no risk factor group (neither anxiety nor type D) (13%; P<0.001). The single risk factors type D personality [odds ratio (OR): 5.82; 95% confidence interval (CI): 2.93-11.56] and anxiety (OR: 4.36; 95% CI: 2.23-8.55) and their co-occurrence (OR: 12.38; 95% CI: 6.11-25.09) remained independent significant predictors of depressive symptoms at 12 months compared with the no risk factor group, adjusting for baseline characteristics. CONCLUSION: Patients with the co-occurrence of type D personality and anxiety, two risk factors independently associated with adverse prognosis, had a considerably higher risk of depressive symptoms 12 months post PCI compared with patients with no or one risk factor. Further research is warranted to examine whether clustering of psychosocial risk factors also has deleterious effects on prognosis.

Assessment of left ventricular ejection fraction after myocardial infarction using contrast echocardiography (Article)

2008-03-01T00:00:00Z

Aims: Despite its relatively high intra- and inter-observer variability for left ventricular ejection fraction (LV-EF) echocardiography is clinically still the most used modality to assess LV-EF. We studied whether adding a second-generation microbubble contrast agent could decrease this variability. Methods and results: Forty-eight patients underwent transthoracic echocardiography in second-harmonic mode (SHI) with and without contrast within 5 days after an acute myocardial infarction. LV-EF was determined using the Simpson's biplane method. With contrast intra-observer variability decreased from 12.5 ± 11.5% to 7.0 ± 7.0% (P < 0.001) and inter-observer variability decreased from 16.9 ± 9.9% to 7.0 ± 6.2% (P < 0.001). Bland-Altman analysis confirmed these findings by demonstrating smaller 95% limits of agreement for both the intra- and inter-observer variability when contrast was used. This improvement in intra- and inter-observer variability was seen to a comparable extent in patients with moderate-to-poor and good quality SHI echocardiograms. Conclusion: Echo contrast significantly improves intra- and inter-observer variability for LV-EF, both in patients with moderate-to-poor and good quality SHI echocardiograms.

Diagnostic performance of coronary CT angiography by using different generations of multisection scanners: Single-center experience (Article)

2008-02-01T00:00:00Z

Purpose: To retrospectively compare sensitivity and specificity of four generations of multidetector computed tomographic (CT) scanners for diagnosing significant (≥50%) coronary artery stenosis, with quantitative conventional coronary angiography as reference standard. Materials and Methods: The institutional review board approved this study. All patients consented to undergo CT studies prior to conventional coronary angiography, after they were informed of the additional radiation dose, and to the use of their data for future retrospective research. Two hundred four patients (157 men, 47 women; mean age, 58 years ± 11 [standard deviation]), classified in four groups of 51 patients each, underwent coronary CT angiography with four-section, first- and second-generation 16-section, and 64-section CT scanners. Patients in sinus rhythm scheduled for conventional coronary angiography (stable angina, atypical chest pain) were included. Patients with bypass grafts and stents were excluded. Two readers unaware of results of conventional coronary angiography evaluated CT scans. Coronary artery segments of 2 mm or larger in diameter were included for comparative evaluation with quantitative coronary angiography. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for detection of significant stenoses (≥50% luminal diameter reduction) were calculated. Results: Image quality was rated poor for the following percentages of coronary artery segments: 33.1% at four-section CT, 14.4% at first-generation 16-section CT, 6.3% at second-generation 16-section CT, and 2.6% at 64-section CT. Sensitivity, specificity, PPV, and NPV, respectively, were as follows: 57%, 91%, 60%, and 90% at four-section CT; 90%, 93%, 65%, and 99% at first-generation 16-section CT; 97%, 98%, 87%, and 100% at second-generation 16-section CT; and 99%, 96%, 80%, and 100% at 64-section CT. Diagnostic performance of four-section CT was significantly poorer than that of second-generation 16-section CT (odds ratio = 4.57) and 64-section CT (odds ratio = 2.89). Conclusion: Diagnostic performance of coronary CT angiography varies among scanners of different generations. Earlier-generation scanners (four sections) had significantly poorer performance; performance of 16- compared with 64-section CT scanners showed progressive, although not significant, improvement.

Prognostic significance of renal function in patients undergoing dobutamine stress echocardiography (Article)

2008-02-01T00:00:00Z

Background. Dobutamine stress echocardiography (DSE) is used for risk stratification of patients with suspected coronary artery disease (CAD). However, the prognostic value of DSE among the entire strata of renal function has yet to be determined. We assessed the prognostic value of renal function relative to DSE findings. Methods. We studied 2292 patients, divided into 729 (32%) patients with normal renal function [creatinine clearance (CrCl) >90 ml/min] and 1563 (68%) with renal dysfunction, classified as mild (CrCl: 60-90 ml/min) in 933, moderate (CrCl: 30-60 ml/min) in 502 and severe (CrCl < 30ml/min) in 128 patients. All patients underwent DSE for the evaluation of known or suspected CAD and were followed for a mean of 8 years. Results. New wall motion abnormalities during DSE and mildly, moderately and severely abnormal CrCl were powerful independent predictors for all-cause mortality, cardiac death and hard cardiac events (cardiac death and non-fatal myocardial infarction). Kaplan-Meier curves demonstrated that patients with normal DSE and renal dysfunction have greater probability for cardiac death and hard cardiac events compared to those with normal renal function. The warranty of a normal DSE in the presence of moderate renal dysfunction was 15 and 36 months for 10 and 20% risk for cardiac death and hard cardiac events, respectively. Conclusions. The presence and severity of renal dysfunction has additional independent prognostic value over DSE findings. The low-risk warrantee period after a normal DSE is determined by the severity of renal dysfunction.

Reduced positive affect (anhedonia) predicts major clinical events following implantation of coronary-artery stents (Article)

2008-02-01T00:00:00Z

Objective. Emotional distress has been related to clinical events in patients with coronary artery disease, but the influence of positive affect (i.e. mood states such as activity, joy and cheerfulness) has received little attention. Therefore, we wanted to investigate the role of positive affect on clinical outcome after percutaneous coronary intervention (PCI) with stent implantation in these patients. Design. Prospective follow-up study. At baseline, patients from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry completed measures of positive affect, depression and anxiety post-PCI. Patients with reduced positive affect scored 1 SD below the mean score. Setting. University Hospital; Thoraxcenter of the Department of Cardiology. Subjects. 874 patients (72% men; 62.2 ± 10.9 years) from the RESEARCH registry. Main outcome measure. Death or myocardial infarction (MI) 2 years post-PCI. Results. At follow-up, there were 52 clinical events (deaths n = 27, MIs n = 25). Reduced positive affect and depression/anxiety were associated with poor prognosis, but reduced positive affect was the only independent predictor of events. The incidence of death/MI in adequate versus reduced positive affect patients was 4% (29/663) vs. 11% (23/211); HR = 2.55 (95% CI 1.46-4.34, P = 0.001), adjusting for clinical variables. Reduced positive affect and diabetes were independent prognostic factors, and patients with one (HR = 2.84, 95% CI 1.58-5.10) or both (HR = 5.61, 95% CI 2.25-13.99) of these factors had a higher risk when compared with nondiabetic patients with adequate positive affect, P ≤ 0.003. Conclusions. Reduced positive affect independently predicted death/MI following stent implantation, and improved risk stratification above and beyond diabetes.

Consequences of a selective approach toward pulmonary valve replacement in adult patients with tetralogy of Fallot and pulmonary regurgitation (Article)

2008-01-01T00:00:00Z

Objective: The aim of the study was to assess the long-term results of a selective policy toward pulmonary valve replacement in adult patients with repaired tetralogy of Fallot and severe pulmonary regurgitation. Methods: Sixty-seven patients with tetralogy of Fallot were followed up from 15 ± 3 years until 27 ± 3 years after surgery. Results: Twenty-two patients had mild-to-moderate pulmonary regurgitation. No significant changes occurred in the follow-up period. Of 45 patients with severe pulmonary regurgitation and severe right ventricular dilatation, 28 (62%) remained free of symptoms and did not undergo pulmonary valve replacement. No changes in right ventricular size or exercise capacity were found. In 3 (11%) of 28 patients, QRS duration increased to more than 180 ms. Seventeen patients had symptoms and underwent pulmonary valve replacement: 9 (54%) of 17 patients improved clinically and echocardiographically, and QRS duration shortened postoperatively. Right ventricular dimensions did not regress despite pulmonary valve replacement in 8 patients. Conclusion: Refraining from pulmonary valve replacement in asymptomatic patients led to no measurable deterioration in 25 (89%) of 28 patients. Referring symptomatic patients for pulmonary valve replacement led to an improvement in 9 (53%) of 17 patients. In 11 (24%) of 45, a selective approach led to questionable or unsatisfactory results.

Renal insufficiency and mortality in patients with known or suspected coronary artery disease (Article)

2008-01-01T00:00:00Z

It remains unclear whether mild renal dysfunction is associated with adverse cardiovascular outcome. We investigated whether estimated glomerular filtration rate (eGFR) was associated with mortality and cardiac death among 6447 patients with known or suspected coronary artery disease over a mean follow-up of 7 yr. Cumulative 5- and 10-yr survival rates decreased in a graded fashion from 88% and 70%, respectively, for those with normal renal function to 43% and 33% for those with eGFR <30 ml/min. Compared with patients with normal renal function, the multivariable adjusted hazard ratios for all-cause mortality among patients with mild, moderate, and severe renal impairment were 1.33 (95% confidence interval [CI], 1.21-1.48), 1.67 (95% CI, 1.44-1.93), and 3.38 (95% CI, 2.73-4.19), respectively. Similar relationships between cardiac death and decreasing renal function were found. In conclusion, renal function is a graded and independent predictor of long-term mortality in patients with known or suspected coronary artery disease. Intense treatment and close surveillance of these patients is encouraged. Copyright

β-Blockers improve outcomes in kidney disease patients having noncardiac vascular surgery (Article)

2007-12-01T00:00:00Z

β-Blockers are known to improve postoperative outcome after major vascular surgery. We studied the effects of β-blockers in 2126 vascular surgery patients with and without kidney disease followed for 14 years. Creatinine clearance was calculated using the Cockcroft-Gault equation, and kidney function was categorized as Stage 1 for a reference group of 550 patients, Stage 2 with 808 patients, Stage 3 with 627 patients, and combined Stages 4 and 5 with 141 patients. Outcome measures were 30-day and long-term all-cause mortality with a mean follow-up of 6 years. Cox proportional hazards models were used to control cardiovascular risk factors, including propensity for β-blocker use. In all, 129 (6%) and 1190 (56%) patients died respectively. Mortality rates were three- and two-fold higher, respectively, for patients at Stages 3-5 compared to the reference group for the two outcomes. β-Blocker use was significantly associated with a lower risk of mortality after surgery. The overall adjusted hazard ratio was 0.35 and 0.62, respectively, for individuals at Stages 3-5 compared to the reference group for 30-day and long-term mortality. This study shows that kidney function is a predictor of all-cause mortality and β-blocker use is associated with a lower risk of death in kidney disease patients undergoing elective vascular surgery.

The Influence of Aging on the Prognostic Value of the Revised Cardiac Risk Index for Postoperative Cardiac Complications in Vascular Surgery Patients (Article)

2007-12-01T00:00:00Z

Objective: The Lee-risk index [Lee-index] was developed to predict major adverse cardiac events [MACE]. However, age is not included as a risk factor. The aim was to assess the value of the Lee-index in vascular surgery patients among different age categories. Methods: Of 2 642 patients cardiovascular risk factors were noted to calculate the Lee-index. Patients were divided into four age categories; ≤ 55(n = 396), 56-65 (n = 650), 66-75 (n = 1 058) and >75 years (n = 538). Outcome measures were postoperative MACE (cardiac death, MI, coronary revascularization and heart failure). The performance of the Lee-index was determined using C-statistics within the four age groups. Results: The incidence of MACE was 10.9%, for Lee-index 1, 2 and ≥3; 6%, 13% and 20%, respectively. However, the prognostic value differed among age groups. The predictive value for MACE was highest among patients under 55 year (0.76 vs 0.62 of patients aged > 75). The prediction of MACE improved in elderly (aged > 75) after adjusting the Lee-index with age, revised risk of operation (low, low-intermediate, high-intermediate and high-risk procedures) and hypertension (0.62 to 0.69). Conclusion: The prognostic value of the Lee-index is reduced in elderly vascular surgery patients, adjustment with age, risk of surgical procedure, and hypertension improves the Lee-index significantly.

Congenital aortic stenosis in adults: Rate of progression and predictors of clinical outcome (Article)

2007-11-30T00:00:00Z

Background: Little data are available on the natural history of young adults with congenital valvular aortic stenosis (AS). The aim of the present study was to determine the progression rate of AS in young adults, and to identify predictors of stenosis progression and outcome. Methods: Retrospective study of all patients seen at a single centre diagnosed with congenital AS (≥ 2.5 m/s) between 1992 and 2005, excluding patients with severe aortic regurgitation. The slope of the regression of the aortic jet velocity on the time elapsed since the baseline study was used to define the rate of progression of stenosis. Results: A total of 84 adults (mean age, 23.5 ± 7.9 years) were studied who had at least two echocardiograms > 1 year (5.6 ± 2.6 years) apart. The annual progression of aortic jet velocity was 0.09 ± 0.15 m/s per year. Multivariable linear regression analysis identified older age (p < 0.001) as an independent predictor of faster haemodynamic progression. During the follow-up period of 7.7 ± 2.7 years, no patient died and 35 patients (42%) underwent aortic valve intervention. By multivariable Cox regression analysis, severe AS (≥ 4.0 m/s) and rapid progression of aortic jet velocity (≥ 0.2 m/s/year) were independent predictors of intervention. Cumulative intervention-free survival for patients with severe AS was 78 ± 8% at 3 years and 48 ± 10% at 5 years versus respectively 98 ± 2% and 96 ± 3% for patients with mild-to-moderate AS (log-rank: p < 0.001). Conclusions: Progression of congenital AS was relatively low in young adults compared to elderly with degenerative AS. Older age was associated with more rapid progression.

Statin therapy is associated with improved outcomes in vascular surgery patients with renal impairment (Article)

2007-11-01T00:00:00Z

Background: Little is known about the association between baseline kidney function, statin therapy, and outcome after vascular surgery in patients with and without chronic kidney disease. Methods: A total of 2126 patients underwent elective major vascular surgery and were divided into 2 categories based on baseline creatinine clearance (CrCl), calculated using the Cockcroft-Gault equation: CrCl ≥60 mL/min (n = 1358, reference) and CrCl <60 mL/min (n = 768). Outcome measures were 30-day and long-term all-cause, cardiac, and cerebrocardiovascular mortality. Mean follow-up was 6.0 ± 3.7 years. Multivariate Cox regression analysis, including potential confounders and propensity score for statin use, was applied. Data are presented as hazard ratios (HRs) with 95% CI. Results: Thirty-day all-cause, cardiac, and cerebrocardiovascular mortality rates were 3.8% versus 10.2%, 1.3% versus 4.2%, and 2.7% versus 7.8%, respectively, according to the 2 categories of kidney function. In addition, long-term all-cause, cardiac, and cerebrocardiovascular mortality rates were 46.6% versus 72.5%, 14.6% versus 26.4%, and 23.0% versus 40.6%, respectively. Statin therapy was associated with an overall significant improved 30-day and long-term all-cause mortality, independent of other important confounders. However, in patients with a CrCl ≥60 mL/min, the long-term cardiac and cerebrocardiovascular beneficial effects did not reach statistical significance (HR 0.93, 95% CI 0.61-1.41 and HR 0.89, 95% CI 0.63-1.24, respectively) when compared with patients with a CrCl of <60 mL/min (HR 0.63, 95% CI 0.41-0.96 and HR 0.67, 95% CI 0.48-0.94, respectively). Conclusions: The level of kidney function is an independent predictor of short- and long-term outcome after major noncardiac surgery. In addition, perioperative statin use in patients with kidney disease is associated with a reduction in the short- and long-term all-cause, cardiac, and cerebrocardiovascular mortality.

Type-D personality and depressive symptoms predict anxiety 12 months post-percutaneous coronary intervention (Article)

2007-11-01T00:00:00Z

Background: We examined whether type-D personality exerts a stable effect on anxiety over time and the clinical relevance of type-D personality as a predictor of anxiety 12 months post-percutaneous coronary intervention (PCI). Methods: Consecutive patients (n = 416) with stable or unstable angina pectoris treated with PCI completed the Type-D Scale (DS14) at baseline and the Hospital Anxiety and Depression Scale (HADS) at baseline and 12 months. Results: At baseline, 26% of the patients were anxious, with 67% of these patients still being anxious 12 months post-PCI (p < 0.001). There was no significant change in anxiety between baseline and 12 months (p = 0.96) nor was the interaction effect type-D personality by time significant (p = 0.41). However, type-D patients experienced significantly higher levels of anxiety than non-type-D patients (p < 0.001). Type-D personality (OR: 2.89; CI: 1.57-5.34), depressive symptoms (OR: 3.27; CI: 1.73-6.18) and anxiety at baseline (OR: 8.38; CI: 4.65-15.12) were independent predictors of anxiety 12 months post-PCI, adjusting for baseline demographic and clinical characteristics. Limitations: A limitation of the study is the attrition rate of 105 patients who did not complete the HADS at 12 months. No information was available on the use of psychotropic medication and participation in cardiac rehabilitation, which could serve as confounders. Conclusion: Type-D exerted a stable effect on anxiety over time and was an independent predictor of anxiety 12 months post-PCI together with depressive symptoms and anxiety at baseline. The DS14 could be used as a screening tool in clinical practice to identify high-risk patients post-PCI.

The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery (Article)

2007-11-01T00:00:00Z

OBJECTIVE: The aim of this study is to determine the prevalence and prognosis of unrecognized myocardial infarction (MI) and silent myocardial ischemia in vascular surgery patients. METHODS: In a cohort of 1092 patients undergoing preoperative dobutamine stress echocardiography and noncardiac vascular surgery, unrecognized MI was determined by rest wall motion abnormalities in the absence of a history of MI. Silent myocardial ischemia was determined by stress-induced wall motion abnormalities in the absence of angina pectoris. Beta blockers and statins were noted at baseline. During follow-up (mean: 6±4 years), all-cause mortality and major cardiac events (cardiac death or nonfatal MI) were noted. RESULTS: The prevalence of unrecognized MI and silent myocardial ischemia was 23 and 28%, respectively. Both diabetes and heart failure were important predictors of unrecognized MI and silent myocardial ischemia. During follow-up, all-cause mortality occurred in 45% and major cardiac events in 23% of patients. In multivariate analysis, unrecognized MI and silent myocardial ischemia were significantly associated with increased risk of mortality [hazard ratio (HR), 1.86; 95% confidence interval (CI), 1.53-2.25 and HR, 1.74; 95% CI, 1.46-2.06, respectively] and major cardiac events (HR, 2.15; 95% CI, 1.59-2.92 and HR, 1.86; 95% CI, 1.43-2.41, respectively). In patients with unrecognized MI, β-blockers and statins were significantly associated with improved survival. Statins improved survival in patients with silent myocardial ischemia. CONCLUSIONS: In patients undergoing major vascular surgery, unrecognized MI and silent myocardial ischemia are highly prevalent (23 and 28%) and associated with increased long-term mortality and major cardiac events.

Three-year clinical outcomes after coronary stenting of chronic total occlusion using sirolimus-eluting stents: Insights from the rapamycin-eluting stent evaluated at Rotterdam Cardiology Hospital-(RESEARCH) registry (Article)

2007-11-01T00:00:00Z

Background: We previously reported that the 1-year survival-free from target lesion revascularization was 97.4% in patients with chronic total occlusion (CTO) treated with sirolimus-eluting stents (SES). There are currently no long-term results of the efficacy of SES in this subset of lesions. We assessed the 3-year clinical outcomes of 147 patients with CTO treated with either SES or bare metal stents (BMS). Methods and Results: A total of 147 (BMS = 71, SES = 76) patients were included. Four patients died in the BMS group while five patients died in the SES group, P = 0.8; two myocardial infarctions occurred in both groups, P = 0.9; and target vessel revascularization was performed in nine patients in the BMS and seven in the SES group, P = 0.5. The cumulative event-free survival of MACE was 81.7% in BMS group and 84.2% in SES group, P = 0.7. Two patients of the SES group had a coronary aneurism at 3-year angiographic follow-up. Conclusions: The use of SES was no longer associated with significantly lower rates of target vessel revascularization and major adverse cardiac events in patients with CTOs after 3 years of followup compared with BMSs.

A randomised controlled study comparing conventional and magnetic guidewires in a two-dimensional branching tortuous phantom simulating angulated coronary vessels (Article)

2007-11-01T00:00:00Z

Objectives: To directly compare the magnetic navigation system (MNS) guidewires with conventional guidewires in branching tortuous phantoms with operators of varying MNS and percutaneous coronary intervention experience. Background: Vessel tortuosity, angulation, and side branches remain limiting factors in coronary interventions. The MNS addresses these limitations by precisely directing the tip of a magnetised guidewire in vivo aided by two permanent adjustable external magnets. Methods: Crossing and fluoroscopy times of six operators were evaluated in five tortuous Perspex® phantom vessels in three consecutive attempts. Standard guidewire (SG) usage was unrestricted. Two 2nd generation magnetic guidewires (MG) were used. Failure was noted if the cross was unsuccessful within 5 min. Results: The magnetic navigation was vastly superior to SG techniques with increasingly tortuous phantoms. It dramatically decreased both the crossing and fluoroscopy times with maximal reduction from 201.7 ± 111 to 36.4 ± 13 sec, P < 0.001 and 204.7 ± 24 to 47.2 ± 19 sec, P < 0.001, respectively. The MNS had a 98.8% procedural success rate compared to 68% with SG techniques. Moreover it considerably limited the amount of wire usage from 5.5 to 1.3. Operators with prior MG experience performed significantly better than those without, except in the simplest phantom where the difference was nonsignificant (33.8 ± 13 sec vs. 41.7 ± 17 sec, P = 0.2). Conclusion: MNS significantly reduces both the crossing and fluoroscopy times in tortuous coronary phantom models achieving excellent success rates with dramatic reductions in guidewire usage. Operators with prior MNS experience had an advantage over the inexperienced.

Angiographic Stent Thrombosis After Routine Use of Drug-Eluting Stents in ST-Segment Elevation Myocardial Infarction. The Importance of Thrombus Burden (Article)

2007-08-14T00:00:00Z

Objectives: This study sought to investigate the impact of thrombus burden on the clinical outcome and angiographic infarct-related artery stent thrombosis (IRA-ST) in patients routinely treated with drug-eluting stent (DES) implantation for ST-segment elevation myocardial infarction (STEMI). Background: There are limited data for the safety and effectiveness of DES in STEMI. Methods: We retrospectively analyzed 812 consecutive patients treated with DES implantation for STEMI. Intracoronary thrombus burden was angiographically estimated and categorized as large thrombus burden (LTB), defined as thrombus burden ≥2 vessel diameters, and small thrombus burden (STB) to predict clinical outcomes. Major adverse cardiac events (MACE) were defined as death, repeat myocardial infarction, and IRA reintervention. Results: Mean duration of follow-up was 18.2 ± 7.8 months. Large thrombus burden was an independent predictor of mortality (hazard ratio [HR] 1.76, p = 0.023) and MACE (HR 1.88, p = 0.001). The cumulative angiographic IRA-ST was 1.1% at 30 days and 3.2% at 2 years, and continued to augment beyond 2 years. It was significantly higher in the LTB compared with the STB group (8.2% vs. 1.3% at 2 years, respectively, p < 0.001). Significant independent predictors for IRA-ST were LTB (HR 8.73, p < 0.001), stent thrombosis at presentation (HR 6.24, p = 0.001), bifurcation stenting (HR 4.06, p = 0.002), age (HR 0.55, p = 0.003), and rheolytic thrombectomy (HR 0.11, p = 0.03). Conclusions: Large thrombus burden is an independent predictor of MACE and IRA-ST in patients treated with DES for STEMI.

Temporary Worsening of Renal Function After Aortic Surgery Is Associated With Higher Long-Term Mortality (Article)

2007-08-01T00:00:00Z

Background: Little is known about acute changes in renal function in the postoperative period and the outcome of patients undergoing major vascular surgery. Specifically, data are scarce for patients in whom renal function temporarily decreases and returns to baseline at 3 days after surgery. Study Design: Retrospective cohort study. Setting & Participants: 1,324 patients who underwent elective open abdominal aortic aneurysm surgery in a single center. Predictor: Renal function (creatinine clearance was measured preoperatively and on days 1, 2, and 3 after surgery. Patients were divided into 3 groups: group 1, improved or unchanged (change in creatinine clearance, ±10% of function compared with baseline); group 2, temporary worsening (worsening > 10% at day 1 or 2, then complete recovery within 10% of baseline at day 3); and group 3, persistent worsening (>10% decrease compared with baseline). Outcomes & Measurements: All-cause mortality. Results: 30-day mortality rates were 1.3%, 5.0%, and 12.6% in groups 1 to 3, respectively. Adjusted for baseline characteristics and postoperative complications, 30-day mortality was the greatest in patients with persistent worsening of renal function (hazard ratio [HR], 7.3; 95% confidence interval [CI], 2.7 to 19.8), followed by those with temporary worsening (HR, 3.7; 95% CI, 1.4 to 9.9). During 6.0 ± 3.4 years of follow-up, 348 patients (36.5%) died. Risk of late mortality was 1.7 (95% CI, 1.3 to 2.3) in the persistent-worsening group followed by those with temporary worsening (HR, 1.5; 95% CI, 1.2 to 1.4). Limitations: No steady state was achieved to assess renal function. Conclusion: Although renal function may recover completely after aortic surgery, temporary worsening of renal function was associated with greater long-term mortality.

Effect of Statin Withdrawal on Frequency of Cardiac Events After Vascular Surgery (Article)

2007-07-15T00:00:00Z

The discontinuation of statin therapy in patients with acute coronary syndromes has been associated with an increase of adverse coronary events. Patients who undergo major surgery frequently are not able to take oral medication shortly after surgery. Because there is no intravenous formula for statins, the interruption of statins in the postoperative period is a serious concern. The objective of this study was to assess the effect of perioperative statin withdrawal on postoperative cardiac outcome. Also, the association between outcome and type of statin was studied. In 298 consecutive statin users who underwent major vascular surgery, detailed cardiac histories were obtained, and medication use was noted. Postoperatively, troponin levels were measured on days 1, 3, 7, and 30 and whenever clinically indicated by electrocardiographic changes. End points were postoperative troponin release, myocardial infarction, and a combination of nonfatal myocardial infarction and cardiovascular death. Multivariate analyses and propensity score analyses were performed to assess the influence of type of statin and the discontinuation of statins for these end points. Statin discontinuation was associated with an increased risk for postoperative troponin release (hazard ratio 4.6, 95% confidence interval 2.2 to 9.6) and the combination of myocardial infarction and cardiovascular death (hazard ratio 7.5, 95% confidence interval 2.8 to 20.1). Extended-release fluvastatin was associated with fewer perioperative cardiac events compared with atorvastatin, simvastatin, and pravastatin. In conclusion, the present study showed that statin withdrawal in the perioperative period is associated with an increased risk for perioperative adverse cardiac events. Furthermore, there seemed to be better outcomes in patients who received statins with extended-release formulas.

Prognostic implications of stress Tc-99m tetrofosmin myocardial perfusion imaging in patients with left ventricular hypertrophy (Article)

2007-07-01T00:00:00Z

Background: Left ventricular hypertrophy (LVH) is associated with an increased risk of cardiac death. Data on the prognostic value of myocardial perfusion imaging (MPI) in patients with LVH are limited. The aim of this study is to assess the independent value of stress technetium 99m tetrofosmin MPI in predicting the long-term mortality rate in patients with LVH. Methods and Results: We studied 177 patients (mean age, 59 ± 12 years; 134 men) with LVH by electrocardiographic criteria who underwent dobutamine or exercise stress Tc-99m tetrofosmin MPI. Endpoints during follow-up were cardiac and all-cause death and hard cardiac events. A normal scan was detected in 42 patients (24%). Myocardial perfusion abnormalities were fixed in 59 patients (33%) and reversible in 76 (43%). Perfusion abnormalities were observed in a single-vessel distribution in 79 patients and in a multivessel distribution in 56. During a mean follow-up period of 5.5 ± 2 years, 60 patients (34%) died. Death was considered cardiac in 42 patients (24%). Nonfatal myocardial infarction occurred in 10 patients (6%). The annual mortality rate was 1.4% in patients with normal perfusion, 3.2% in those with perfusion abnormalities in a single-vessel distribution, and 8% in those with a multivessel distribution. In a multivariate analysis independent predictors of death were age (risk ratio [RR], 1.05; 95% confidence interval [CI], 1.02-1.07), male gender (RR, 1.9; 95% CI, 1.1-3.6), hypercholesterolemia (RR, 1.7; 95% CI, 1.0-2.9), and abnormal perfusion (RR, 2.7; 95% CI, 1.5-4.8). Conclusion: In patients referred for stress MPI, LVH is associated with a high mortality rate, with approximately one third of patients dying over a period of 5 years. Stress Tc-99m tetrofosmin MPI provides independent information for predicting death in these patients.

Chronic total occlusion treatment in post-CABG patients: Saphenous vein graft versus native vessel recanalization - Long-term follow-up in the drug-eluting stent era (Article)

2007-07-01T00:00:00Z

Objective: To compare the postprocedural and long-term clinical outcomes of two groups of patients, all presenting with chronic saphenous vein graft (SVG) occlusion, who underwent either SVG or native vessel reopening. Background: Chronic total occlusions (CTO) treatment in patients who underwent previous surgical revascularization is a dilemma and the choice of performing native vessel or SVG recanalization is not always easy. Methods: Between July 2002 and October 2004, a total of 260 patients were successfully treated for a CTO. Of them, we selected all patients (n = 24) who had previous bypass surgery with graft occlusion. Of this final group, 13 patients underwent a percutaneous graft recanalization while 11 underwent native vessel reopening. Results: Primary end points were in-hospital and 3-year rates of death, myocardial infarction, target lesion revascularization, and target vessel revascularization. No events occurred in either group during the in-hospital period. Cumulative 3-year event-free survival in the native vessel and SVG group was 81.8% and 83.9% respectively (P = NS). One death and one TVR occurred in each group. Conclusion: In selected cases, SVG reopening instead of the native vessel is feasible. In such a high-risk population, drug-eluting stent implantation in both SVG and native CTO lesions is associated with good long-term outcomes.

Improving Risk Assessment with Cardiac Testing in Peripheral Arterial Disease (Article)

2007-06-01T00:00:00Z

Purpose: The study's objective was to evaluate the prognostic value of left ventricular ejection fraction and stress-induced ischemia during dobutamine stress echocardiography, in addition to ankle-brachial index measurements and clinical risk factors in patients with suspected or known peripheral arterial disease. Methods: In 852 patients with suspected or known peripheral arterial disease (mean age 63 years, 70% male), the ankle-brachial index was measured, left ventricular ejection fraction was assessed, and all patients underwent additional stress testing. Endpoints were all-cause mortality and hard cardiac events (cardiac death or nonfatal myocardial infarction). Results: During a mean follow-up of 7.6 ± 4.4 years, death occurred in 288 patients (34%), and hard cardiac events occurred in 216 patients (25%). Mean left ventricular ejection fraction was 50% ± 17%, and stress-induced ischemia was observed in 352 patients (41%). In multivariate analysis with adjustment for clinical risk factors and ankle-brachial index, each 5% decrease in left ventricular ejection fraction was associated with increased all-cause mortality (hazard ratio [HR] 1.05, 95% confidence interval [CI], 1.02-1.09) and hard events (HR 1.14, 95% CI, 1.08-1.21). Stress-induced ischemia also independently predicted all-cause mortality (HR 2.01, 95% CI, 1.38-2.79) and hard events (HR 2.06, 95% CI, 1.39-3.08). Left ventricular ejection fraction and stress-induced ischemia provided incremental prognostic information over clinical data and ankle-brachial index values (P <.001). Conclusions: Left ventricular ejection fraction and stress-induced ischemia independently predict long-term outcome and improve prognostic risk assessment, in addition to ankle-brachial index and clinical risk factors in patients with suspected or known peripheral arterial disease.

Relation of Body Mass Index to Outcome in Patients With Known or Suspected Coronary Artery Disease (Article)

2007-06-01T00:00:00Z

Increased body mass index (BMI), a parameter of total body fat content, is associated with an increased mortality in the general population. However, recent studies have shown a paradoxic relation between BMI and mortality in specific patient populations. This study investigated the association of BMI with long-term mortality in patients with known or suspected coronary artery disease. In a retrospective cohort study of 5,950 patients (mean age 61 ± 13 years; 67% men), BMI, cardiovascular risk markers (age, gender, hypertension, diabetes, current smoking, angina pectoris, old myocardial infarction, heart failure, hypercholesterolemia, and previous coronary revascularization), and outcome were noted. The patient population was categorized as underweight, normal, overweight, and obese based on BMI according to the World Health Organization classification. Mean follow-up time was 6 ± 2.6 years. Incidences of long-term mortality in underweight, normal, overweight, and obese were 39%, 35%, 24%, and 20%, respectively. In a multivariate analysis model, the hazard ratio (HR) for mortality in underweight patients was 2.4 (95% confidence interval [CI] 1.7 to 3.7). Overweight and obese patients had a significantly lower mortality than patients with a normal BMI (HR 0.65, 95% CI 0.6 to 0.7, for overweight; HR 0.61, 95% CI 0.5 to 0.7, for obese patients). In conclusion, BMI is inversely related to long-term mortality in patients with known or suspected coronary artery disease. A lower BMI was an independent predictor of long-term mortality, whereas an improved outcome was observed in overweight and obese patients.

Value of Myocardial Viability Estimation Using Dobutamine Stress Echocardiography in Assessing Risk Preoperatively Before Noncardiac Vascular Surgery in Patients With Left Ventricular Ejection Fraction <35% (Article)

2007-06-01T00:00:00Z

Patients with heart failure (HF) scheduled for vascular surgery have an increased risk of adverse postoperative outcome, and stratification usually depends on dichotomous risk factors. A quantitative prognostic model for patients with HF was developed using wall motion patterns during dobutamine stress echocardiography (DSE). A total of 295 consecutive patients (mean age 67 ± 12 years) with ejection fraction ≤35% were studied. During DSE, wall motion patterns of dysfunctional segments were scored as scar, ischemia, or sustained improvement. Cardiac death and myocardial infarction were noted perioperatively and during 5 years of follow-up. Of 4,572 dysfunctional segments; 1,783 (39%) had ischemia, 1,280 (28%) had sustained improvement, and 1,509 (33%) had scar. In 212 patients, ≥1 ischemic segment was present; 83 had only sustained improvement. Perioperative and late cardiac event rates were 20% and 30%, respectively. Using multivariate analysis, number of ischemic segments was associated with perioperative cardiac events (odds ratio per segment 1.6, 95% confidence interval 1.05 to 1.8), whereas number of segments with sustained improvement was associated with improved outcome (odds ratio per segment 0.2, 95% confidence interval 0.04 to 0.7). Multivariate independent predictors of late cardiac events were age and ischemia. Sustained improvement was associated with improved survival. In conclusion, DSE provides accurate risk stratification of patients with HF undergoing vascular surgery.

Lower progression rate of end-stage renal disease in patients with peripheral arterial disease using statins or angiotensin-converting enzyme inhibitors (Article)

2007-06-01T00:00:00Z

Patients with peripheral arterial disease (PAD) are at increased risk for ESRD and cardiovascular events. The primary objective was to assess the association between ankle-brachial index (ABI) values and renal outcome. The secondary objective was to evaluate whether statins and angiotensin-converting enzyme inhibitors (ACEI) are associated with improved renal and cardiovascular outcome in patients with PAD. In a prospective observational cohort study of 1940 consecutive patients with PAD, ABI was measured and chronic statin and ACEI therapy was noted at baseline. Serial creatinine concentrations were obtained at baseline, 6 mo, and every year after enrollment. End points were ESRD, all-cause mortality, and cardiac events during a median follow-up period of 8 yr. Baseline estimated GFR <60 ml/min per 1.73 m2was assessed in 27% of patients. ESRD, all-cause mortality, and cardiac events occurred in 10, 46, and 31% of patients, respectively. In multivariate analysis, a lower baseline ABI was significantly associated with a higher progression rate of ESRD (hazard ratio [HR] per 0.10 decrease 1.34; 95% confidence interval [CI] 1.21 to 1.49). Chronic use of statins and ACEI were significantly associated with lower ESRD (HR 0.41 [95% CI 0.28 to 0.63] and 0.74 [95% CI 0.54 to 0.98], respectively), mortality (HR 0.66; [95% CI 0.55 to 0.82] and 0.84 [95% CI 78 to 0.95], respectively), and cardiac events (HR 0.71 [95% CI 0.56 to 0.91] and 0.81 [95% CI 0.68 to 0.96], respectively). In patients with PAD, low ABI values independently predict the onset of ESRD. Less progression toward ESRD and improved cardiovascular outcome was observed among patients who were on long-term statins and ACEI. Copyright

Prognostic Significance of Myocardial Ischemia During Dobutamine Stress Echocardiography in Asymptomatic Patients With Diabetes Mellitus and No Prior History of Coronary Events (Article)

2007-05-01T00:00:00Z

The prognostic significance of myocardial ischemia assessed by dobutamine stress echocardiography in asymptomatic patients with diabetes mellitus who have no previous coronary artery disease remains unclear. We assessed the value of dobutamine stress echocardiography for risk stratification in 161 asymptomatic patients with type 2 diabetes (mean 62 ± 12 years of age; 96 men) who had no previous myocardial infarction or revascularization. End point during follow-up was hard cardiac events (cardiac death and nonfatal myocardial infarction). Ischemia was detected in 45 patients (28%). During a median follow-up of 5 years, 40 patients (25%) died (18 cardiac deaths) and 7 patients had nonfatal myocardial infarction (25 hard cardiac events). An abnormal dobutamine stress echocardiogram was associated with a higher mortality compared with a normal dobutamine stress echocardiogram (p = 0.03). In an incremental multivariate analysis model, clinical predictors of hard cardiac events were age and hypercholesterolemia. Ischemia was incremental to the clinical parameters. In conclusion, myocardial ischemia is an independent predictor of cardiac events in asymptomatic diabetic patients with no previous coronary artery disease.

The long prognostic value of wall motion abnormalities during the recovery phase of dobutamine stress echocardiography after receiving acute β-blockade (Article)

2007-05-01T00:00:00Z

OBJECTIVE: To assess the prognostic value of wall motion abnormalities during the recovery phase of dobutamine stress echocardiography in addition to wall motion abnormalities at peak stress. METHODS: Wall motion abnormalities were assessed at peak and during recovery phase of dobutamine stress echocardiography in 187 consecutive patients, who were followed for occurrence of cardiac events. RESULTS: During follow-up (mean 36±28 months), 19 patients (10%) died from cardiac causes, 34 (18%) patients suffered nonfatal myocardial infarction, and 77 (41%) patients underwent late revascularization. Univariable predictors of cardiac events by Cox regression analysis were age (hazard ratio: 1.01; confidence interval: 1.00-1.03), dyslipidemia (hazard ratio: 1.41; confidence interval: 1.02-1.95), rest wall motion abnormalities (hazard ratio: 1.37; confidence interval: 1.14-1.64), new wall motion abnormalities (hazard ratio: 1.18; confidence interval: 0.95-1.45) at peak and new wall motion abnormalities (hazard ratio: 1.33; confidence interval: 1.11-1.59) at recovery phase of dobutamine stress echocardiography. The best multivariable model to predict cardiac events included new wall motion abnormality (hazard ratio: 5.34; confidence interval: 1.71-16.59) at recovery phase of dobutamine stress echocardiography, after controlling for clinical and peak dobutamine stress echocardiography data. CONCLUSIONS: Myocardial ischemia at recovery phase of dobutamine stress echocardiography is an independent predictor of cardiac events and has an incremental value when added to ischemia at peak.

Reproducible coronary plaque quantification by multislice computed tomography (Article)

2007-05-01T00:00:00Z

Background: The aim of this study was to investigate reproducibility end accuracy of computer-assisted coronary plaque measurements by multislice computed tomography coronary angiography (QMSCT-CA). Methods and Results: Forty-sight patients undergoing MSCT-CA end coronary arteriography for symptomatic coronary artery disease and quantitative intravascular ultrasound (IVUS, QCU) were examined. Two investigators performed the QMSCT-CA twice end e third investigator performed the QCU, all blinded for each other's results. There was no difference found for the matched region of interest (ROI) lengths (QCU 29.4 ± 13 mm vs. QMSCT-CA 29.6 ± 13 mm, P = 0.6; total length = 1,400 mm). The comparison of volumetric measurements showed (lumen QCU 267 ± 139 mm3vs. mean QMSCT-CA 177 ± 91 mm3, P < 0.001; vessel 454 ± 194 mm3vs. 398 ± 187 mm3, P < 0.001; and plaque 189 ± 93 mm3vs. 222 ± 121 mm3; investigator 1, P = 0.02; and investigator 2, P = 0.07) significant differences. Automated lumen detection was also applied for QMSCT-CA (218 ± 112 mm3, P < 0.001 vs. QCU). The Interinvestigator variability measurements for QMSCT-CA showed no significant differences. Conclusion: QMSCT-CA systematically underestimates absolute coronary lumen- and vessel dimensions when compared with QCU. However, repeated measurements of coronary plaque by QMSCT-CA showed no statistically significant differences, although, the outcome showed a scattered result. Automated lumen detection for QMSCT-CA showed improved results when compered with those of human investigators.

Comparison of Three-Year Clinical Outcome of Sirolimus- and Paclitaxel-Eluting Stents Versus Bare Metal Stents in Patients With ST-Segment Elevation Myocardial Infarction (from the RESEARCH and T-SEARCH Registries) (Article)

2007-04-15T00:00:00Z

Sirolimus-eluting stents (SESs) recently proved to be superior to bare metal stents (BMSs) in decreasing the need for repeat revascularization in patients with ST-segment elevation myocardial infarction (STEMI) at 1 year. Whether this also holds for paclitaxel-eluting stents (PESs) is currently unclear and the long-term relatively efficacy of the 2 drug-eluting stents is currently unknown. We investigated the 3-year efficacy of SESs and PESs versus BMSs in patients with STEMI. Primary angioplasty was performed in a consecutive group of 505 patients (BMSs in 183, SESs in 186, PESs in 136). At 3 years, the cumulative mortality rate was comparable in the 3 groups: 13.3% in the BMS group, 11.5% in the SES group, and 12.4% in the PES group (nonsignificant for all). The rate of target vessel revascularization (TVR) was 12.0% in the BMS group compared with 8.0% and 7.7% in the SES and PES groups, respectively (p = 0.12 for BMS vs SES, 0.30 for BMS vs PES, 0.62 for SES vs PES). The cumulative incidence of death, MI, or TVR was 25.5% in the BMS group compared with 17.9% and 20.6% in the SES and PES groups, respectively (p = 0.06 for BMS vs SES, 0.32 for BMS vs PES, 0.45 for SES vs PES). Angiographic stent thrombosis occurred in 2.4% of all patients (BMS 1.6%, SES 2.7%, PES 2.9%). In conclusion, in this relatively small consecutive patient cohort, the use of SESs and PESs was no longer associated with significantly lower rates of TVR and major adverse cardiace events in patients with STEMI after 3 years of follow-up. A high frequency of stent thrombosis was observed in the 2 drug-eluting stent groups.

Type-D personality exerts a stable, adverse effect on vital exhaustion in PCI patients treated with paclitaxel-eluting stents (Article)

2007-04-01T00:00:00Z

Objective: Vital exhaustion is associated with the pathogenesis of cardiovascular disease (CVD), but its prevalence after percutaneous coronary intervention (PCI) with drug-eluting stent implantation, as well as the impact of personality on exhaustion, is not known. In PCI patients, we examined (a) the prevalence of exhaustion, (b) the impact of type-D personality on exhaustion over time, and (c) the clinical significance of type-D personality compared with gender and age as predictors of exhaustion. Methods: Consecutive patients (n=419) with stable or unstable angina treated with PCI with drug-eluting stent implantation completed the Type-D Scale (DS14) at baseline and the Maastricht Questionnaire (which assesses exhaustion) at baseline and at 1 year. Results: Of all patients, 53% were exhausted at baseline and at 1 year, with 41% experiencing chronic symptoms. Type-D patients [F(1, 417)=98.688; P<.001] had significantly higher exhaustion levels than non type-D patients both at the time of the index PCI and at 1 year. There was a general improvement in symptoms of exhaustion over time [F(1, 417)=5.005; P=.03], but type-D exerted a stable effect on exhaustion (P=.06). In multivariable analysis, type-D (OR=3.53; 95% CI=1.88-6.64) remained an independent predictor of exhaustion at 1 year, adjusting for demographic and clinical risk factors and exhaustion at baseline. The impact of type-D on exhaustion was large compared with a small effect for gender and age, as measured by Cohen's effect size index. Conclusions: Symptoms of exhaustion were still highly prevalent in PCI patients 1 year post-PCI despite treatment with the latest technique in interventional cardiology. Type-D exerted a large and stable effect on exhaustion compared with that of gender and age. CVD research and clinical practice may benefit by adopting a personality approach in order to identify high-risk patients.

Fatigue, depressive symptoms, and hopelessness as predictors of adverse clinical events following percutaneous coronary intervention with paclitaxel-eluting stents (Article)

2007-04-01T00:00:00Z

Objective: We investigated the relative effects of fatigue, depressive symptoms, and hopelessness on prognosis at 2-year follow-up in percutaneous coronary intervention (PCI) patients. Methods: Consecutively admitted PCI patients (n=534) treated with paclitaxel-eluting stent as the default strategy completed the Maastricht Questionnaire (MQ) at baseline. Apart from an overall vital exhaustion score, the MQ also assesses fatigue (seven items; Cronbach's α=.87) and depressive symptoms (seven items; Cronbach's α=.83), with hopelessness (one item) comprised in the depressive symptom items. Patients were followed up for adverse clinical events (mortality and nonfatal myocardial infarction) at 2 years. Results: At 2-year follow-up, there were 31 clinical events. In univariable analyses, overall vital exhaustion and depressive symptoms, but not fatigue, were associated with adverse prognosis; in multivariable analysis, depressive symptoms [hazard ratio (HR)=2.69; 95% confidence interval (95% CI)=1.31-5.55] remained the only predictor of clinical outcome. Among the depressive symptoms, hopelessness (HR=3.44; 95% CI=1.65-7.19) was the most cardiotoxic symptom. The incidence of clinical events was higher in the high-hopelessness patients (11% vs. 3%; P=.001) than in the low-hopelessness patients. Hopelessness (HR=3.36; 95% CI=1.58-7.14; P=.002) remained an independent predictor of clinical outcome at 2 years in adjusted analysis. Conclusion: Symptoms of depression, but not fatigue, predicted adverse clinical events. Hopelessness was the most cardiotoxic symptom, associated with a more than three-fold risk of clinical events 2 years post-PCI. Screening for hopelessness may lead to the identification of high-risk patients.

Type-D personality predicts chronic anxiety following percutaneous coronary intervention in the drug-eluting stent era (Article)

2007-04-01T00:00:00Z

Background: Anxiety is an often overlooked risk factor in coronary artery disease (CAD). Hence, little is known about predictors of unremitting chronic anxiety in CAD patients. We examined whether the distressed personality (type-D) predicts chronic anxiety post percutaneous coronary intervention (PCI). Methods: Unselected patients (n = 167) treated with PCI using sirolimus-eluting or bare metal stents as part of the RESEARCH registry, who were anxious 6 months post-PCI, qualified for inclusion. Patients completed the Hospital Anxiety and Depression Scale at 6 and 12 months and the Type-D Scale (DS14) 6 months post-PCI. Results: Of 167 patients anxious at 6 months, 108 (65%) were still anxious 12 months post-PCI. Significant univariable predictors of chronic anxiety were type-D personality (OR: 3.17; 95% CI: 1.64-6.14) and sirolimus-eluting stent implantation (OR: 0.51; 95% CI: 0.27-0.98), with sirolimus-eluting stent showing a protective effect. In multivariable analyses, type-D personality (OR: 3.31; 95% CI: 1.59-6.87) and sirolimus-eluting stent implantation (OR: 0.44; 95% CI: 0.21-0.92) remained significant independent predictors of chronic anxiety adjusting for depressive symptoms at 6 months, demographic and clinical risk factors. Limitations: All psychological measures were based on self-report, and we had no information on cardiac rehabilitation or use of pharmacotherapy; however our sample represented patients seen in daily clinical practice. Conclusions: These findings suggest that type-D personality is a risk factor and sirolimus-eluting stent implantation a protective factor for the occurrence of chronic anxiety. The protective effect of sirolimus-eluting stents in relation to anxiety warrants replication in future studies.

Myocardial viability estimation during the recovery phase of stress echocardiography after acute beta-blocker administration (Article)

2007-04-01T00:00:00Z

Background: Myocardial viability assessment in severely dysfunctional segments by dobutamine stress echocardiography (DSE) is less sensitive than nuclear scanning. Aim: To assess the additional value of using the recovery phase of DSE after acute beta-blocker administration for identifying viable myocardium. Methods: The study included 49 consecutive patients with ejection fraction (LVEF) ≤ 35%. All patients underwent DSE evaluation at low-high dose and during recovery phase, and dual-isotope single photon emission tomography (DISA-SPECT) evaluation for viability of severely dysfunctional segments. Patients with ≥ 4 viable segments were considered viable. Coronary revascularization followed within 3 months in all patients. Radionuclide evaluation of LVEF was performed before and 12 months after revascularization. Results: Viability with DISA-SPECT was detected in 463 (59%) segments, while 154 (19.7%) segments presented as scar. The number of viable segments increased from 415 (53%) at DSE to 463 (59%) at DSE and recovery, and the number of viable patients increased from 43 to 49 respectively. LVEF improved by ≥ 5% in 27 patients. Multivariate regression analysis showed that, DSE with recovery phase was the only independent predictor of ≥ 5% LVEF improvement after revascularization (OR 14.6, CI 1.4-133.7). Conclusion: In this study, we demonstrate that the recovery phase of DSE has an increased sensitivity for viability estimation compared to low-high dose DSE.

Plasma natriuretic peptide levels reflect changes in heart failure symptoms, left ventricular size and function after surgical mitral valve repair (Article)

2007-04-01T00:00:00Z

Background and aim: N-terminal pro-B-type natriuretic peptide (NT-proBNP) has diagnostic and prognostic value in patients with heart failure. The present prospective study was designed to assess whether changes in NT-proBNP levels after surgical mitral valve repair reflect changes in heart failure symptoms and changes in left atrial size, left ventricular size and left ventricular function. Methods: The study population consisted of 22 patients (mean age: 62.8 ± 14.2 years, 68% male) undergoing surgical mitral valve repair. Serial NT-proBNP measurements, transthoracic echocardiography and New York Heart Association (NYHA) class assessment were performed before and 6 months after surgery. Results: All patients underwent successful mitral valve repair and no patients died during follow-up. The decrease in NT-proBNP level was associated with the reduction in left atrial dimension (r = 0.72, P < 0.001), left ventricular end-systolic dimension (r = 0.63, P = 0.002), left ventricular end-diastolic dimension (r = 0.46, P = 0.031), and the increase in fractional shortening (r = -0.63, P = 0.002). Finally, patients with decreasing NT-proBNP levels revealed a significant improvement in heart failure symptoms (NYHA class). Conclusion: Changes in NT-proBNP after surgical mitral valve repair reflect changes in heart failure symptoms and changes in left atrial and ventricular dimensions and function.

Prognostic Significance of Akinesis Becoming Dyskinesis During Dobutamine Stress Echocardiography (Article)

2007-03-01T00:00:00Z

Background: Akinesis becoming dyskinesis (AKBD) at high-dose dobutamine stress echocardiography (DSE) has been disregarded as a marker of myocardial ischemia. However, its prognostic significance is unknown. Objectives: We sought to assess the long-term outcome of patients with AKBD during DSE. Methods: A total of 731 patients (age 62 ± 15 years, 628 men) with two or more akinetic left ventricular segments at rest underwent DSE and were followed up for a mean period of 5 ± 2.7 years. The end points considered during follow-up were hard cardiac events (cardiac death and nonfatal myocardial infarction) and heart failure. Results: Dyskinesis in two or more segments at peak stress developed in 60 patients (8%). Resting wall-motion score index was 2.6 ± 0.56 in patients with AKBD versus 2.3 ± 0.55 in patients without AKBD (P = .0002). Ischemia occurred in 197 patients (27%). During follow-up, 254 patients (35%) developed hard cardiac events and 204 patients (28%) developed heart failure. In all, 226 patients (31%) died of various causes (cardiac death in 172 patients). The annualized hard cardiac event rate was 11% in patients with AKBD and 6% in patients without (P = .03). The incidence of heart failure was significantly higher in patients with AKBD than without (47% vs 26%, P < .001). Independent predictors of hard cardiac events were age (hazard ratio [HR] 1.03 [confidence interval {CI} = 1.01-1.04]), previous myocardial infarction (HR 1.4 [CI = 1.1-1.9]), diabetes mellitus (HR 1.8 [CI = 1.3-2.5]), resting wall-motion score index (HR 1.11 [CI = 1.01-1.04]), and AKBD (HR 1.6 [CI = 1.1-2.4]). Conclusion: AKBD at peak DSE is associated with increased risk of cardiac events in patients with akinetic segments at baseline echocardiogram.

Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study (Article)

2007-02-24T00:00:00Z

Background: Stent thrombosis is a safety concern associated with use of drug-eluting stents. Little is known about occurrence of stent thrombosis more than 1 year after implantation of such stents. Methods: Between April, 2002, and Dec, 2005, 8146 patients underwent percutaneous coronary intervention with sirolimus-eluting stents (SES; n=3823) or paclitaxel-eluting stents (PES; n=4323) at two academic hospitals. We assessed data from this group to ascertain the incidence, time course, and correlates of stent thrombosis, and the differences between early (0-30 days) and late (>30 days) stent thrombosis and between SES and PES. Findings: Angiographically documented stent thrombosis occurred in 152 patients (incidence density 1·3 per 100 person-years; cumulative incidence at 3 years 2·9%). Early stent thrombosis was noted in 91 (60%) patients, and late stent thrombosis in 61 (40%) patients. Late stent thrombosis occurred steadily at a constant rate of 0·6% per year up to 3 years after stent implantation. Incidence of early stent thrombosis was similar for SES (1·1%) and PES (1·3%), but late stent thrombosis was more frequent with PES (1·8%) than with SES (1·4%; p=0·031). At the time of stent thrombosis, dual antiplatelet therapy was being taken by 87% (early) and 23% (late) of patients (p<0·0001). Independent predictors of overall stent thrombosis were acute coronary syndrome at presentation (hazard ratio 2·28, 95% CI 1·29-4·03) and diabetes (2·03, 1·07-3·83). Interpretation: Late stent thrombosis was encountered steadily with no evidence of diminution up to 3 years of follow-up. Early and late stent thrombosis were observed with SES and with PES. Acute coronary syndrome at presentation and diabetes were independent predictors of stent thrombosis.

Adverse clinical events in patients treated with sirolimus-eluting stents: The impact of Type D personality (Article)

2007-02-01T00:00:00Z

BACKGROUND: Little is known about the impact of psychological risk factors on cardiac prognosis in the drug-eluting stent era. We examined whether the distressed personality (Type D) moderates the effect of percutaneous coronary intervention with sirolimus-eluting stent implantation on adverse clinical events at 2-year follow-up. Type D is an emerging risk factor in patients with cardiovascular disease. DESIGN: Prospective follow-up study. METHODS: Three hundred and fifty-eight patients with ischemic heart disease, who consecutively underwent percutaneous coronary intervention with sirolimus-eluting stent as part of the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital registry, completed the Type D Scale (DS14) post-percutaneous coronary intervention (PCI). The end-point was a composite of death and non-fatal myocardial infarction 2 years after PCI. RESULTS: At follow-up, there were 22 events (12 deaths and 11 myocardial infarctions). Type D patients had a greater than two-fold risk of an event at follow-up compared with non-Type D patients (10.4 vs. 4.4%, P=0.031). In multivariable analysis, Type D remained an independent predictor of adverse outcome (hazard ratio: 2.61; 95% confidence interval: 1.12-6.09; P=0.027) adjusting for sex, age, and history of coronary artery disease, multivessel disease, diabetes, hypercholesterolemia, hypertension, renal impairment and smoking. Previous cardiac history was also an independent predictor of death or myocardial infarction (hazard ratio: 2.83; 95% confidence interval: 1.00-7.96; P=0.049). CONCLUSIONS: Type D personality moderated the effect of percutaneous coronary intervention on hard clinical events despite treatment with the latest innovation in interventional cardiology. The inclusion of psychological risk factors in general and personality factors in particular may optimize risk stratification in the drug-eluting stent era.

Impaired health status in Type D patients following PCI in the drug-eluting stent era (Article)

2007-01-18T00:00:00Z

Background: Drug-eluting stenting reduces restenosis post-percutaneous coronary intervention (PCI), but subgroups of patients may not benefit optimally from this procedure. We examined the impact of Type D personality on health status over time and the clinical relevance of Type D as a predictor of impaired health status at 12 months in unselected post-PCI patients. Methods: Consecutive patients (n = 692) participating in the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry completed the Type D Scale at 6 months and the Short Form Health Survey 36 (SF-36) at 6 and 12 months post-PCI. Results: Although there was a significant improvement in health status over time (p < 0.001), Type D patients reported a substantially lower score on all health status domains of the SF-36 compared with non-Type D patients (p < 0.001). Type D personality was an independent predictor of impaired health status on all SF-36 sub domains at 12 months except for physical functioning, adjusting for baseline demographic and clinical variables and health status at 6 months. In these adjusted analyses, Type D personality increased the likelihood of impaired health status at 12 months post-PCI from 60% (OR: 1.60; 95% CI: 1.04-2.46) to almost 300% (OR: 3.99; 95% CI: 2.52-6.32), varying among the parameters analyzed. Conclusions: Type D personality was associated with impaired health status in post-PCI patients treated in the drug-eluting stent era. The role of personality factors as determinants of clinical outcome and health status should not be overlooked as these factors may have much explanatory power.

Effects of evening vs morning thyroxine ingestion on serum thyroid hormone profiles in hypothyroid patients (Article)

2007-01-01T00:00:00Z

Objective: Standard drug information resources recommend that l-thyroxine be taken half an hour before breakfast on an empty stomach, to prevent interference of its intestinal uptake by food or medication. We observed cases in which TSH levels improved markedly after changing the administration time of l-thyroxine to the late evening. We therefore conducted a pilot-study to investigate whether l-thyroxine administration at bedtime improves TSH and thyroid hormones, and whether the circadian rhythm of TSH remains intact. Design: Patients were studied on two occasions: on a stable regimen of morning thyroxine administration and two months after switching to night-time thyroxine using the same dose. On each occasion patients were admitted for 24 h and serial blood samples were obtained. Patients: We investigated 12 women treated with l-thyroxine because of primary hypothyroidism, who used no medication known to interfere with l-thyroxine uptake. Measurements: Patients were admitted to hospital and blood samples were obtained at hourly intervals for 24 h via an indwelling catheter. Following this first hospital admission, all women were asked to switch the administration time from morning to bedtime or vice versa. After 2 months they were readmitted for a 24-h period of hourly blood sampling. Blood samples were analysed for serum TSH (immunometric assay), FT4 and T3 (competitive immunoassay), T4 and rT3 (radioimmunoassay), serum TBG (immunometric assay) and total protein and albumin (colourimetric methods). Results: A significant difference in TSH and thyroid hormones was found after switching to bedtime administration of l-thyroxine. Twenty-four-hour average serum values amounted to (mean ± SD, morning vs bedtime ingestion): TSH, 5.1 ± 0.9 vs 1.2 ± 0.3 mU/l (P < 0.01); FT4, 16.7 ± 1.0 vs 19.3 ± 0.7 pmol/l (P < 0.01); T3, 1.5 ± 0.05 vs 1.6 ± 0.1 nmol/l (P < 0.01). There was no significant change in T4, rT3, albumin and TBG serum levels, nor in the T3/rT3 ratio. The relative amplitude and time of the nocturnal TSH surge remained intact. Conclusions: l-thyroxine taken at bedtime by patients with primary hypothyroidism is associated with higher thyroid hormone concentrations and lower TSH concentrations compared to the same l-thyroxine dose taken in the morning. At the same time, the circadian TSH rhythm stays intact. Our findings are best explained by a better gastrointestinal uptake of l-thyroxine during the night.

Two-year clinical outcome after coronary stenting of small vessels using 2.25-mm sirolimus- and paclitaxel-eluting stents: Insight into the research and T-search registries (Article)

2007-01-01T00:00:00Z

Objectives: To evaluate long-term outcomes after drug-eluting stents (DES) implantation in small coronary vessels. Background: Sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) have been reported to improve both the angiographic and clinical outcomes compared with bare metal stents even in 'real world' settings. Currently, no data is available on long-term outcomes after DES implantation in small vessels. Methods: Since April 2002, our institution has implanted DES, either SES or PES, as a default strategy in all patients irrespective of their clinical presentation. Between October 2002 and September 2003, 197 consecutive patients were enrolled: 107 consecutive patients received at least one 2.25-mm SES (SES group) and 90 consecutive patients received at least one 2.25-mm PES (PES group). Results: The two cohorts presented with high-risk characteristics. At 2 years, the cumulative incidence of major adverse cardiac events (MACE) in the SES group was significantly lower than that in the PES group (10.3% vs. 23.3%, P = 0.02). There were two subacute angiographic stent thromboses in the PES group and none in the SES group. By multivariate analysis, PES utilization (HR 2.37, 95% CI 1.07-5.26), presentation with acute coronary syndromes (ACS) (HR 3.34, 95% CI 1.44-7.70) and multi-vessel disease (MVD) (HR 3.91, 95% CI 1.27-12.0) were identified as independent predictors of MACE. Conclusions: In an unselected population treated for small vessel disease, SES were associated with significantly better 2-year clinical outcomes than PES. The use of PES and the presentation with ACS and MVD were identified as independent predictors of MACE.

The impact of the introduction of drug-eluting stents on the clinical practice of surgical and percutaneous treatment of coronary artery disease. (Article)

2005-04-01T00:00:00Z

AIMS: Sirolimus-eluting stents (SES) have recently been shown to reduce restenosis in selected patients. The impact of this new stent on the use of coronary bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in clinical practice is yet unknown. Therefore, we investigated the impact of SES on the clinical practice of CABG and PCI in a series of unselected consecutive patients. METHODS AND RESULTS: Between April and October 2002, a policy of SES implantation for all procedures has been instituted in our hospital. In total, 798 patients were referred to PCI and 275 to CABG (SES group). A control group was composed of all interventions (806 PCI and 314 CABG) performed during the preceding 6 months (pre-SES). The main outcome was the occurrence of major adverse cardiac events (MACE) at 15 months. In the SES era, a significant shift was noted in the PCI group towards more multi-vessel stenting (28 vs. 24%; P<0.05), more bifurcation stenting (18 vs. 7%; P<0.0001), and the use of more stents (1.9 vs. 1.5; P<0.05). In the PCI elective patients, a shift was noted towards more three-vessel disease (pre-SES: 16% vs. SES: 23%; P=0.02). Furthermore, we observed a shift in the CABG group towards more impaired LV function (pre-SES: 34% vs. SES: 41%; P=0.02) and towards more three-vessel disease (pre-SES: 67% vs. SES: 75%; P=0.03). Overall, the cumulative MACE percentages at 1 year after coronary revascularization (PCI and CABG combined) decreased from 16.8 to 13.8% (P=0.03). The cumulative MACE percentages in the pure SES group and the pre-SES bare metal stent group at 12 months were 15.6 and 19.8%, respectively (P<0.01). CONCLUSION: The introduction of the SES has certainly had an impact on the treatment strategy of coronary artery disease (CAD). Increased use of these stents allows more complex coronary anatomy to be treated by PCI, and results in lower repeat revascularization rates.

Short- and long-term clinical outcome after drug-eluting stent implantation for the percutaneous treatment of left main coronary artery disease: insights from the Rapamycin-Eluting and Taxus Stent Evaluated At Rotterdam Cardiology Hospital registries (RESEARCH and T-SEARCH). (Article)

2005-03-22T00:00:00Z

BACKGROUND: The impact of drug-eluting stent (DES) implantation on the incidence of major adverse cardiovascular events in patients undergoing percutaneous intervention for left main (LM) coronary disease is largely unknown. METHODS AND RESULTS: From April 2001 to December 2003, 181 patients underwent percutaneous coronary intervention for LM stenosis at our institution. The first cohort consisted of 86 patients (19 protected LM) treated with bare metal stents (pre-DES group); the second cohort comprised 95 patients (15 protected LM) treated exclusively with DES. The 2 cohorts were well balanced for all baseline characteristics. At a median follow-up of 503 days (range, 331 to 873 days), the cumulative incidence of major adverse cardiovascular events was lower in the DES cohort than in patients in the pre-DES group (24% versus 45%, respectively; hazard ratio [HR], 0.52 [95% CI, 0.31 to 0.88]; P=0.01). Total mortality did not differ between cohorts; however, there were significantly lower rates of both myocardial infarction (4% versus 12%, respectively; HR, 0.22 [95% CI, 0.07 to 0.65]; P=0.006) and target vessel revascularization (6% versus 23%, respectively; HR, 0.26 [95% CI, 0.10 to 0.65]; P=0.004) in the DES group. On multivariate analysis, use of DES, Parsonnet classification, troponin elevation at entry, distal LM location, and reference vessel diameter were independent predictors of major adverse cardiovascular events. CONCLUSIONS: When percutaneous coronary intervention is undertaken at LM lesions, routine DES implantation, which reduces the cumulative incidence of myocardial infarction and the need for target vessel revascularization compared with bare metal stents, should currently be the preferred strategy.

The 'bio-assay' quality of life might be a better marker of disease activity in acromegalic patients than serum total IGF-I concentrations. (Article)

2005-02-01T00:00:00Z

OBJECTIVES: To investigate the quality of life (QoL) in acromegalic patients in relation to biochemical parameters. DESIGN AND METHODS: Single-center, open label study in 14 acromegalic patients (eight woman and six men, age 33-77 years), with normal serum IGF-I levels during long-term treatment with monthly injections of 20 mg of long-acting octreotide. We investigated which biochemical parameter might reflect optimal QoL, using the SF-36 questionnaire. RESULTS: We observed that six patients had a low QoL score at baseline in the same range as observed in cancer patients. The other eight patients had a normal QoL. GH, IGF-I nor free IGF-I could discriminate these two subgroups at baseline. After skipping one monthly injection, all six subjects with the low QoL escaped in their free IGF-I concentrations. Also total IGF-I concentrations escaped in four of these six. In the subjects with normal QoL, free IGF-I levels remained normal in all, while total IGF-I levels only escaped in one. CONCLUSIONS: This study tells us that the currently used biochemical criteria for disease control in acromegaly might be sufficient in assessing long-term mortality and morbidity, but they are insufficient in addressing the most important parameter from the patient's perspective--QoL.

One year clinical follow up of paclitaxel eluting stents for acute myocardial infarction compared with sirolimus eluting stents (Article)

2005-01-01T00:00:00Z

OBJECTIVE: To compare clinical outcome of paclitaxel eluting stents (PES) versus sirolimus eluting stents (SES) for the treatment of acute ST elevation myocardial infarction. DESIGN AND PATIENTS: The first 136 consecutive patients treated exclusively with PES in the setting of primary percutaneous coronary intervention for acute myocardial infarction in this single centre registry were prospectively clinically assessed at 30 days and one year. They were compared with 186 consecutive patients treated exclusively with SES in the preceding period. SETTING: Academic tertiary referral centre. RESULTS: At 30 days, the rate of all cause mortality and reinfarction was similar between groups (6.5% v 6.6% for SES and PES, respectively, p = 1.0). A significant difference in target vessel revascularisation (TVR) was seen in favour of SES (1.1% v 5.1% for PES, p = 0.04). This was driven by stent thrombosis (n = 4), especially in the bifurcation stenting (n = 2). At one year, no significant differences were seen between groups, with no late thrombosis and 1.5% in-stent restenosis (needing TVR) in PES versus no reinterventions in SES (p = 0.2). One year survival free of major adverse cardiac events (MACE) was 90.2% for SES and 85% for PES (p = 0.16). CONCLUSIONS: No significant differences were seen in MACE-free survival at one year between SES and PES for the treatment of acute myocardial infarction with very low rates of reintervention for restenosis. Bifurcation stenting in acute myocardial infarction should, if possible, be avoided because of the increased risk of stent thrombosis.

Long term outcome in patients with silent versus symptomatic ischaemia during dobutamine stress echocardiography (Article)

2005-01-01T00:00:00Z

OBJECTIVES: To compare the long term prognosis of patients having silent versus symptomatic ischaemia during dobutamine stress echocardiography (DSE). DESIGN: Observational study. SETTING: Tertiary referral centre. PATIENTS: 931 patients who experienced stress induced myocardial ischaemia during DSE. RESULTS: Silent ischaemia was present in 643 of 931 patients (69%). The number of dysfunctional segments at rest (mean (SD) 9.6 (5.1) v 8.8 (5.0), p = 0.1) and of ischaemic segments (3.5 (2.2) v 3.8 (2.1), p = 0.2) was comparable in both groups. During a mean (SD) follow up of 5.5 (3.3) years, there were 169 (18%) cardiac deaths and 86 (9%) non-fatal infarctions. Multivariable Cox regression analysis showed age (hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02 to 1.05), previous myocardial infarction (HR 1.4, 95% CI 1.1 to 2.0), and number of ischaemic segments during the test (HR 2.0, 95% CI 1.0 to 3.7) as independent predictors of cardiac death and myocardial infarction. For every additional ischaemic segment there was a twofold increment in risk of late cardiac events. The annual cardiac death or myocardial infarction rate was 3.0% in patients with symptomatic ischaemia and 4.6% in patients with silent ischaemia (p < 0.01). Silent induced ischaemia was an independent predictor of cardiac death and myocardial infarction (HR 1.7, 95% CI 1.1 to 2.0). During follow up symptomatic patients were treated more often with cardioprotective therapy (p < 0.01) and coronary revascularisation (145 of 288 (50%) v 174 of 643 (27%), p < 0.001). CONCLUSIONS: Patients with silent ischaemia had a similar extent of myocardial ischaemia during DSE compared to patients with symptomatic ischaemia but received less cardioprotective treatment and coronary revascularisation and experienced a higher cardiac event rate.

Improvement of stress LVEF rather than rest LVEF after coronary revascularisation in patients with ischaemic cardiomyopathy and viable myocardium (Article)

2005-01-01T00:00:00Z

OBJECTIVE: To evaluate prospectively the response of left ventricular ejection fraction (LVEF) to high dose dobutamine infusion in patients showing substantial viability, with and without improved resting LVEF after revascularisation. METHODS: Before and 9-12 months after revascularisation, 50 patients with ischaemic cardiomyopathy (LVEF 32 (8)%) and substantial myocardial viability (> or = 4 viable segments) underwent radionuclide ventriculography and dobutamine stress echocardiography. Patients were divided into group 1, patients with, and group 2, patients without significant improvement in resting LVEF (> or = 5% by radionuclide ventriculography) after revascularisation. The response of LVEF during dobutamine stress echocardiography was compared in these two groups. RESULTS: Groups 1 and 2 were comparable in baseline characteristics, resting LVEF, and number of viable segments (mean (SD) 7 (4) v 6 (2), not significant). After revascularisation, the LVEF response during dobutamine stress echocardiography improved significantly in both groups (group 1, 34 (10)% to 56 (8)%; group 2, 32 (10)% to 46 (11)%; both p < 0.001). Interestingly, although resting LVEF did not improve in group 2, peak stress LVEF after revascularisation did (p < 0.001). Group 1 patients had, however, a greater increase in peak stress LVEF (group 1, 22 (10)%; group 2, 13 (9)%; p < 0.01). New York Heart Association and Canadian Cardiovascular Society classes decreased in both groups. CONCLUSIONS: Although patients with viable myocardium did not always have improved rest LVEF after revascularisation, peak stress LVEF improved. Assessment of improvement of resting function may not be the ideal end point to evaluate successful revascularisation.

Long term outcome after intracoronary beta radiation therapy (Article)

2005-01-01T00:00:00Z

OBJECTIVES: To determine the long term outcome after intracoronary beta radiation therapy (IRT). SETTING: Tertiary referral centre. METHODS: The rate of major adverse cardiac events (MACE) was retrospectively determined in 301 consecutive patients who were treated with IRT. MACE was defined as death, myocardial infarction, or any reintervention. Long term clinical outcome was obtained from an electronic database of hospital records and from questionnaires to the patients and referring physicians. Long term survival status was assessed by written inquiries to the municipal civil registries. RESULTS: The mean (SD) follow up was 3.6 (1.2) years. The cumulative incidence of MACE at six months was 19.1%, at one year 36.4%, and at four years 58.3%. The target lesion revascularisation (TLR) rate at six months was 12.9%, at one year 28.3%, and at four years 50.4%. From multivariate analysis, dose < 18 Gy was the most significant predictor of TLR. At four years the cumulative incidence of death was 3.8%, of myocardial infarction 13.4%, and of coronary artery bypass surgery 11.3%. Total vessel occlusion was documented in 12.3% of the patients. CONCLUSIONS: In the long term follow up of patients after IRT, there are increased adverse cardiac events beyond the first six months.

Comparison of late luminal loss response pattern after sirolimus-eluting stent implantation or conventional stenting. (Article)

2004-11-16T00:00:00Z

BACKGROUND: We investigated the pattern of late luminal loss after sirolimus-eluting or bare stent implantation. METHODS AND RESULTS: The study population comprised 238 patients treated with sirolimus-eluting stents and 526 patients treated with conventional stents. The distribution of late loss of sirolimus stents was largely skewed to the right and differed from the distribution for bare stents. When divided according to the presence of binary restenosis (diameter stenosis >50%), restenotic lesions in the bare stent group (26.0%) had a late loss of 1.40+/-0.64 mm and in the sirolimus group (7.9%) of 1.16+/-0.76 mm. Nonrestenotic lesions in the bare stent group had a late loss of 0.58+/-0.44 mm, whereas the late loss of nonrestenotic lesions in the sirolimus group remained close to zero (-0.05+/-0.33 mm). Differences between poststenting and follow-up measurements in the sirolimus group (late loss) resembled variations observed in repeated angiographic measurements, as assessed from a random sample of 30 segments measured repeatedly. After multivariate adjustment, stent type did not influence the degree of late loss in restenotic lesions. However, nonrestenotic bare stents had a significantly larger estimated luminal loss (0.58 mm; 95% CI, 0.52 to 0.65) than sirolimus-eluting stents, for which the predicted late loss was almost 0 (-0.04 mm; 95% CI, -0.10 to 0.02). CONCLUSIONS: The pattern of late loss after sirolimus-eluting stent implantation follows a peculiar behavior, different from lesions treated with conventional stents. Whether this is explained by an unusual statistical distribution or a biological all-or-none response of restenosis after sirolimus-eluting stenting remains to be investigated.

Type D personality predicts death or myocardial infarction after bare metal stent or sirolimus-eluting stent implantation: a Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) registry substudy. (Article)

2004-09-01T00:00:00Z

Objectives: We investigated the effect of Type D personality on the occurrence of adverse events at nine months in patients with ischemic heart disease (IHD) after percutaneous coronary intervention (PCI) with sirolimus-eluting stents (SESs) or bare stents. Type D patients experience increased negative emotions and tend not to express these emotions in social interactions. Background: The SES is a new advent in interventional cardiology that reduces the restenosis rate and the risk of a major adverse cardiac event, but the SES has not been shown to confer any benefits on death or myocardial infarction (MI). Methods: Consecutive patients with IHD (n = 875) enrolled in the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry completed the Type D Personality Scale (DS14) six months after PCI. The end point was a composite of death and MI. Events occurring before administration of the DS14 were excluded from analyses. Results: At nine months' follow-up, there were 20 events. Type D patients were at a cumulative increased risk of adverse outcome compared with non-Type D patients: 5.6% versus 1.3% (p < 0.002). Type D personality (odds ratio [OR] 5.31; 95% confidence interval [CI] 2.06 to 13.66) remained an independent predictor of adverse outcome adjusting for all other variables, including SES versus bare-stent implantation. Conclusions: Type D personality was an independent predictor of adverse events in patients optimally treated with the latest advent in interventional cardiology. The DS14 could be used as a screening instrument in routine clinical practice to optimize risk stratification in IHD patients.

Decline in ventricular function and clinical condition after Mustard repair for transposition of the great arteries (a prospective study of 22-29 years). (Article)

2004-07-01T00:00:00Z

BACKGROUND: Great concern exists about the ability of the anatomic right ventricle to sustain the systemic circulation in patients with transposition of the great arteries who have undergone a Mustard procedure. A prospective study was made to examine long-term survival, clinical outcome, and right ventricular function 25 years after surgery. METHODS: Ninety-one consecutive patients underwent the Mustard procedure between 1973 and 1980. After 14 years and again after 25 years (range 22-29 years), patients were studied with ECG, echocardiography, exercise testing, and Holter monitoring. RESULTS: The cumulative survival and event-free survival were 77% and 36%, respectively, after 25 years. Reoperation was necessary in 46%. No major loss of sinus rhythm was found. While all patients had good right ventricular function 14 years after repair, 61% of patients showed moderate-to-severe dysfunction after 25 years, when studied by echocardiography. Furthermore, the QRS complex widened and exercise capacity decreased. CONCLUSION: The anatomic right ventricle appears to be unable to sustain the systemic circulation at long-term follow-up and the clinical condition of patients late after Mustard repair is declining. We can expect more deaths or need for heart transplantation in the next decade.

Clinical outcomes for sirolimus-eluting stent implantation and vascular brachytherapy for the treatment of in-stent restenosis. (Article)

2004-07-01T00:00:00Z

Abstract The purpose of this study was to compare the mid-term clinical outcome of sirolimus-eluting stent (SES) implantation and vascular brachytherapy (VBT) for in-stent restenosis (ISR). We assessed the 9-month occurrence of major adverse cardiac events (MACE) in 44 consecutive patients with ISR treated with SES implantation and 43 consecutive patients treated with VBT in the period immediately prior. Baseline clinical and angiographic characteristics of the two groups were similar. During follow-up, three patients (7%) died in the VBT group and none in the SES group. The incidence of myocardial infarction was 2.3% in both groups. Target lesion revascularization was performed in 11.6% of the VBT patients and 16.3% of the SES patients (P = NS). The 9-month MACE-free survival was similar in both groups (79.1% VBT vs. 81.5% SES; P = 0.8 by log rank). The result of this nonrandomized study suggests that sirolimus-eluting stent implantation is at least as effective as vascular brachytherapy in the treatment of in-stent restenosis.

Post-sirolimus-eluting stent restenosis treated with repeat percutaneous intervention: late angiographic and clinical outcomes. (Article)

2004-06-01T00:00:00Z

BACKGROUND: We evaluated the clinical and angiographic outcomes of patients presenting with restenosis after sirolimus-eluting stent (SES) implantation treated with repeated percutaneous intervention. METHODS AND RESULTS: A total of 24 consecutive patients have undergone repeated percutaneous intervention to treat post-SES restenosis (27 lesions). The restenosis was located within the stent in 93% of lesions. From the 27 lesions, 1 (4%) was re-treated with a bare stent, 3 (11%) were treated with balloon dilatation, and the remaining 23 lesions (85%) were treated with repeated drug-eluting stent implantation (SES in 12 lesions [44%], paclitaxel-eluting stents in 11 lesions [41%]). The event-free survival rate was 70.8% after a median follow-up of 279 days from the post-SES treatment. The overall recurrent restenosis rate was 42.9%. The risk of recurrent restenosis was increased for patients with hypercholesterolemia, previous angioplasty, failed brachytherapy, post-SES restenosis needing early (<6 months) treatment, and post-SES restenosis treated with balloon dilatation. The recurrent restenosis rate of originally de novo lesions re-treated with drug-eluting stents was 18.2%. CONCLUSIONS: Even though de novo lesions treated with SES at baseline and re-treated with drug-eluting stents had reasonably better outcomes than other lesion types and strategies, our study shows that the treatment of post-SES restenosis is currently suboptimal and warrants further investigation.

Outcome of patients after surgical closure of ventricular septal defect at young age: longitudinal follow-up of 22-34 years. (Article)

2004-06-01T00:00:00Z

BACKGROUND: Long-term survival and clinical outcome after surgical closure of a VSD is poorly documented. Such data are important for the future perspectives, medical care, employability, and insurability of these patients. METHODS: 176 consecutive patients underwent surgical closure of an isolated VSD between 1968 and 1980 in our hospital. A systematic follow-up study was performed in 1990 and again in 2001. FINDINGS: Late survival was poorer than in the general population. Pulmonary hypertension and right ventricular hypertrophy were present in the 4 patients who died suddenly, late after operation. During follow-up no new pulmonary hypertension became manifest. Re-operations were necessary in 6%. Some patients (4%) developed sinus node disease late after repair, requiring pacemaker implantation. At last follow-up (91 survivors) 92% of the patients were in NYHA class I. Pulmonary hypertension was found in 4%, and aorta insufficiency in 16%. Patients experienced difficulties when applying for insurance. CONCLUSION: Among patients with surgically repaired VSDs, late results were good, although some late sudden deaths occurred in the patients with pulmonary hypertension. Furthermore, some patients developed sinus node disease late after repair, requiring pacemaker implantation. Employability is good, but pregnancy and insurance matters need further attention.

Very long sirolimus-eluting stent implantation for de novo coronary lesions. (Article)

2004-04-01T00:00:00Z

Long-length stenting has a poor outcome when bare metal stents are used. The safety and efficacy of the sirolimus-eluting stent (SES) in long lesions has not been evaluated. Therefore, the aim of the present study was to evaluate the clinical and angiographic outcomes of SES implantation over a very long coronary artery segment. Since April 2002, all patients treated percutaneously at our institution received a SES as the device of choice as part of the Rapamycin Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. During the RESEARCH registry, stents were available in lengths of 8, 18, and 33 mm. The present report includes a predefined study population consisting of patients treated with >36-mm-long stented segments. Patients had a combination of >or=2 overlapping stents at a minimum length of 41 mm (i.e., one 33-mm SES overlapping an 8-mm SES) to treat native de novo coronary lesions. The incidence of major cardiac adverse events (death, nonfatal myocardial infarction, and target lesion revascularization) was evaluated. The study group comprised 96 consecutive patients (102 lesions). Clinical follow-up was available for all patients at a mean of 320 days (range 265 to 442). In all, 20% of long-stented lesions were chronic total occlusions, and mean stented length per lesion was 61.2 +/- 21.4 mm (range 41 to 134). Angiographic follow-up at 6 months was obtained in 67 patients (71%). Binary restenosis rate was 11.9% and in-stent late loss was 0.13 +/- 0.47 mm. At long-term follow-up (mean 320 days), there were 2 deaths (2.1%), and the overall incidence of major cardiac events was 8.3%. Thus, SES implantation appears safe and effective for de novo coronary lesions requiring multiple stent placement over a very long vessel segment.

Clinical and angiographic outcomes after overdilatation of undersized sirolimus-eluting stents with largely oversized balloons: an observational study. (Article)

2004-04-01T00:00:00Z

The purpose of this study was to assess the safety and effectiveness of sirolimus-eluting stent (SES) postdilatation with largely oversized balloons. We evaluated the clinical outcome of 68 consecutive patients enrolled in the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) registry who underwent percutaneous coronary intervention with SES implantation and further postdilatation with balloons > 1 mm larger than the stent nominal size. Angiographic follow-up was either scheduled for selected subgroups or clinically driven. Overall, 75 lesions were treated. The procedure was successful in 98.5% of the cases. One patient (1.5%) underwent emergency coronary bypass surgery for acute vessel occlusion. During 10.1 +/- 1.7 months of follow-up, three patients (4.5%) died, one (1.5%) had acute myocardial infarction, and four (6%) had target vessel revascularization. At angiographic follow-up, loss index was 0.13 +/- 0.34 and restenosis rate was 7.7%. Although not routinely recommended in every patient, SES postdilatation with largely oversized balloons appears a safe and effective strategy for selected patients.

Clinical, angiographic, and procedural predictors of angiographic restenosis after sirolimus-eluting stent implantation in complex patients (Article)

2004-03-23T00:00:00Z

BACKGROUND: The factors associated with the occurrence of restenosis after sirolimus-eluting stent (SES) implantation in complex cases are currently unknown. METHODS AND RESULTS: A cohort of consecutive complex patients treated with SES implantation was selected according to the following criteria: (1) treatment of acute myocardial infarction, (2) treatment of in-stent restenosis, (3) 2.25-mm diameter SES, (4) left main coronary stenting, (5) chronic total occlusion, (6) stented segment >36 mm, and (7) bifurcation stenting. The present study population was composed of 238 patients (441 lesions) for whom 6-month angiographic follow-up data were obtained (70% of eligible patients). Significant clinical, angiographic, and procedural predictors of post-SES restenosis were evaluated. Binary in-segment restenosis was diagnosed in 7.9% of lesions (6.3% in-stent, 0.9% at the proximal edge, 0.7% at the distal edge). The following characteristics were identified as independent multivariate predictors: treatment of in-stent restenosis (OR 4.16, 95% CI 1.63 to 11.01; P<0.01), ostial location (OR 4.84, 95% CI 1.81 to 12.07; P<0.01), diabetes (OR 2.63, 95% CI 1.14 to 6.31; P=0.02), total stented length (per 10-mm increase; OR 1.42, 95% CI 1.21 to 1.68; P<0.01), reference diameter (per 1.0-mm increase; OR 0.46, 95% CI 0.24 to 0.87; P=0.03), and left anterior descending artery (OR 0.30, 95% CI 0.10 to 0.69; P<0.01). CONCLUSIONS: Angiographic restenosis after SES implantation in complex patients is an infrequent event, occurring mainly in association with lesion-based characteristics and diabetes mellitus.

Treatment of very small vessels with 2.25-mm diameter sirolimus-eluting stents (from the RESEARCH registry). (Article)

2004-03-01T00:00:00Z

A total of 91 patients with 112 lesions received 2.25-mm sirolimus-eluting stents (SESs), and these lesions were compared with those treated with SESs of ≥2.5-mm diameter in the same procedure (n = 109). The reference diameters were 1.88 ± 0.34 and 2.52 ± 0.57 mm, respectively (p <0.01). At follow-up, the late lumen loss was 0.07 ± 0.48 mm for the 2.25-mm SES versus 0.03 ± 0.38 mm for the larger SES (p = 0.5), and the binary restenosis rate was 10.7% versus 3.9%, respectively (p = 0.1). The 12-month target lesion revascularization rate was 5.5%. In conclusion, 2.25-mm SESs were associated with low rates of clinical and angiographic late complications.

Unrestricted utilization of sirolimus-eluting stents compared with conventional bare stent implantation in the "real world": the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. (Article)

2004-01-20T00:00:00Z

BACKGROUND: The effectiveness of sirolimus-eluting stents in unselected patients treated in the daily practice is currently unknown. METHODS AND RESULTS: Sirolimus-eluting stent implantation has been used as the default strategy for all percutaneous procedures in our hospital as part of the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. Consecutive patients with de novo lesions (n=508) treated exclusively with sirolimus-eluting stents (SES group) were compared with 450 patients who received bare stents in the period just before (pre-SES group). Patients in the SES group more frequently had multivessel disease, more type C lesions, received more stents, and had more bifurcation stenting. At 1 year, the cumulative rate of major adverse cardiac events (death, myocardial infarction, or target vessel revascularization) was 9.7% in the SES group and 14.8% in the pre-SES group (hazard ratio [HR], 0.62 [95% CI, 0.44 to 0.89]; P=0.008). The 1-year risk of clinically driven target vessel revascularization in the SES group and in the pre-SES group was 3.7% versus 10.9%, respectively (HR, 0.35 [95% CI, 0.21 to 0.57]; P<0.001). CONCLUSIONS: Unrestricted utilization of sirolimus-eluting stents in the "real world" is safe and effective in reducing both repeat revascularization and major adverse cardiac events at 1 year compared with bare stent implantation.

Prognostic value of dobutamine stress echocardiography in patients with previous coronary revascularisation (Article)

2004-01-01T00:00:00Z

OBJECTIVE: To assess the prognostic value of dobutamine stress echocardiography (DSE) in patients with previous myocardial revascularisation. DESIGN: Prospective study. SETTING: Tertiary referral centre in Rotterdam, the Netherlands. PATIENTS: 332 consecutive patients with previous percutaneous or surgical coronary revascularisation underwent DSE. Follow up was successful for 331 (99.7%) patients. Thirty eight patients who underwent early revascularisation (

Sirolimus-eluting stent implantation in ST-elevation acute myocardial infarction: a clinical and angiographic study. (Article)

2003-10-21T00:00:00Z

BACKGROUND: Sirolimus-eluting stents (SES) have recently been proven to reduce restenosis and reintervention compared with bare stents. Safety and effectiveness of SES in acute myocardial infarction remain unknown. METHODS AND RESULTS: Since April 16, 2002, a policy of routine SES implantation has been instituted in our hospital, with no clinical or anatomic restrictions, as part of the RESEARCH (Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital) registry. During 6 months of enrollment, 96 patients with ST-elevation acute myocardial infarction underwent percutaneous recanalization and SES implantation; these patients comprise the study population. The incidence of major adverse cardiac events (death, nonfatal myocardial infarction, reintervention) was evaluated. Six-month angiographic follow-up was scheduled per protocol. At baseline, diabetes mellitus was present in 12.5% and multivessel disease in 46.9%. Primary angioplasty was performed in 89 patients (92.7%). Infarct location was anterior in 41 (42.7%) of the cases, and 12 patients (12.5%) had cardiogenic shock. Postprocedural TIMI-3 flow was achieved in 93.3% of the cases. In-hospital mortality was 6.2%. One patient (1.1%) had reinfarction and target lesion reintervention the first day as a result of distal dissection and acute vessel occlusion. During follow-up (mean follow-up of 218+/-75 days), 1 patient died (1.1%), no patient had recurrent myocardial infarction, and there were no additional reinterventions. No early or late stent thromboses were documented. At angiographic follow-up (70%), late loss was -0.04+/-0.25, and no patient presented angiographic restenosis. CONCLUSIONS: In this study, sirolimus-eluting stent implantation for patients with ST-elevation acute myocardial infarction was safe without documented angiographic restenosis at 6 months.

Impact of different anatomical patterns of left main coronary stenting on long-term survival. (Article)

2003-09-15T00:00:00Z

Acute myocardial infarction is a common disease with serious consequences in mortality, morbidity, and cost to the society. Coronary atherosclerosis plays a pivotal part as the underlying substrate in many patients. In addition, a new definition of myocardial infarction has recently been introduced that has major implications from the epidemiological, societal, and patient points of view. The advent of coronary-care units and the results of randomised clinical trials on reperfusion therapy, lytic or percutaneous coronary intervention, and chronic medical treatment with various pharmacological agents have substantially changed the therapeutic approach, decreased in-hospital mortality, and improved the long-term outlook in survivors of the acute phase. New treatments will continue to emerge, but the greatest challenge will be to effectively implement preventive actions in all high-risk individuals and to expand delivery of acute treatment in a timely fashion for all eligible patients

Coronary restenosis after sirolimus-eluting stent implantation: morphological description and mechanistic analysis from a consecutive series of cases. (Article)

2003-07-22T00:00:00Z

BACKGROUND: We describe the clinical and morphological patterns of restenosis after sirolimus-eluting stent (SES) implantation. METHODS AND RESULTS: From 121 patients with coronary angiography obtained >30 days after SES implantation, restenosis (diameter stenosis >50%) was identified in 19 patients and 20 lesions (located at the proximal 5-mm segment in 30% or within the stent in 70%). Residual dissection after the procedure or balloon trauma outside the stent was identified in 83% of the proximal edge lesions. Lesions within the stent were focal, and stent discontinuity was identified in some lesions evaluated by intravascular ultrasound. CONCLUSIONS: Sirolimus-eluting stent edge restenosis is frequently associated with local trauma outside the stent. In-stent restenosis occurs as a localized lesion, commonly associated with a discontinuity in stent coverage. Local conditions instead of intrinsic drug-resistance to sirolimus are likely to play a major role in post-SES restenosis.

Psychosocial functioning of the adult with congenital heart disease: a 20-33 years follow-up (Article)

2003-04-01T00:00:00Z

AIMS: Since knowledge about the psychosocial function of adult patients with congenital heart disease is limited, we compared biographical characteristics, and emotional and social functioning of these patients with that of the reference groups. METHODS AND RESULTS: Patients with congenital heart disease (N=362, aged 20-46 years), belonging to five diagnostic groups, were subjected to extensive medical and psychological examination, 20-33 years after their first open heart surgery. All the patients were seen by the same psychologist, who examined their psychosocial functioning using a structured interview and questionnaires. The majority (78%)was living independently and showed favourable outcome regarding the marital status. Among married/cohabitant patients, 25-39-year-olds showed normal offspring rates. None of the 20-24-year-old patients had any children. The offspring rate dropped after the age of 40. The proportion of adult patients with a history of special education was high (27%). Accordingly, patients showed lower educational and occupational levels compared to reference groups. As regard to the emotional and social functioning (leisure-time activities), the sample showed favourable results. CONCLUSIONS: Overall, this sample of patients with congenital heart disease seemed capable of leading normal lives and seemed motivated to make good use of their abilities.

Excellent survival and low incidence of arrhythmias, stroke and heart failure long-term after surgical ASD closure at young age. A prospective follow-up study of 21-33 years (Article)

2003-01-01T00:00:00Z

AIMS: Although studies have suggested good long-term results, arrhythmias, pulmonary hypertension and left ventricular dysfunction are mentioned as sequelae long-term after surgical atrial septal defect closure at young age. Most studies were performed only by questionnaire and in a retrospective manner. The long-term outcome is very important with regard to future employment and acceptance on insurance schemes. METHODS AND RESULTS: One hundred and thirty-five consecutive ASD-patients, operated on in childhood, were studied longitudinally with ECG, echocardiography, exercise testing and Holter-recording 15 (10-22) and 26 (21-33) years after surgery. During follow-up no cardiovascular mortality, stroke, heart failure and no pulmonary hypertension occurred. Symptomatic supraventricular tachyarrhythmias were present in 6% after 15 years, and an additional 2% occurred in the last decade; 5% needed pacemaker implantation. No relation was found between arrhythmias and type of ASD, baseline data, right ventricular dimensions, or age at operation. Left and right ventricular function and dimension remained unchanged. Slightly more patients had right atrial dilatation at last follow-up. Exercise capacity was comparable with the normal Dutch population. CONCLUSIONS: The long-term outcome after ASD closure at young age shows excellent survival and low morbidity. The incidence of supraventricular arrhythmias is lower than in natural history studies of ASD patients and also lower than after surgical correction at adult age.

Prognostic value of dobutamine stress echocardiography in patients with diabetes (Article)

2003-01-01T00:00:00Z

OBJECTIVE: The aim of this study was to assess the incremental value of dobutamine stress echocardiography (DSE) for the risk stratification of diabetic patients who are unable to perform an adequate exercise stress test. Exercise capacity is frequently impaired in patients with diabetes. The role of pharmacologic stress echocardiography in the risk stratification of diabetic patients has not been well defined. RESEARCH DESIGN AND METHODS: We studied 396 diabetic patients (mean age 61 +/- 11 years, 252 men [64%]) with limited exercise capacity who underwent DSE for evaluation of known or suspected coronary artery disease (CAD). End points were hard cardiac events (cardiac death and nonfatal myocardial infarction) and all causes of mortality. RESULTS: During a median follow-up of 3 years, 97 patients (24%) died (55 cardiac deaths), and 27 patients had nonfatal myocardial infarction. In an incremental multivariate analysis model, clinical predictors of hard cardiac events were history of congestive heart failure, previous myocardial infarction, hypercholesterolemia, and ejection fraction at rest. The percentage of ischemic segments was incremental to the clinical model in the prediction of hard cardiac events (chi(2) = 37 vs. 18, P < 0.05). Clinical predictors of all causes of mortality were history of congestive heart failure, age, hypercholesterolemia, and ejection fraction at rest. Wall motion score index at peak stress was incremental to the clinical model in the prediction of mortality (chi(2) = 52 vs. 43, P < 0.05). CONCLUSIONS: DSE provides incremental data for the prediction of mortality and hard cardiac events in patients with diabetes who are unable to perform an adequate exercise stress test.

Excellent survival and low incidence of arrhythmias, stroke and heart failure long-term after surgical ASD closure at young age (Article)

2003-01-01T00:00:00Z

Aims Although studies have suggested good long-term results, arrhythmias, pulmonary hypertension and left ventricular dysfunction are mentioned as sequelae long-term after surgical atrial septal defect closure at young age. Most studies were performed only by questionnaire and in a retrospective manner. The long-term outcome is very important with regard to future employment and acceptance on insurance schemes. Methods and Results One hundred and thirty-five consecutive ASD-patients, operated on in childhood, were studied longitudinally with ECG, echocardiography, exercise testing and Holter-recording 15 (10–22) and 26 (21–33) years after surgery. During follow-up no cardiovascular mortality, stroke, heart failure and no pulmonary hypertension occurred. Symptomatic supraventricular tachyarrhythmias were present in 6% after 15 years, and an additional 2% occurred in the last decade; 5% needed pacemaker implantation. No relation was found between arrhythmias and type of ASD, baseline data, right ventricular dimensions, or age at operation. Left and right ventricular function and dimension remained unchanged. Slightly more patients had right atrial dilatation at last follow-up. Exercise capacity was comparable with the normal Dutch population. Conclusions The long-term outcome after ASD closure at young age shows excellent survival and low morbidity. The incidence of supraventricular arrhythmias is lower than in natural history studies of ASD patients and also lower than after surgical correction at adult age.

Clinical utility and cost effectiveness of a personal ultrasound imager for cardiac evaluation during consultation rounds in patients with suspected cardiac disease (Article)

2003-01-01T00:00:00Z

OBJECTIVE: To assess the clinical utility and cost effectiveness of a personal ultrasound imager (PUI) during consultation rounds for cardiac evaluation of patients with suspected cardiac disease. METHODS: 107 unselected patients from non-cardiac departments (55% men) were enrolled in the study. After the physical examination the consultant cardiologist performed an echocardiographic study with a PUI. The final report was given instantly to the referring physician. All patients subsequently underwent a study with a standard echocardiographic device (SED). For each patient the consultant cardiologist noted whether the findings of the PUI were adequate for final diagnosis. The total cost when full echocardiography was used was compared with the cost when the PUI was used. The time interval from request to diagnosis was also compared. RESULTS: In 84 (78.5%) patients no further examination with an SED was regarded as necessary. Twenty three patients (21.5%) required a further detailed examination with the SED because of the need for haemodynamic information. There was an excellent agreement for the detection of abnormalities between the two devices (96%). The total cost was euro;132 per patient with the SED and euro;75 per patient with the PUI. According to this study, the use of the PUI can lead to a 33.4% reduction of total cost. The mean time from request to diagnosis at the authors' institution was four days for the SED and instantly for the PUI, for additional potential cost savings. CONCLUSIONS: Immediate echocardiographic assessment during consultation rounds can lead to significant cost savings and can shorten the time to diagnosis.

Coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. Twenty-year clinical outcome. (Article)

2002-04-01T00:00:00Z

AIMS: The purpose of this study is to compare the long-term outcome (up to 20 years) of coronary artery bypass surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) in a consecutive patient series at a single centre. Survival is similar after CABG and PTCA up to 8 years follow-up in patients with multivessel disease, with a reduced need for repeat revascularization after CABG. As coronary artery disease is a lifetime disease, longer-term follow-up of these revascularization therapies is necessary to help clinical decision-making. METHODS AND RESULTS: The CABG study population consisted of the first 1041 consecutive patients who underwent a first elective coronary bypass surgery between 1970 and 1980. The PTCA study population consisted of 702 consecutive patients who underwent a first elective coronary angioplasty procedure between 1980 and 1985. Mortality and subsequent revascularization up to 20 years were captured. Survival rates were adjusted using proportional hazards methods to account for baseline differences. RESULTS: The unadjusted survival rates were 92%, 77%, 57% and 49% after CABG at respectively, 5-, 10-, 15- and 17 years and 91%, 80%, 64% and 59% after PTCA. In the multivessel disease subgroup, survival was similar with a benefit apparent after CABG in the first 8 years of follow-up. The therapy chosen, CABG or PTCA, was a univariate predictor of mortality in favour of PTCA (RR: 1.28; 95% CI: 1.10-1.49), but after correction for baseline characteristics, the relative risk of mortality for CABG vs PTCA was comparable (RR: 1.03; 95% CI: 0.87-1.24). The adjusted survival curves in the subgroup of diabetic elderly patients with multivessel disease were similar after the tenth year with only a slightly better survival in the CABG population in the first 10 years. Repeat intervention was more frequently required after PTCA during the first 8 years, but after this time more frequently in the CABG group. CONCLUSION: When comparing CABG and PTCA it can be concluded that both strategies are equally effective in terms of 20-year survival. In particular, after more than 10 years all differences tend to disappear. While repeat intervention was significantly higher in the first year after PTCA, after 7-8 years, reintervention was greater in patients who had initial CABG.

Long-term prognostic value of dobutamine stress 99mTc-sestamibi SPECT: single-center experience with 8-year follow-up (Article)

2002-01-01T00:00:00Z

PURPOSE: To determine the long-term prognostic value of dobutamine stress technetium 99m (99mTc)-labeled sestamibi single photon emission computed tomography (SPECT) in patients with limited exercise capacity. MATERIALS AND METHODS: Clinical data and SPECT results were analyzed in 531 consecutive patients. Follow-up was successful in 528 (99.4%) patients; 55 underwent early revascularization and were excluded. Normal or abnormal findings were considered in the absence or presence of fixed and/or reversible perfusion defects. A summed stress score was calculated to estimate the extent and severity of perfusion defects. Univariate and multivariate Cox proportional hazards regression models were used to identify independent predictors of late cardiac events. The incremental value of myocardial perfusion scintigraphy over clinical variables in predicting events was determined according to two models. The probability of survival was calculated by using the Kaplan-Meier method. RESULTS: Findings were abnormal in 312 patients. During 8.0 years +/- 1.5 of follow-up (range, 4.5-10.6 years), cardiac death occurred in 67 patients (total deaths, 165); nonfatal myocardial infarction, in 34; and late revascularization, in 49. The annual rates for cardiac death, cardiac death or infarction, and all events were 0.9%, 1.2%, and 1.5%, respectively, after normal findings and 2.7%, 3.4%, and 4.4%, respectively, after abnormal findings (P <.05). In a multivariable Cox proportional hazards model, not only an abnormal finding but also the summed stress score provided incremental prognostic information in addition to clinical data. The hazard ratio for cardiac death was 1.09 (95% CI: 1.01, 1.18) per 1-unit increment of the summed stress score. CONCLUSION: The incremental prognostic value of dobutamine stress 99mTc-sestamibi SPECT over clinical data was maintained over an 8-year follow-up in patients with limited exercise capacity.

Percutane transluminale coronairangioplastiek in 1980/1985 en in 1995/6: vaker meervatslijden, minder heringrepen en ongewijzigde sterfte na 1 en 5 jaar na de ingreep (Article)

2002-01-01T00:00:00Z

Doel. Beschrijven van de karakteristieken van patiënten die in de loop van de laatste 20 jaar percutane transluminale coronairangioplastiek (PTCA, dotterprocedure) ondergingen en de uitkomsten na 1 en 5 jaar. Opzet. Prospectief vervolgonderzoek. Methode. Alle patiënten die een eerste PTCA ondergingen in het Thoraxcentrum van het Erasmus Medisch Centrum te Rotterdam in de periode 1 september 1980-30 november 1985 (groep I) werden vergeleken met alle patiënten die eveneens zo'n eerste ingreep ondergingen in de periode 1 september 1995-31 december 1996 (groep II). Gegevens over de patiënten, de ingrepen, eventuele heringrepen en sterfte werden verkregen uit statussen, van huisartsen en uit gemeentearchieven. De cumulatieve overlevingskansen en het cumulatief gevrijwaard-blijven van een heringreep (rePTCA of CABG) werden geanalyseerd met de Kaplan-Meier-methode. Resultaten. Groep I bestond uit 856 patiënten, groep II uit 840 patiënten. Het percentage mannen daalde van 80 naar 69. De gemiddelde leeftijd steeg van 56 naar 60 jaar; de oudste patiënt in groep I was 75 jaar en in groep II 87 jaar. Het percentage meervatslijden steeg van 36 naar 44. Stentimplantatie was in groep I nog niet aan de orde, maar werd in groep II bij 55% van de patiënten toegepast. De noodzaak tot een spoedbypassoperatie na een mislukte PTCA daalde van 9,4 tot 1,0%. Na 1 jaar was het percentage heringrepen in groep I 28,8% en in groep II 22,6% (p = 0,01). De perioperatieve sterfte was niet significant verschillend (groep I: 1,3%, groep II: 2,4%). Hetzelfde gold voor de 5-jaarsoverlevingskans (groep I: 90%; groep II: 88%). In beide groepen waren onafhankelijke voorspellers van een hoger sterfterisico na 5 jaar: hogere leeftijd, verminderde ejectiefractie, uitgebreider vaatlijden en geen behandeling met statinen. In groep II waren nierfunctiestoornissen de belangrijkste voorspeller voor hogere sterfte.

Prognostic value of dobutamine-atropine stress myocardial perfusion imaging in patients with diabetes (Article)

2002-01-01T00:00:00Z

OBJECTIVE: Exercise tolerance in patients with diabetes is frequently impaired due to noncardiac disease such as claudication and polyneuropathy. This study assesses the prognostic value of dobutamine stress myocardial perfusion imaging in patients with diabetes. RESEARCH DESIGN AND METHODS: A total of 207 consecutive diabetic patients who were unable to undergo exercise stress testing underwent dobutamine-atropine stress myocardial perfusion imaging. Follow-up was successful in 206 of 207 (99.5%) patients. A total of 12 patients underwent early (<60 days) revascularization and were excluded from the analysis. End points during follow-up were hard cardiac events, defined as cardiac death and nonfatal myocardial infarction. RESULTS: Abnormal myocardial perfusion was detected in 125 (64%) patients. During 4.1 +/- 2.4 years of follow-up, 73 (38%) deaths occurred, 36 (49%) of which were due to cardiac causes. Nonfatal myocardial infarction occurred in 7 (4%) patients, and 45 (23%) patients underwent late coronary revascularization. Cardiac death occurred in 2 of 69 (3%) patients with normal myocardial perfusion and in 34 of 125 (27%) patients with perfusion abnormalities (P < 0.0001). A multivariable Cox proportional hazard model demonstrated that, in addition to clinical and stress test data, an abnormal scan had an incremental prognostic value for prediction of cardiac death (hazard ratio 7.2, 95% CI 1.7-30). The summed stress score was an important predictor of cardiac death; the hazard ratio was 1.2 (95% CI 1.07-1.34) per one-unit increment. CONCLUSIONS: Dobutamine-atropine stress myocardial perfusion imaging provides additional prognostic information incremental to clinical data in patients with diabetes who are unable to undergo exercise stress testing.

Platelet GP IIb/IIIa receptor blockers for failed thrombolysis in acute myocardial infarction, alone or as adjunct to other rescue therapies; single centre retrospective analysis of 548 consecutive patients with acute myocardial infarction (Article)

2002-01-01T00:00:00Z

In order to study the safety of 'rescue' strategies in the treatment of patients with failed thrombolysis, all 548 patients admitted with evolving myocardial infarction to the Thoraxcenter, Rotterdam, from January 1997 until April 1999 were reviewed. Of these patients, 49% had received thrombolysis. Of patients treated with thrombolysis and not referred from other hospitals (n = 154) 36% received rescue therapy for failed thrombolysis. Three rescue therapies were used after failed thrombolysis: percutaneous coronary intervention (74%), retreatment with thrombolysis (39%) and platelet glycoprotein (GP) IIb/IIIa receptor blockers (53%), often in combination. Platelet GP IIb/IIIa receptor blockers were administered in 64% of patients treated with rescue percutaneous coronary intervention. Major bleeding occurred in 14% of all thrombolysis treated patients, and in 30% of patients who received multiple rescue therapies. Bleeding was related to heparin usage and platelet GP IIb/IIIa receptor blockers, as was the insertion of catheters for percutaneous coronary intervention or intra-aortic balloon pumps. Major bleeding resulted in one death due to a ruptured ventricle, one haemorrhagic stroke, and three cases of tamponade for which surgery was needed. Four of these patients had received combination rescue therapy. Rescue therapy is a widely used strategy for failed thrombolysis, but is associated with a high bleeding rate. Alternative reperfusion strategies to avoid failed thrombolysis should be considered in high risk patients.

Long-term clinical outcome after coronary balloon angioplasty: identification of a population at low risk of recurrent events during 17 years of follow-up. (Article)

2001-07-20T00:00:00Z

AIMS: This study reports the clinical outcome, up to 17 years, of the first 856 consecutive patients treated by coronary angioplasty at a single centre and attempts to identify a subgroup of patients at low risk of adverse events. METHODS AND RESULTS: Follow-up status was established via hospital and general practitioner records and the civil registry. Median follow-up was 16 years. The overall 5-, 10-, 15- and 17-year survival was 90%, 78%, 64% and 58%, respectively and corresponding event-free survival was 53%, 33%, 22% and 19%. After 32% of patients had experienced a major adverse cardiac event in the first year, the annual coronary re-intervention incidence thereafter and, even beyond year 10, remained at 2%--3%. Using multivariable Cox regression, significant independent predictors of mortality were advanced age, diabetes, multivessel disease and impaired left ventricular function at the time of PTCA. A subgroup of 26% of the patients with none of these risk factors had a survival rate similar to the general Dutch population matched for age and gender (at 5 years: 96%, at 10 years: 89% and at 15 years: 83%). CONCLUSION: Although the majority of patients (>80%) experienced a further cardiac event during the 17 years after their first angioplasty procedure, in those non-diabetics under 60 years with single-vessel disease and good left ventricular function, prognosis was similar to the general population.

High fat intake in hyperlipidaemic patients is related to male gender, smoking, alcohol intake and obesity (Article)

2001-07-16T00:00:00Z

BACKGROUND: In individuals at high cardiovascular risk, such as patients with hyperlipidaemia, low dietary fat intake is used to reduce this risk. The aim of the present study was to identify determinants of (saturated) fat intake in hyperlipidaemic patients. METHODS: Cross sectional study in a lipid clinic of a tertiary referral centre. A total of 1169 patients (714 males and 455 females) with hyperlipidemia were studied. Food frequency questionnaires were present of 1026 patients. In 615 patients a detailed diet analysis was performed. The main outcomes measures were determinants of fat intake, indicated by a regression coefficient (beta-coefficient). RESULTS: The following variables were independently related to fat intake: present smoking (beta-coefficient 3.7), male gender ((beta 1.6), familial hypercholesterolemia (beta -1.6), alcohol (beta 0.6 per glass of alcohol), body mass index (beta 0.6). No interaction between gender and smoking or between gender and alcohol intake was observed in relation to fat intake. The percentage of energy from fats were higher in males than in females, 34.2+/-8.3% and 31.7+/-8.3%, respectively (P<0.001). The higher total and saturated fat intake in males is due to a larger consumption of cheese, meat products, bread and potato products. Women had a higher relative intake of carbohydrate 48.5+/-8.7% versus 46.5+/-8.8% in males (P<0.05), due to a relatively higher intake of fruit, milk products and pastry and biscuits. CONCLUSIONS: A specific gender-oriented approach may improve the results of dietary counselling of hyperlipidaemic patients.

Long-term prognostic value of serial troponin T bedside tests in patients with acute coronary syndromes (Article)

2000-09-15T00:00:00Z

The early presence of troponin T in serum strongly predicts short-term mortality and myocardial infarction in patients with acute coronary syndromes. We investigated the long-term outcome of the prognostic significance of the troponin T rapid bedside assay (TROPT) and compared this with the quantitative troponin T assay (cTnT enzyme-linked immunosorbent assay), myoglobin and creatine kinase-MB (CK-MB) mass. One hundred sixty-three patients with chest pain and suspected acute coronary syndromes were studied and followed prospectively for 3 years. Serial blood specimens were obtained at admission and at 3, 6, 12, 24, 48, 72, and 96 hours after admission. Patients were classified as having acute myocardial infarction in 99 patients (61%), unstable angina in 34 patients (21%), and no evidence for acute cardiac ischemia in 30 patients (18%). At 3 years, 28 patients (17%) had died of which 25 deaths (15%) were for cardiac reasons. Twenty-one patients (13%) had a nonfatal (recurrent) myocardial infarction. At admission 29% of the patients were TROPT positive (≥0.2 μg/L), another 31% became positive within 12 hours, and 39% remained negative. When adjusted for baseline variables, a positive TROPT (any sample 0 to 12 hours) was independently associated with a higher risk of cardiac mortality (RR 4.3, 95% confidence interval [CI] 1.3 to 14.0). Because troponin T stays elevated up to 2 weeks, later TROPT results between 24 and 96 hours remained significantly predictive for mortality. The cTnT enzyme-linked immunosorbent assay (any sample 0 to 12 hours; cutoff ≥0.2 μg/L) was similarly predictive (RR 2.9, 95% CI 1.0 to 8.6). Early myoglobin results were significantly prognostic for cardiac mortality up to 12 hours after admission (RR 3.7; 95% CI 1.0 to 12.0). In contrast, serial CK-MB mass measurements were not predictive of mortality. Thus, a combination of a baseline TROPT and an additional TROPT 12 hours or later identifies a subgroup of patients at high risk for subsequent mortality and reinfarction, both at short-term but also at long-term. Article Outline

Mortality and repeat interventions up until 20 years after aorto-coronary bypass surgery with saphenous vein grafts. A follow-up study of 1041 patients. (Article)

2000-05-01T00:00:00Z

AIMS: To determine very long-term survival and incidence of recurrent interventions following aorto-coronary bypass surgery using venous grafts. METHODS AND RESULTS: A group of 1041 consecutive patients operated upon between 1971 and 1980 were followed for a median of 19 years (range 13-26). Peri-operative mortality was 1.2%. Survival probability at 5, 10, 15, and 20 years was 92%, 77%, 57%, and 40%, respectively. After 5 or more years following operation the mortality was higher than in the matched Dutch population. Age, extent of coronary artery disease, and ejection fraction are independent predictors of mortality. Of the 593 deceased patients at least 63% died of a probable cardiac cause, while cardiovascular mortality is 40% in the general Dutch population. Repeat revascularization procedures (aorto-coronary bypass surgery or percutaneous transluminal coronary angioplasty) were performed in 343 patients (33%), with an increasing incidence after 7 years. CONCLUSION: Aorto-coronary bypass surgery using vein grafts is safe and has a reasonable long-term prognosis for survival, although less than a matched population. After approximately 7 years both mortality and the need for repeated revascularizations increased. Since a majority of patients died of a cardiac cause and a substantial number of patients required repeated revascularization, aorto-coronary bypass surgery is a palliative treatment of a progressive disease.

Safety and prognostic value of early dobutamine-atropine stress echocardiography in patients with spontaneous chest pain and a non-diagnostic electrocardiogram. (Article)

2000-03-04T00:00:00Z

AIMS: To risk stratify and shorten hospital stay in patients with spontaneous (resting) chest pain and a non-diagnostic electrocardiogram (ECG). METHODS AND RESULTS: The study comprised 102 patients (mean age 58+/-12 years, 67 men) with spontaneous chest pain and a non-diagnostic ECG. Forty-three patients had suspected coronary artery disease and 59 had known (but of unknown actual significance) coronary artery disease. All patients underwent serial creatine kinase enzyme measurements, continuous ECG monitoring for at least 12 h and early dobutamine-atropine stress echocardiography in patients with negative creatine kinase enzymes and normal findings at ECG monitoring. Dobutamine-atropine stress echocardiography was considered positive in patients with new or worsening wall thickening abnormalities. Patients with negative dobutamine-atropine stress echocardiography were discharged after the test. In-hospital and 6 month follow-up events noted were cardiac death, non-fatal myocardial infarction, unstable angina, and coronary artery bypass surgery or angioplasty. Thirteen patients had evidence of evolving myocardial infarction by elevated creatine kinase enzymes, or unstable angina by ECG monitoring. In the remaining 89 patients, dobutamine-atropine stress echocardiography was performed after a median observation period of 31 h (range 12-68 h). During dobutamine-atropine stress echocardiography no serious complications (death, non-fatal myocardial infarction, sustained ventricular tachycardia or ventricular fibrillation) occurred. Dobutamine-atropine stress echocardiography results were of poor quality in three, non-diagnostic in six, negative in 44 and positive in 36 patients. In the 80 patients with diagnostic dobutamine-atropine stress echocardiography, variables associated with in-hospital events (n=7) were history of exertional angina (P<0. 005), chest pain score (P<0.005), stress-induced angina (P<0.001) and positive dobutamine-atropine stress echocardiography (P<0.005). Variables associated with follow-up events (n=11) were history of exertional angina (P<0.05), chest pain score (P<0.001), stress-induced angina (P<0.01) and positive dobutamine-atropine stress echocardiography (P<0.01). At multivariate analysis the only significant predictor of events was positive dobutamine-atropine stress echocardiography (P<0.01). CONCLUSION: Early dobutamine-atropine stress echocardiography may safely distinguish between low- and high-risk subsets for subsequent cardiac events in patients with spontaneous chest pain and a non-diagnostic ECG.

Time-dependent diagnostic performance of a rapid troponin T version 2 bedside test in patients with acute coronary syndromes (Article)

2000-01-01T00:00:00Z

The grade of worsening of regional function during dobutamine stress echocardiography predicts the extent of myocardial perfusion abnormalities (Article)

2000-01-01T00:00:00Z

AIM: To evaluate the angiographic, myocardial perfusion, and wall motion abnormalities in patients with severe compared with mild worsening of regional function during dobutamine stress echocardiography (DSE) for evaluation of myocardial ischaemia. METHODS: 147 patients with significant coronary artery disease and new or worsening wall motion abnormalities during DSE were enrolled. Left ventricular function was evaluated using a 16 segment/4 grade score model where 1 = normal and 4 = dyskinesis. Simultaneous sestamibi SPECT myocardial perfusion imaging was performed in all patients. RESULTS: Severe worsening of regional function (an increase in wall motion score of two grades or more in >/= 1 segment) was detected in 37 patients, while 110 patients had mild worsening (an increase in wall motion score of no more than one grade in >/= 1 segment). Patients with severe worsening of regional function had more stenotic coronary arteries (2.31 (0.8) v 1.97 (0. 8) (mean (SD)) (p <0.05), a higher prevalence of left anterior descending coronary artery disease (95% v 73%) (p < 0.05), a higher resting wall motion score index (1.71 (0.42) v 1.51 (0.40) (p = 0. 01), and more stress perfusion defects (3.8 (1.5) v 2.8 (1.5) (p < 0.001) compared with patients with mild worsening. Multivariate analysis identified the number of stress perfusion defects (p < 0. 005, chi(2) = 8.8) and the number of ischaemic segments on echocardiography (p < 0.05, chi(2) = 4.3) as independent variables associated with severe worsening of regional function. CONCLUSIONS: The grade of worsening of regional function during DSE predicts the underlying extent of myocardial perfusion abnormalities. The occurrence of severe worsening of regional function is associated with variables known to predict worse prognosis in patients with coronary artery disease.

Safety, hemodynamic profile, and feasibility of dobutamine stress technetium myocardial perfusion single-photon emission CT imaging for evaluation of coronary artery disease in the elderly (Article)

2000-01-01T00:00:00Z

OBJECTIVES: Cardiovascular disease is the leading cause of morbidity and mortality in the elderly. The evaluation of coronary artery disease by exercise stress testing is frequently limited by the patient's inability to exercise. Although pharmacologic stress testing with dobutamine is an alternative, the safety of dobutamine myocardial perfusion scintigraphy in the elderly has not been previously studied. PATIENTS AND METHODS: We studied the safety and feasibility of dobutamine (up to 40 microg/kg/min)-atropine (up to 1 mg) stress myocardial perfusion scintigraphy using technetium single-photon emission CT imaging in 227 patients > or = 70 years old (mean +/- SD age, 75 +/- 4 years). A control group of 227 patients < 70 years old (mean age, 55 +/- 11 years; matched for gender, prevalence of previous infarction, beta-blocker therapy, and severity of resting perfusion abnormalities) was studied to assess age-related differences in the safety and the hemodynamic response. A feasible test was defined as the achievement of the target heart rate and/or an ischemic end point (angina, ST-segment depression, or reversible perfusion abnormalities). RESULTS: No myocardial infarction or death occurred during the test. The target heart rate was achieved more frequently in the elderly patients (87% vs 79%; p < 0.05). The elderly patients had a higher prevalence of supraventricular tachycardia (7% vs 1%; p < 0.005) and premature ventricular contraction (74% vs 32%; p < 0.005) during the test, as compared to the younger patients. There was a trend to a higher prevalence of ventricular tachycardia (5% vs 2%) and atrial fibrillation (3% vs 0.4%) in the elderly patients. Arrhythmias were terminated spontaneously by termination of dobutamine infusion or by administration of metoprolol. Independent predictors of supraventricular tachyarrhythmias and ventricular tachycardia were older age (p < 0.001; chi(2), 9.8) and myocardial perfusion defect score at rest (p < 0.01; chi(2), 6.8) respectively, by using a multivariate analysis of clinical and stress test variables. Elderly patients had a higher prevalence of systolic BP drop > 20 mm Hg during the test (37% vs 12%; p < 0.05). The test was terminated due to hypotension in 2% of the elderly patients and in 1% of the control group. Age was the most powerful predictor of hypotension (p < 0.005; chi(2), 10.3). The test was considered feasible in 216 elderly patients (95%) and in 209 patients of the control group (92%). CONCLUSION: Dobutamine-atropine stress myocardial perfusion scintigraphy is a highly feasible method for the evaluation of coronary artery disease in the elderly. Elderly patients have a higher risk for developing hypotension and supraventricular tachyarrhythmias during a dobutamine stress test. However, dobutamine-induced hypotension is often asymptomatic and rarely necessitates the termination of the test.

Sustained benefit at 10-14 years follow-up after thrombolytic therapy in myocardial infarction (Article)

1999-06-01T00:00:00Z

AIMS: To investigate whether the benefit of thrombolytic therapy was sustained beyond the first decade. We report the 10-14 year outcome of 533 patients who were randomized to treatment with intracoronary streptokinase or to conventional therapy during the years 1980-1985. METHODS AND RESULTS: Details of survival and cardiac events were obtained from the civil registry, from medical records or from the patient's physician. At follow-up, 158 patients (59%) of the 269 patients allocated to thrombolytic treatment and only 129 patients (49%) of the 264 conventionally treated patients were alive. The cumulative 1-, 5- and 10-year survival rates were 91%, 81% and 69% in patients treated with streptokinase and 84%, 71% and 59% in the control group, respectively (P=0.02). Reinfarction during 10-years of follow-up was more frequent after thrombolytic therapy, particularly during the first year. Coronary bypass surgery and coronary angioplasty were more frequently performed after thrombolytic therapy. At 10 years approximately 30% of the patients were free from subsequent cardiac events.Independent determinants of mortality were elderly age, indicators of impaired residual left ventricular function, multivessel disease and an inability to perform an exercise test at the time of hospital discharge. CONCLUSION: Improved survival after thrombolytic therapy is maintained beyond the first decade. Age, left ventricular function, multivessel disease and an inability to perform an exercise test were independent predictors for long-term mortality, as they are predictors for early mortality.

Long term outcome after coronary stent implantation: a 10 year single centre experience of 1000 patients (Article)

1999-01-01T00:00:00Z

OBJECTIVE: To describe the long term clinical outcome (up to 11 years) after coronary stenting. DESIGN: A single centre observational study encompassing 1000 consecutive patients with a first stent implantation (1560 stents) between 1986 and 1996, who were followed for at least one year with a median follow up of 29 months (range 12-132 months). RESULTS: Up to July 1997 the cumulative incidence of the major adverse cardiac events (MACE) of death, non-fatal acute myocardial infarction, coronary artery bypass grafting, and repeat percutaneous transluminal coronary angioplasty was 8.2%, 12.8%, 13.1%, and 22.4%, respectively. Survival at one, three, and five years was 95%, 91%, and 86%, respectively. Comparison of MACE incidence during the "anticoagulant era" and the "ticlopidine era" revealed significantly improved event free survival with ticlopidine (27% v 13%; p < 0.005). Multivariable analyses showed that ejection fraction < 50% (relative risk (RR) 4. 1), multivessel disease (RR 3.0), diabetes (RR 2.9), implantation in saphenous vein graft (RR 2.1), indication for unstable angina (RR 1. 9), and female sex (RR 1.7) were independent predictors of increased mortality after stenting. Independent predictors of any MACE were multivessel stenting (RR 2.0), implantation in saphenous bypass graft (RR 1.6), diabetes (RR 1.5), anticoagulant treatment (versus ticlopidine and aspirin) (RR 1.5), bailout stenting (RR 1.5), multivessel disease (RR 1.4), and multiple stent implantation (RR 1. 5). CONCLUSIONS: Long term survival and infarct free survival was good, particularly in non-diabetic men with single vessel disease and good ventricular function, who had a single stent implanted in a native coronary artery. A dramatic improvement was observed in event free survival, both early and late, with the replacement of anticoagulation by ticlopidine. This, of course, cannot be separated from improved stent implantation techniques between 1986 and 1995. Ultimately, almost 40% of the patients experienced an adverse cardiac event (mainly repeat intervention) in the long term. New advances in restenosis treatments and in secondary prevention must be directed at this aspect of patient management after stenting.

Unstable angina: good long-term outcome after a complicated early course (Article)

1998-07-01T00:00:00Z

Objectives. This study was performed to investigate the long-term outcome of patients with unstable angina within subgroups of the Braunwald classification. Background. Long-term follow-up studies of patients with unstable angina are rare and date from more than two decades ago. This study was performed to establish the prognosis of different subgroups of patients with unstable angina (Braunwald criteria) during a 7-year follow-up period. Methods. We registered a well defined group of 417 consecutive patients, admitted to the hospital for suspected unstable angina. The definite diagnosis was unstable angina in 282 patients (68%) and evolving myocardial infarction in 26; in 109 patients (26%), the symptoms were attributed to other or nonspecific causes. Patients with definite unstable angina were subclassified according to the Braunwald classification. Survival, survival without infarction and survival without infarction or intervention were determined for each class. Results. After a median follow-up period of 94 months, the mortality rate in the first year was 6% and 2% to 3% in the following years. The frequency of revascularization was 47% in the first year, and that for myocardial infarction was 11% in the first year and 1% to 3% thereafter. The Braunwald classification appeared to be appropriate for risk stratification in the first year. However, at 7 years the event rates in all classes were similar. In particular, the Braunwald classification had no long-term impact on mortality or infarction rates. However, patients with acute angina at rest or postinfarction angina and patients with extensive anginal treatment had high intervention rates. Conclusions. To our knowledge, this study is the first to demonstrate that despite a complicated course during the first year, current management results in good long-term outcome in patients with unstable angina.

Long-term survival and predictors of mortality in Coronat)' Heart Disease (Doctoral Thesis)

1998-04-22T00:00:00Z

Coronruy heart disease (CHD) is by far the most important cause of death, and a main cause of disability in the Netherlands. Accordingly, coronruy heart disease has a great impact on society. In 1995 cardiac death occurred in about 40,000 persons (28% of all monality) and ischemic heart disease was the reason for 170,000 hospital admissions. I Since the 1980s an inunediate benefit is achieved in patients with acute manifestations of CHD, with pharmacologic therapy such as thrombolytic therapy in patients with evolving myocru·dial infarction and coronary interventions such as coronary aorto bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty procedure (PTCA). Together with improved secondalY prevention through diet, reduced smoking and medical regimens such as antiplatelets, beta-blockers, ace-inhibitors and statins the life expectancy has been improved. This resulted in an increase of patients with chronic manifestations of CHD including heart failure and a population of survivors with a high risk of recurrent coronary events. This make the investigation of the long-telm outcome after a cardiac event more imponant than ever. We investigated subgroups of patients who undelwent myocardial infarction (Ml), an episode of unstable angina pectoris (UAP), CABG or PTCA. This chapter will give an overview of previous studies which reponed the long-term outcome of the different groups of patients including: survivors of a myocardial infarction (1.1.1), patients with evolving myocardial infarction who were treated with thrombolytic therapy or conventional therapy (1.1.2), patients hospitalized for unstable angina (1.2), patients who undelwent CABG surgery (1.3) and patients who undelwent a PTCA procedure either without (1.4.1) or with stent implantation (1.4.2). The most imponant baseline characteristics of each of these subgroups and their effects on medium- and long-term outcome are presented.

The cardiac infarction injury score as a predictor for long-term mortality in survivors of a myocardial infarction (Article)

1998-01-01T00:00:00Z

AIMS: The Cardiac Infarction Injury Score (CIIS) is an electrocardiographic classification system that was developed as a diagnostic tool to assess the extent of cardiac injury in acute myocardial infarction. We investigated the prognostic value of the CIIS in post-myocardial infarction patients. METHODS AND RESULTS: The prognostic values of the CIIS for total and cardiac mortality was assessed in a large series (n = 3395) of patients who were enrolled in the ASPECT trial. Standard 12-lead electrocardiograms, recorded prior to hospital discharge were coded according to the CIIS and the Minnesota Code. Mean CIIS was 26 (range--8 to 59). After adjustment for other baseline characteristics, the CIIS was directly related to the risk of total mortality and cardiac mortality. At one-year follow-up the relative risks of CIIS > or = 40, CIIS 30-40 and CIIS 20-30 were significantly higher than in those with a CIIS < 20. The relative risks were, respectively, 2.3 (1.2-4.4), 2.2 (1.3-3.9) and 1.6 (0.9-2.9). At 3 year follow-up, the relative risks were, respectively, 2.1 (1.4-3.2), 1.7 (1.2-2.4) and 1.5 (1.0-2.1). The relative risks for total mortality were similar. When patients with major ECG abnormalities, as defined by the Minnesota code, were excluded, the associations were still significant in the CIIS classes 30-40 and > 40. CONCLUSION: The CIIS ECG scoring system is an important predictor for long-term cardiac mortality in post myocardial infarction patients. It can easily be automated and is efficient for classifying cardiac injury in epidemiological studies.

Noninvasive diagnosis of coronary artery stenosis in women with limited exercise capacity: comparison of dobutamine stress echocardiography and 99mTc sestamibi single-photon emission CT (Article)

1998-01-01T00:00:00Z

OBJECTIVES: To compare the accuracy of dobutamine stress echocardiography (DSE) and simultaneous 99mTc sestamibi (MIBI) single-photon emission CT (SPECT) imaging for the diagnosis of coronary artery stenosis in women. PATIENTS: Seventy women with limited exercise capacity referred for evaluation of myocardial ischemia. METHODS: DSE (up to 40 microg/kg/min) was performed in conjunction with stress MIBI SPECT. Resting MIBI images were acquired 24 h after the stress test. Ischemia was defined as new or worsened wall motion abnormalities confirmed by DSE and as reversible perfusion defects confirmed by MIBI. Significant coronary artery disease was defined as > or = 50% luminal diameter stenosis. RESULTS: DSE was positive for ischemia in 35 of 45 patients with coronary artery stenosis and in 2 of 25 patients without coronary artery stenosis (sensitivity = 78% CI, 68 to 88; specificity = 92% CI, 85 to 99; and accuracy = 83% CI, 74 to 92). A positive MIBI study for ischemia occurred in 29 patients with coronary artery stenosis and in 7 patients without coronary artery stenosis (sensitivity = 64% CI, 53 to 76; specificity = 72% CI, 61 to 83; and accuracy = 67% CI, 56 to 78 [p < 0.05 vs DSE]). In the 59 vascular regions with coronary artery stenosis, the regional sensitivity of DSE was higher than MIBI (69% CI, 62 to 77 vs 51% CI, 42 to 59, p < 0.05), whereas specificity in the 81 vascular regions without significant stenosis was similar (89% CI, 84 to 94 vs 88% CI, 82 to 93, respectively). CONCLUSION: DSE is a useful noninvasive method for the diagnosis of coronary artery stenosis in women and provides a higher overall and regional diagnostic accuracy than dobutamine MIBI SPECT in this particular population.

Safety and feasibility of dobutamine-atropine stress echocardiography for the diagnosis of coronary artery disease in diabetic patients unable to perform an exercise stress test (Article)

1998-01-01T00:00:00Z

OBJECTIVE: Dobutamine stress testing is increasingly used for the diagnosis and functional evaluation of coronary artery disease. However, little is known about the safety and feasibility of this stress modality in diabetic patients. RESEARCH DESIGN AND METHODS: We studied the impact of diabetes on hemodynamic profile and on the safety and feasibility of dobutamine (up to 40 microg x kg(-1) x min(-1)) and atropine (up to 1 mg) stress echocardiography for the diagnosis of coronary artery disease in 1,446 consecutive patients (aged 60+/-12 years, 962 men) with limited exercise capacity and suspected myocardial ischemia. Of these, 184 patients were known to have IDDM or NIDDM. The test was considered feasible when 85% of the maximal heart rate and/or an ischemic end point (new or worsened wall motion abnormalities, ST segment depression, or angina) was achieved. RESULTS: No myocardial infarction or death occurred during the test. There was no significant difference between diabetic and nondiabetic patients with regard to heart rate increase during dobutamine stress echocardiography (58+/-25 vs. 61+/-24 beats/min), peak rate pressure product (18,400+/-3,135 vs. 18,048+/-4454), or the prevalence of hypotension (systolic blood pressure drop of >40 mmHg) (7 vs. 5%), ventricular tachycardia (5.4 vs. 4.5%), and supraventricular tachycardia (3 vs. 4%) during the test. Dobutamine stress echocardiography was feasible in 92% of the diabetic patients and in 90% of the nondiabetic patients. Coronary angiography was performed in 55 diabetic and 240 nondiabetic patients. Sensitivity, specificity, and accuracy of dobutamine stress echocardiography for the diagnosis of coronary artery disease in diabetic patients were 81, 85, and 82%. Those in nondiabetic patients were 74, 87, and 77%, respectively (NS). CONCLUSIONS: Dobutamine stress echocardiography is a feasible method for the diagnosis of coronary artery disease in patients with limited exercise capacity with a comparable safety, feasibility, and accuracy in diabetic and nondiabetic patients.

Relation between ST segment elevation during dobutamine stress test and myocardial viability after a recent myocardial infarction (Article)

1997-01-01T00:00:00Z

OBJECTIVE: To assess the relation between ST segment elevation during the dobutamine stress test and late improvement of function after acute Q wave myocardial infarction. PATIENTS AND DESIGN: 70 patients were studied a mean (SD) 8 (3) days after acute myocardial infarction with high dose dobutamine-atropine stress echocardiography and a follow up echocardiogram at 85 (10) days. A score model based on 16 segments and four grades was used to assess left ventricular function. Functional improvement was defined as a reduction of wall motion score > or = 1 in > or = 1 segments at follow up. INTERVENTION: Myocardial revascularisation was performed in 23 patients (33%) before follow up studies. RESULTS: ST segment elevation occurred in 40 patients (57%). Late functional improvement occurred in 35 patients (50%). Functional improvement was more common in patients with ST segment elevation (68% v 30%, P < 0.005) and they had a higher mean (SD) number of improved segments at follow up (1.9 (2.2) v 0.5 (1.1), P < 0.005). The wall motion score index decreased between baseline and follow up in patients with ST segment elevation (1.54 (0.50) v 1.48 (0.43), P < 0.05) but not in patients without ST segment elevation (1.39 (0.60) v 1.45 (0.47)). The accuracy of ST segment elevation for the prediction of functional improvement was similar to that of low dose dobutamine echocardiography in patients with anterior infarction (80% v 83%) and in patients who underwent revascularisation (78% v 83% respectively). CONCLUSION: In patients with a recent Q wave myocardial infarction, dobutamine-induced ST segment elevation is a valuable marker of myocardial viability particularly when the test is performed without or with suboptimal echocardiographic imaging.

Women fare no worse than men 10 years after attempted coronary angioplasty. (Article)

1996-09-01T00:00:00Z

A retrospective review of cardiac events occurring in all patients who underwent attempted coronary angioplasty in the first 5 years of our experience (1980-1985) was undertaken. Follow-up data were obtained from the civil registry, hospital records, patient, family, and referring physician. Patient survival curves were constructed and the outcome of women and men was compared. Eight hundred fifty-six patients, 172 women and 684 men with a mean age of 60.0 and 55.3 years, respectively, underwent attempted coronary angioplasty with an overall procedural success rate of 82%, 77.7% in women and 83.1% in men. Follow-up data were obtained in 837 patients (97.8%) with a mean period of 9.6 years (range 0-13.3 years). The estimated 10 year survival in women was identical to men [79%, 95% confidence interval (CI) 72.6–85.4% vs. 78%, 95% CI 74.6–81.4%] as was the 10 year event-free survival (men 36%, 95% CI 32.0–40.0% vs. women 37%, 95% CI 29.2-44.8%), with a similar proportion of major cardiac events—death, myocardial infarction, coronary artery bypass surgery, and repeat angioplasty. When women were matched to men for age and previous myocardial infarction, factors found to be associated with an adverse outcome, there was no significant difference. Additionally, outcome was compared after patients were matched for maximum nominal balloon size as an estimate of vessel size, with no significant difference between women and men. At follow-up, women complained of significantly more anginal symptoms than men (59.2% vs. 44.0%, P < 0.05) and took significantly more antianginal medication.

Clinical outcome 10 years after attempted percutaneous transluminal coronary angioplasty in 856 patients. (Article)

1996-06-01T00:00:00Z

Abstract OBJECTIVES: This study reports the 10-year outcome of 856 consecutive patients who underwent attempted coronary angioplasty at the Thoraxcenter during the years 1980 to 1985. BACKGROUND: Coronary balloon angioplasty was first performed in 1977, and this procedure was introduced into clinical practice at the Thoraxcenter in 1980. Although advances have been made, extending our knowledge of the long-term outcome in terms of survival and major cardiac events remains of interest and a valuable guide in the treatment of patients with coronary artery disease. METHODS: Details of survival, cardiac events, symptoms and medication were retrospectively obtained from the Dutch civil registry, medical records or by letter or telephone or from the patient's physician and entered into a dedicated data base. Patient survival curves were constructed, and factors influencing survival and cardiac events were identified. RESULTS: The procedural clinical success rate was 82%. Follow-up information was obtained in 837 patients (97.8%). Six hundred forty-one patients (77%) were alive, of whom 334 (53%) were symptom free, and 254 (40%) were taking no antianginal medication. The overall 5- and 10-year survival rates were 90% (95% confidence interval [CI] 87.6% to 92.4%) and 78% (95% CI 75.0% to 81.0%), respectively, and the respective freedom from significant cardiac events (death, myocardial infarction, coronary artery bypass surgery and repeat angioplasty) was 57% (95% CI 53.4% to 60.6%) and 36% (95% CI 32.4% to 39.6%). Factors that were found to adversely influence 10-year survival were age > or = 60 years (> or = 60 years [67%], 50 to 59 years [82%], < 50 years [88%]), multivessel disease (multivessel disease [69%], single-vessel disease [82%]), impaired left ventricular function (ejection fraction < 50% [57%], > or = 50% [80%]) and a history of previous myocardial infarction (previous myocardial infarction [72%], no previous infarction [83%]). These factors were also found to be independent predictors of death during the follow-up period by a multivariate stepwise logistic regression analysis. Other factors tested, with no influence on survival, were gender, procedural success and stability of angina at the time of intervention. CONCLUSIONS: The long-term prognosis of patients after coronary angioplasty is good, particularly in those <60 years old with single-vessel disease and normal left ventricular function. The majority of patients are likely to experience a further cardiac event in the 10 years after their first angioplasty procedure.

Repeat interventions as a long-term treatment strategy in the management of progressive coronary artery disease. (Article)

1996-05-01T00:00:00Z

Objectives. This study investigates whether repeat coronary interventions, applied over an extended time period, can successfully curtail the progression of ischemic symptoms and angiographic lumen narrowing. Background. Coronary artery disease is a chronic and generally progressive disorder, and potential treatment strategies should be examined and compared with this chronicity in mind. Percutaneous interventional revascularization procedures could theoretically be useful in controlling progression of the disease through repeated use as new coronary lesions arise. However, the outcome of this long-term management concept has not previously been subjected to detailed investigation. Methods. From a consecutive series of 4,357 interventional cardiac procedures, 544 patients were identified who received two or more interventions during the 13-year study period. These patients were categorized into one of three groups: restenosis (repeat interventions limited to the same target segment, N = 261), new stenosis (all repeat interventions directed to stenoses not previously treated, N = 155) or both (repeat interventions directed both to the same and to different target lesions, N = 128). Results. Two to five procedures were performed per patient; the time period (mean ± SD) separating each procedure was significantly less (p < 0.0001) for the restenosis group (4.2 ± 2.3 months) than for the new stenosis (24.2 ± 23.5 months) or the “both” groups (11.4 ± 11.0 months). Despite the need for repeat procedures, the severity of angina (mean New York Heart Association functional class 1.6 ± 0.9) after 6.2 ± 2.3 years of follow-up was substantially better than before the initial procedure (mean functional class 3.2 ± 0.8), with a similar magnitude of change found in all three groups. This long-term functional improvement was mirrored by a corresponding anatomic improvement, with the mean number of diseased vessels remaining constant at the time of each procedure (1.5 ± 0.7, 1.5 ± 0.7 and 1.6 ± 0.7, respectively, for the first, second and third procedures, P = NS). The restenosis and the new stenosis groups also demonstrated statistically similar annual rates of mortality (1.9% vs. 1.8%) and coronary surgery (2.3% vs. 2.6%), although the restenosis group had a lower rate of infarction (1.4% vs. 3.2%, P = 0.002). Conclusions. Repeat interventional treatment of newly acquired stenoses provides a rational approach for the long-term management of chronic coronary artery disease. In addition to yielding a favorable late outcome, the use of this strategy can result in sustained functional improvement and can check the progression of clinically significant stenoses.

Akinesis becoming dyskinesis during dobutamine stress echocardiography. A predictor of poor functional recovery after surgical revascularization (Article)

1996-01-01T00:00:00Z

BACKGROUND: Akinesis becoming dyskinesis at high-dose dobutamine stress echocardiography (DSE) has been disregarded as a marker of myocardial ischemia. However, to our knowledge, the relationship between this pattern and myocardial viability has not been assessed. METHODS: We studied 42 patients with myocardial infarction who underwent DSE (up to 40 micrograms/kg/min) before coronary artery bypass surgery, and resting echocardiogram 3 months after surgery. Viability in akinetic segments was considered to be present if systolic thickening occurred with low-dose dobutamine (LDD). RESULTS: During high-dose DSE, dyskinesis occurred in 35 of the 164 akinetic segments (group A). The remaining 129 segments comprised group B. Segments of group B had a higher prevalence of viability pattern with LDD (18% vs 0%; p < 0.01) and a higher prevalence of functional improvement (20% vs 0%; p < 0.005) compared with group A. In absence of viability pattern with LDD, postoperative improvement occurred in 10% of segments in group B and in none of segments in group A, resulting in a higher negative predictive value of LDD in group A vs B (100% vs 90%; p < 0.05). CONCLUSION: The phenomenon of akinesis becoming dyskinesis with high-dose DSE is associated with absence of viability pattern with LDD and poor functional outcome after surgical revascularization. Observation of this pattern provides additional data to those obtained only with LDD echocardiography.

Immediate and long term results of percutaneous coronary angioplasty in patients aged 70 and over (Article)

1992-01-01T00:00:00Z

OBJECTIVE: To study the immediate and long term clinical success of percutaneous transluminal coronary balloon angioplasty in patients over 70 years old. DESIGN--Patients undergoing percutaneous transluminal angioplasty were prospectively entered in a specially designed database. The clinical and angiographic data of all patients over 70 were reviewed. Follow up data were collected by interview, during outpatient visits, by questionnaire, or through the referring physician. SETTING--A tertiary referral cardiac centre. PATIENTS--166 patients over 70 (median 73, range 70-84) underwent coronary angioplasty because of unstable angina (81 patients), stable angina (76 patients), or acute myocardial infarction (nine patients). RESULTS--The initial clinical success rate was 86% (142 of 166 patients). A major procedural complication occurred in 10 patients (6%): four patients (2%) died, six patients (4%) underwent emergency bypass surgery, and five patients (3%) sustained an acute myocardial infarction. In 14 patients (8%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 226 lesions were attempted. The initial angiographic success rate was 192 out of 226 lesions (85%). The median follow up was 21 (range 0.5-66) months. Sixteen patients (10%) died during follow up, eight patients (5%) sustained a non-fatal myocardial infarction, 21 patients (13%) underwent a second or third balloon dilatation, and 17 patients (10%) underwent elective bypass surgery. Of the 146 survivors, 99 patients (68%) had sustained clinical improvement. The estimated survival at four years (Kaplan-Meier method) was 89 (SD 4)%. The event free survival at four years for the total study population was 61 (8)%. Multivariate logistic regression analysis showed that the extent of vessel disease was the only independent predictive factor for event free survival: the event free survival rate was 81 (10)% at four years for patients with single vessel disease, compared with 45 (12)% for patients with multivessel disease. CONCLUSIONS--Coronary angioplasty in patients over 70 was a safe and effective treatment for obstructive coronary artery disease. The extent of vessel disease, and not the completeness of revascularisation, was the only independent predictive factor for event free survival.

Acute coronary artery occlusion during and after percutaneous transluminal coronary angioplasty. Frequency, prediction, clinical course, management, and follow-up (Article)

1991-01-01T00:00:00Z

BACKGROUND. Acute coronary artery occlusion after percutaneous transluminal coronary angioplasty (PTCA) continues to remain a serious complication despite significant improvement in operator performance and technological advancements. This retrospective study was performed to ascertain the frequency, predictive variables, management, and outcome of acute coronary artery occlusion. METHODS AND RESULTS. The study was based on data from 1,423 consecutive patients who underwent an elective coronary angioplasty between January 1986 and December 1988. Acute coronary artery occlusion occurred in 104 patients (7.3%). Acute occlusion developed during the dilatation procedure in 80 patients (5.6%) and within 24 hours after the procedure in 24 patients (1.7%). Four clinical and 14 angiographic variables predictive for acute coronary artery occlusion were analyzed in these 104 patients with a complicated procedure and were compared with those in 104 representative patients with successful attempts. Multivariate analysis found three independent predictive variables: unstable angina, multivessel disease, and complex lesions. The overall clinical outcome after management of acute coronary artery occlusion including immediate repeat dilatation (95 patients), use of intracoronary streptokinase (34 patients), or autoperfusion catheter (12 patients) was successful (reduction of lumen diameter to less than 50%, no death, no myocardial infarction [MI], and no emergency surgery) in 42 patients (40%), was a failure without major complication in four patients (4%), and was a failure with major complication (death, MI, and emergency surgery) in 58 patients (56%). The overall mortality rate was 6% (six patients), the overall MI rate was 36% (37 patients), and emergency bypass surgery was required in 30% of patients (31 patients). At 6 months' follow-up of 42 patients with successful management, recurrent angina pectoris due to restenosis occurred in 10 patients (24%), and a late MI occurred in one patient (3%). At 6 months' follow-up of 56 survivors with unsuccessful management (development of MI or need for emergency bypass surgery), recurrent angina occurred in nine patients (16%), and cardiac death in two patients (4%). However, the majority of patients in both groups were either symptom free or had mild angina pectoris. CONCLUSION. Acute coronary artery occlusion during PTCA is often unpredictable, but its frequency is higher in patients with unstable angina, multivessel disease, and complex lesions. Despite immediate redilatation, use of intracoronary streptokinase, and emergency bypass surgery, PTCA is associated with a high mortality and morbidity.

Coronary angioplasty for unstable angina: immediate and late results in 200 consecutive patients with identification of risk factors for unfavorable early and late outcome (Article)

1988-01-01T00:00:00Z

Two hundred patients (mean age 56 years, range 36 to 74) with unstable angina (chest pain at rest, associated with ST-T changes) underwent coronary angioplasty. In 65 patients with multivessel disease, only the "culprit" lesion was dilated. The initial success rate was 89.5% (179 of 200 patients). At least one major procedure-related complication occurred in 21 patients (10.5%): (death in 1, myocardial infarction in 16 and urgent surgery in 18). All patients were followed up for 2 years. Five patients died late; 8 had a late nonfatal myocardial infarction and 52 had recurrence of angina pectoris. The restenosis rate was 32% (51 of 158) in the patients with initial successful angioplasty who had repeat angiography. At the 2 year follow-up, after attempted coronary angioplasty in all 200 patients, the total incidence rate of death was 3% (one procedure related; five late deaths), of nonfatal myocardial infarction 12% (16 procedure related and 8 late after angioplasty), and 13% (26 patients) were still symptomatic although they had improved in functional class. Multivariate analysis showed that variables indicating an increased risk 1) for major procedure-related complications were: ST segment elevation, persistent negative T wave and stenosis greater than or equal to 65% (odds ratio 3.7, 3.7 and 3.3, respectively); 2) for angiographic restenosis were: presence of collateral vessels, ST segment depression, multivessel disease, left anterior descending coronary artery stenosis and history of recent onset of symptoms (odds ratio: 2.2, 2.0, 1.9, 1.9 and 0.54, respectively); and 3) for late coronary events (recurrence of angina, late myocardial infarction or late death) were: multivessel disease, total occluded vessel and ST segment elevation (odds ratio 3.7, 2.8 and 0.44, respectively). Thus, coronary angioplasty for unstable angina can be performed with a high initial success rate, but at an increased risk of major complications. The prognosis is favorable after initial successful coronary angioplasty.

Intracoronary thrombolysis in patients with acute myocardial infarction: The Netherlands randomized trial and current status (Article)

1987-01-01T00:00:00Z

Value of immediate coronary angioplasty following intracoronary thrombolysis in acute myocardial infarction (Article)

1987-01-01T00:00:00Z

A total of 533 patients with acute myocardial infarction of less than 4-h duration were enrolled in the multicenter randomized trial of intracoronary thrombolysis compared to conventional treatment. In two of the five participating centers, an additional coronary angioplasty immediately after thrombolysis was attempted in 46 patients. According to the treatment allocation and early and late patency of the infarct related vessel, patients were subdivided into three groups: conventionally treated (group A); successful coronary angioplasty following thrombolysis with persistent patent infarct related vessel (group B); and late patency of the infarct related vessel postthrombolytic therapy without angioplasty (group C). The highest global ejection fractions were observed in group B (54% +/- 10%) and group C (55% +/- 13%), while the lowest ejection fraction was found in group A (47% +/- 14%). The sequential changes in global ejection fraction from the acute to the chronic stage was + 4% (p = 0.05) in group B, while no significant changes could be demonstrated in group C. Furthermore, in the group successfully treated by angioplasty, the improvement in global ejection fraction was more pronounced and persisted up to three months after the intervention. This was supported by analysis of regional myocardial function of the infarct zone (+ 16% improvement, p = 0.01). The long-term clinical follow-up (median 24 months) of the patients successfully treated by combined procedure of thrombolysis and angioplasty (group B) was most favourable with a lower incidence of re-infarction (6%), and late coronary bypass surgery (13%) and/or (re)-percutaneous transluminal coronary angioplasty (3%) was performed less frequently. These results suggest that reperfusion may need to be supplemented by additional revascularization procedures in order to optimize the changes of obtaining full functional recovery and so to improve the prognosis.

Preservation of global and regional left ventricular function after early thrombolysis in acute myocardial infarction (Article)

1986-01-01T00:00:00Z

The effect of early myocardial reperfusion (within 4 hours after onset of symptoms) on regional left ventricular function in patients with acute myocardial infarction has been quantitated by analysis of segmental wall motion. Of 533 patients randomized either to conventional coronary care unit therapy or to a reperfusion strategy, in 332 high quality angiograms were obtained 2 to 8 weeks after the onset of myocardial infarction. In those assigned to thrombolytic therapy, angiographic data were also available after acute reperfusion. Analysis on an "intention to treat" basis revealed significant preservation of left ventricular function after thrombolytic therapy (ejection fraction 53%) compared with conventional treatment (ejection fraction 47%). In addition, wall motion analysis showed significant improvement of regional function in the infarct zone in both inferior and anterior infarction. In addition, significant changes occurred in regional function of the remote "noninfarct zone" in the acute as well as the chronic stage. It is concluded that improved regional and global left ventricular function can be achieved with early reperfusion and that this is the likely explanation for the reduction of early and late mortality after thrombolysis observed in this study.

Which patients benefit most from early thrombolytic therapy with intracoronary streptokinase? (Article)

1986-01-01T00:00:00Z

The effect of thrombolysis in acute myocardial infarction on enzymatic infarct size, left ventricular function, and early mortality was studied in subsets of patients in a randomized trial. Early thrombolytic therapy with intracoronary streptokinase (152 patients) or with intracoronary streptokinase preceded by intravenous streptokinase (117 patients) was compared with conventional treatment (264 patients). All 533 patients were admitted to the coronary care unit within 4 hr after onset of symptoms indicative of acute myocardial infarction. Four hundred eighty-eight patients were eligible for this detailed analysis, and 245 of these were allocated to thrombolytic therapy and 243 to conventional treatment. Early angiographic examinations were performed in 212 patients allocated to thrombolytic therapy. Patency of the infarct-related artery was achieved in 181 patients (85%). Enzymatic infarct size, as measured from cumulative alpha-hydroxybutyrate dehydrogenase release, was smaller in patients allocated to thrombolytic therapy (median 760 vs 1170 U/liter in control patients, p = .0001). Left ventricular ejection fraction measured by radionuclide angiography before discharge from the hospital was higher after thrombolytic therapy (median 50% vs 43% in control patients, p = .0001). Three month mortality was lower in patients allocated to thrombolytic therapy (6% vs 14% in the control group, p = .006). With the use of multivariate regression analysis, infarct size limitation, improvement in left ventricular ejection fraction, and three month mortality were predicted by sum of the ST segment elevation, time from onset of symptoms to admission, and Killip class at admission. Thrombolysis was most effective in patients admitted within 2 hr after onset of symptoms and in patients with a sum of ST segment elevation of 1.2 mV or more. On the other hand, no beneficial effects of streptokinase on enzymatic infarct size, left ventricular function, or mortality were observed in the subset of patients with a sum of ST segment elevation of less than 1.2 mV who were admitted between 2 and 4 hr after onset of symptoms.

Effect of intracoronary thrombolytic therapy on global and regional left ventricular function. A three year experience with randomization (Article)

1985-01-01T00:00:00Z

The effect of myocardial reperfusion on regional left ventricular function has been quantitated by analysis of segmental wall motion in 185 patients enrolled in a randomized trial comparing thrombolysis with conventional treatment in patients with acute myocardial infarction. When analyzing the hemodynamic data on an "intention to treat" basis we found a significant preservation of left ventricular function after thrombolytic therapy when compared to conventional treatment. In addition, the wall motion analysis showed that a significant improvement of regional function in the "infarct zone" was observed in inferior infarction as well as in anterior infarction, although significant changes in regional function of the remote "non infarct zone" were observed at the acute as well as at the chronic stage. However, our follow-up data indicate that as yet it has not been resolved whether this method of treatment does indeed improve prognosis in patients with acute myocardial infarction. Accordingly, we maintain the view that such invasive treatment should not be generally applied until more follow-up data become available from larger randomized trials.

Tien jaar coronairachirurgie; resultaten bij 1041 patienten, geopereerd in het Thoraxcentrum te Rotterdam (Article)

1983-01-01T00:00:00Z