Poldermans, D.

The impact of gender on prognosis after non-cardiac vascular surgery (Article)

2011-10-01T00:00:00Z

Objectives: The objective was to evaluate the impact of gender on long-term survival of patients who underwent non-cardiac vascular surgery. Design, Material and Methods: Our prospectively collected data contained information on 560 patients undergoing carotid endarterectomy (CEA), 923 elective abdominal aortic aneurysm repairs (AAA) and 1046 lower limb reconstructions (LLR). Patient characteristics and long-term mortality of women were compared to that of men. Kaplan-Meier (KM) survival curves were constructed for men and women, on which we superimposed age- and sex-matched KM survival curves of the general population. Cox proportional hazards regression was used to identify risk factors for mortality. Results: Men in the CEA group had statistically significant higher all-cause mortality, hazard rate ratio (HRR) 1.41 (95% CI 1.01-1.98) No differences in mortality between the genders were observed in the AAA and LLR groups. Overall, men had more co-morbidities but received more disease-specific medication compared to women. Women retained their higher life expectancy after CEA but lost it in the AAA and LLR groups. Conclusion: Women retain their higher life expectancy after CEA; however, after AAA repair and LLR, this advantage is lost. Both men and women received too little disease-specific medication, but women were worse off.

Perioperative cardiac evaluation, monitoring, and risk reduction strategies in noncardiac surgery patients (Article)

2011-10-01T00:00:00Z

PURPOSE OF REVIEW: Cardiac complications after noncardiac surgery cause significant morbidity and mortality. This review will discuss recent developments in risk stratification, monitoring, and risk reduction strategies. RECENT FINDINGS: The addition of biomarkers for ischemia, left ventricular function, and atherosclerosis to classic cardiac risk factors improves the prediction of both short-term and long-term outcome after noncardiac surgery. Intraoperative monitoring, using continuous 12-lead ECG assessment and transesophageal echocardiography, may timely identify treatable myocardial ischemia and arrhythmias. A prudent perioperative beta-blocker and statin regimen can reduce cardiac complications and mortality without increasing the risk of stroke in intermediate to high-risk patients. The use of circulatory assist devices might improve outcomes after major surgery in patients with severely reduced left ventricular function. SUMMARY: Systematic preoperative assessment can identify patients at high risk of cardiac complications and guide the application of appropriate risk reduction strategies.

Reprinted Article "a combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery" (Article)

2011-09-01T00:00:00Z

Objective: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). Background: Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. Methods: We studied 570 patients (mean age 69 ±9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. Results: Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p = 0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24,95% CI: 0.10-0.70; p = 0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. Conclusions: A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.

A randomised study of perioperative esmolol infusion for haemodynamic stability during major vascular surgery; Rationale and design of DECREASE-XIII (Article)

2011-09-01T00:00:00Z

Objectives: This article describes the rationale and design of the DECREASE-XIII trial, which aims to evaluate the potential of esmolol infusion, an ultra-short-acting beta-blocker, during surgery as an add-on to chronic low-dose beta-blocker therapy to maintain perioperative haemodynamic stability during major vascular surgery. Design: A double-blind, placebo-controlled, randomised trial. Materials & methods: A total of 260 vascular surgery patients will be randomised to esmolol or placebo as an add-on to standard medical care, including chronic low-dose beta-blockers. Esmolol is titrated to maintain a heart rate within a target window of 60-80 beats per minute for 24 h from the induction of anaesthesia. Heart rate and ischaemia are assessed by continuous 12-lead electrocardiographic monitoring for 72 h, starting 1 day prior to surgery. The primary outcome measure is duration of heart rate outside the target window during infusion of the study drug. Secondary outcome measures will be the efficacy parameters of occurrence of cardiac ischaemia, troponin T release, myocardial infarction and cardiac death within 30 days after surgery and safety parameters such as the occurrence of stroke and hypotension. Conclusions: This study will provide data on the efficacy of esmolol titration in chronic beta-blocker users for tight heart-rate control and reduction of ischaemia in patients undergoing vascular surgery as well as data on safety parameters.

Epidural analgesia is associated with improved health outcomes of surgical patients with chronic obstructive pulmonary disease (Article)

2011-08-01T00:00:00Z

Background: Patients with chronic obstructive pulmonary disease (COPD) have increased postoperative morbidity and mortality. Epidural analgesia (EDA) improves postoperative outcome but may worsen postoperative lung function. It is unknown whether patients with COPD benefit from EDA. The objective of this study was to determine whether patients with COPD undergoing major abdominal surgery benefit from EDA in addition to general anesthesia. Methods: This cohort study included 541 consecutive patients with COPD who underwent major abdominal surgery between 1995 and 2007 at a university medical center. Propensity scores estimating the probability of receiving EDA were used in multivariate correction. The primary outcome was postoperative pneumonia and 30-day mortality. Results: There were 324 patients (60%) who received EDA in addition to general anesthesia. The incidence of postoperative pneumonia (16% vs. 11%; P = 0.08) and 30-day mortality (9% vs. 5%; P = 0.03) was lower in patients who received EDA. After correction EDA was associated with improved outcome for postoperative pneumonia (OR 0.5; 95% CI: 0.3-0.9; P = 0.03). The strongest preventive effect was seen in patients with the most severe type of COPD. Conclusion: This study provides evidence that in patients with COPD who are scheduled for major abdominal surgery, epidural analgesia decreases postoperative pulmonary complications. Copyright

Influence of noninvasive cardiovascular imaging in primary prevention: Systematic review and meta-analysis of randomized trials (Article)

2011-06-13T00:00:00Z

Background: Despite extensive use in practice, the impact of noninvasive cardiovascular imaging in primary prevention remains unclear. Methods: We searched for randomized trials that compared imaging with usual care and reported any of the following outcomes in a primary prevention setting: medication prescribing, lifestyle modification (including diet, exercise, or smoking cessation), angiography, or revascularization. Results: Seven trials were included. Trials screened patients for inducible myocardial ischemia (2 trials), coronary calcification (3 trials), carotid atherosclerosis (1 trial), or left ventricular hypertrophy (1 trial). Imaging had no effect on medication prescribing overall (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.76-1.33) or on provision of lipid-modifying agents (OR, 1.08; 95% CI, 0.58-2.01), antihypertensive drugs (OR, 1.05; 95% CI, 0.75-1.47), or antiplatelet agents (OR, 1.05; 95% CI, 0.84-1.32). Similarly, no effect was seen on dietary improvement (OR, 0.78; 95% CI, 0.22-2.85), physical activity (0.02 vs-0.08 point change for imaging vs control on a 5-point scale; P=.23), or smoking cessation (OR, 2.24; 95% CI, 0.97-5.19). Imaging was not associated with invasive an-giography (OR, 1.26; 95% CI, 0.89-1.79). Conclusions: We found limited evidence suggesting that noninvasive cardiovascular imaging alters primary prevention efforts. However, given the imprecision of these results, further high-quality studies are needed.

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.

Quality assurance in perioperative care (Article)

2011-06-01T00:00:00Z

Nowadays more and more clinical guidelines are developed. Clinical guidelines aim to assist practitioner and patient decision making about appropriate care for specific clinical conditions. Furthermore, guidelines can play a crucial role in the quality cycle form guidelines to clinical practice. However, this does not necessarily mean that these guidelines are actually implemented and the ultimately goal, improved patient outcome, is achieved. Care gaps exist between guidelines and daily clinical practice in perioperative care. Research should be focused on identification of barriers to adherence and subsequent effect implementation strategies to achieve higher standards of quality of care. A multifactorial approach to improving use of guidelines in clinical practice may improve the treatment of patients with peripheral arterial disease.

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.

Radial force measurements in carotid stents: Influence of stent design and length of the lesion (Article)

2011-05-01T00:00:00Z

Purpose: To assess the differences in radial force of carotid stents and whether the length of the lesion influences the measurements. Materials and Methods: Different models of tapered stents of similar size (length, 30 mm) were used. The tapered nitinol Acculink, Protg, and Cristallo Ideale carotid artery stents and the straight, braided Elgiloy carotid Wallstent were compared. A measurement device consisting of three film loops along the stent body connected to aluminium rods with copper strain gauges was developed. Five stents of each type were deployed within 3-mm stenoses in simulated long (26 mm) and short (8 mm) stenoses. Results: In the short stenosis simulation, the greatest radial force was seen in the Protg stent, at 3.14 N ± 0.45, followed by the Cristallo Ideale stent (1.73 N ± 0.51), Acculink (1.16 N ± 0.21), and Wallstent (0.84 N ± 0.10; P < .001). In the long stenosis simulation, peak radial force again was highest in the Protg stent (1.67 N ± 0.37), but the Acculink stent was second (0.95 N ± 0.12) and the Wallstent third (0.80 N ± 0.06). The Cristallo Ideale stent, in contrast to the short stenosis simulation, produced the least radial force (0.44 N ± 0.13) in the long stenosis simulation (P = .001). Conclusions: Radial forces exerted by carotid stents vary significantly among stent designs. Differences between stent types are dependent on the length of the stenosis. An understanding of radial force is necessary for a well-considered choice of stent type in each individual patient.

Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery: A systematic review and meta-analysis (Article)

2011-04-01T00:00:00Z

Background: There is uncertainty regarding the prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurements after noncardiac surgery. Methods: The current study undertook a systematic review and meta-analysis. The study used six search strategies and included noncardiac surgery studies that provided data from a multivariable analysis assessing whether a postoperative troponin or creatine kinase muscle and brain isoenzyme measurement was an independent predictor of mortality or a major cardiovascular event. Independent investigators determined study eligibility and abstracted data in duplicate. Results: Fourteen studies, enrolling 3,318 patients and 459 deaths, demonstrated that an increased troponin measurement after surgery was an independent predictor of mortality (odds ratio [OR] 3.4, 95% confidence interval [CI] 2.2-5.2), but there was substantial heterogeneity (I = 56%). The independent prognostic capabilities of an increased troponin value after surgery in the 10 studies that assessed intermediate-term (≤ 12 months) mortality was an OR = 6.7 (95% CI 4.1-10.9, I = 0%) and in the 4 studies that assessed long-term (more than 12 months) mortality was an OR = 1.8 (95% CI 1.4-2.3, I = 0%; P < 0.001 for test of interaction). Four studies, including 1,165 patients and 202 deaths, demonstrated an independent association between an increased creatine kinase muscle and brain isoenzyme measurement after surgery and mortality (OR 2.5, 95% CI 1.5-4.0, I = 4%). Conclusions: An increased troponin measurement after surgery is an independent predictor of mortality, particularly within the first year; limited data suggest an increased creatine kinase muscle and brain isoenzyme measurement also predicts subsequent mortality. Monitoring troponin measurements after noncardiac surgery may allow physicians to better risk stratify and manage their patients.

Authors' reply (Article)

2011-04-01T00:00:00Z

Effects of adherence to guidelines for the control of major cardiovascular risk factors on outcomes in the REduction of Atherothrombosis for Continued Health (REACH) Registry Europe (Article)

2011-04-01T00:00:00Z

Objectives: To examine the impact of cardiovascular risk factor control on 3-year cardiovascular event rates in patients with stable symptomatic atherothrombotic disease in Europe. Methods: The REduction of Atherothrombosis for Continued Health (REACH) Registry recruited patients aged ≥45 years with established atherothrombotic disease or three or more risk factors, of whom 20 588 symptomatic patients from 18 European countries were analysed in this study at baseline and 12, 24 and 36 months. 'Good control' of cardiovascular risk factors was defined as three to five risk factors at target values of international guideline recommendations (systolic blood pressure <140 mm Hg, diastolic blood pressure <90 mm Hg, fasting glycaemia <110 mg/dl, total cholesterol <200 mg/dl, non-smoking). Independent predictors of 'good control' of major risk factors were assessed by multivariate analysis. Results: Among symptomatic patients in the REACH Registry Europe (mean age 67 years, 70.6% male), 59.4% had good control of risk factors at baseline. Good risk factor control was associated with lower cardiovascular death/non-fatal stroke/non-fatal myocardial infarction (OR 0.76; 95% CI 0.69 to 0.83) and mortality (OR 0.89; 95% CI 0.79 to 0.99) at 36 months, compared with poor control. Independent predictors of good control of risk factors included residence in western versus eastern Europe (OR 1.29), high level of education (OR 1.16), established coronary artery disease (OR 1.18), treatment with one or more antithrombotic (OR 1.59) and one or more lipid-lowering agent (OR 1.16). Conclusions: In REACH, less than 60% of patients with stable atherothrombotic disease had good control of the five major cardiovascular risk factors. Improved risk factor control is associated with a positive impact on 3-year cardiovascular event rates and mortality.

Clinical and echocardiographic predictors of nonresponse to cardiac resynchronization therapy (Article)

2011-03-03T00:00:00Z

Background: Lack of response to cardiac resynchronization therapy (CRT) ranges between 30% to 40% of heart failure (HF) patients. The present study aimed to evaluate the clinical and echocardiographic determinants of nonresponse to CRT. Methods: A total of 581 patients (66.4 ± 10.0 years, 77.9% male) with advanced HF scheduled for CRT implantation were included. Clinical and echocardiographic evaluations were performed at baseline and 6 months of follow-up. Nonresponse was defined as no improvement in the New York Heart Association functional class, death from worsening HF or heart transplantation, and <15% reduction in left ventricular (LV) end-systolic volume. Results: At 6 months of follow-up, 254 patients (44%) did not respond to CRT. The nonresponders were more frequently male (81.9% vs 74.3%, P = .030) and had ischemic cardiomyopathy (69.7% vs 53.2%, P < .001), shorter QRS duration (150.6 ± 29.9 milliseconds vs 156.0 ± 32.5 milliseconds, P = .041), worse New York Heart Association functional class (2.8 ± 0.6 vs 2.7 ± 0.6, P = .008) and shorter 6-minute walk distance (297.9 ± 110.7 m vs 331.8 ± 112.6 m, P = .001), larger left atrial volumes (44.9 ± 16.9 mL/m2vs 40.9 ± 17.6 mL/m2, P = .006), less baseline LV dyssynchrony (56.2 ± 41.3 milliseconds vs 69.1 ± 39.9 milliseconds, P < .001), and, more frequently, anterior LV lead position (12.4% vs 4.0%, P = .007). At multivariate analysis, only the ischemic etiology of HF (odds ratio [OR] 2.264, P = .005), shorter 6-minute walk distance at baseline (OR 0.998, P = .030), less baseline LV dyssynchrony (OR 0.989, P < .001), and anterior LV lead position (OR 3.713, P < .010) remained independent predictors of nonresponse to CRT. Conclusions: Ischemic etiology of HF, shorter baseline 6-minute walk distance, less baseline LV dyssynchrony, and anterior LV lead position are independent determinants of nonresponse to CRT.

Aortic surgery complications evaluated by an implanted continuous electrocardiography device: A case report (Article)

2011-03-01T00:00:00Z

Introduction: Cardiac arrhythmias are a major cause for morbidity and mortality in patients undergoing non-cardiac vascular surgery. Report: An implantable loop recorder (Reveal® XT) was used for continuous heart rhythm monitoring to detect perioperative arrhythmias in a 69-year-old man undergoing major vascular surgery for an infected aortobifemoral prosthesis. The Reveal® detected several episodes of asymptomatic new-onset atrial fibrillation postoperatively, associated with elevated serum levels of troponin-T and N-terminal pro-B-type natriuretic peptide NT-proBNP). Discussion: Continuous heart rhythm monitoring with assessment of serum cardiac biomarkers may allow early identification and treatment of patients at high risk of perioperative cardiovascular complications, in particular, cardiac arrhythmias.

High thrombin activatable fibrinolysis inhibitor levels are associated with an increased risk of premature peripheral arterial disease (Article)

2011-03-01T00:00:00Z

Background: Previous studies suggested that hypofibrinolysis is associated with increased risk of peripheral arterial disease. Thrombin activatable fibrinolysis inhibitor (TAFI) has been identified as an important inhibitor of fibrinolysis. The aim of our study was to assess the role of TAFI in young patients with peripheral arterial disease. Methods: In a single-center case-control study we measured plasma TAFI antigen levels and functional TAFI in consecutive young patients (men 18-45 years and women 18-55 years) with a first manifestation of peripheral arterial disease and compared these with a population-based control group. Results: A total of 47 peripheral arterial disease patients and 141 controls (mean age 43) were included. Intact TAFI antigen levels were significantly higher in patients with peripheral arterial disease (112.4 ± 21.1%) than in controls (104.9 ± 19.9%, p = 0.03). The risk of peripheral arterial disease increased with 18% (OR 1.18; CI 1.01-1.34) per 10% increase of TAFI antigen. Functional TAFI levels were slightly higher in patients compared to controls, however this difference was not significant. For individuals with the highest functional TAFI levels, above the 90th percentile, the increased risk for peripheral arterial disease was most pronounced (OR 3.1; CI 1.02-9.41). Conclusion: High TAFI levels are associated with increased risk of premature peripheral arterial disease.

Usefulness of repeated N-Terminal Pro-B-type natriuretic peptide measurements as incremental predictor for long-term cardiovascular outcome after vascular surgery (Article)

2011-02-15T00:00:00Z

Plasma N-terminal proB-type natriuretic peptide (NTpro-BNP) levels improve preoperative cardiac risk stratification in vascular surgery patients. However, single preoperative measurements of NTpro-BNP cannot take into account the hemodynamic stress caused by anesthesia and surgery. Therefore, the aim of the present study was to assess the incremental predictive value of changes in NTpro-BNP during the perioperative period for long-term cardiac mortality. Detailed cardiac histories, rest left ventricular echocardiography, and NTpro-BNP levels were obtained in 144 patients before vascular surgery and before discharge. The study end point was the occurrence of cardiovascular death during a median follow-up period of 13 months (interquartile range 5 to 20). Preoperatively, the median NTpro-BNP level in the study population was 314 pg/ml (interquartile range 136 to 1,351), which increased to a median level of 1,505 pg/ml (interquartile range 404 to 6,453) before discharge. During the follow-up period, 29 patients (20%) died, 27 (93%) from cardiovascular causes. The median difference in NTpro-BNP in the survivors was 665 pg/ml, compared to 5,336 pg/ml in the patients who died (p = 0.01). Multivariate Cox regression analyses, adjusted for cardiac history and cardiovascular risk factors (age, angina pectoris, myocardial infarction, stroke, diabetes mellitus, renal dysfunction, body mass index, type of surgery and the left ventricular ejection fraction), demonstrated that the difference in NTpro-BNP level between pre- and postoperative measurement was the strongest independent predictor of cardiac outcome (hazard ratio 3.06, 95% confidence interval 1.36 to 6.91). In conclusion, the change in NTpro-BNP, indicated by repeated measurements before surgery and before discharge is the strongest predictor of cardiac outcomes in patients who undergo vascular surgery.

Mutations in SMAD3 cause a syndromic form of aortic aneurysms and dissections with early-onset osteoarthritis (Article)

2011-02-01T00:00:00Z

Thoracic aortic aneurysms and dissections are a main feature of connective tissue disorders, such as Marfan syndrome and Loeys-Dietz syndrome. We delineated a new syndrome presenting with aneurysms, dissections and tortuosity throughout the arterial tree in association with mild craniofacial features and skeletal and cutaneous anomalies. In contrast with other aneurysm syndromes, most of these affected individuals presented with early-onset osteoarthritis. We mapped the genetic locus to chromosome 15q22.2-24.2 and show that the disease is caused by mutations in SMAD3. This gene encodes a member of the TGF-β pathway that is essential for TGF-β signal transmission. SMAD3 mutations lead to increased aortic expression of several key players in the TGF-β pathway, including SMAD3. Molecular diagnosis will allow early and reliable identification of cases and relatives at risk for major cardiovascular complications. Our findings endorse the TGF-β pathway as the primary pharmacological target for the development of new treatments for aortic aneurysms and osteoarthritis.

The influence of polyvascular disease on the obesity paradox in vascular surgery patients (Article)

2011-02-01T00:00:00Z

Background Obesity is a risk factor for atherosclerosis, a polyvascular process associated with reduced survival. In nonvascular surgery populations, a paradox between body mass index (BMI) and survival is described. This paradox includes reduced survival in underweight patients, whereas overweight and obese patients have a survival benefit. No clear explanation for this paradox has been given. Therefore, we evaluated the presence of the obesity paradox in vascular surgery patients and the influence of polyvascular disease on the obesity paradox. Methods In this retrospective study, 2933 consecutive patients were classified according to their preoperative BMI (kg/m2) and screened for polyvascular disease and cardiovascular risk factors before surgery. In addition, medication use at the time of discharge was noted. Outcome was all-cause mortality during a median follow-up of 6.0 years (interquartile range, 2-9 years). Results BMI (kg/m2) groups included 68 (2.3%) underweight (BMI <18.5), 1379 (47.0%) normal (BMI 18.5-24.9, reference), 1175 (40.0%) overweight (BMI 25-29.9), and 311 (10.7%) obese (BMI <30) patients. No direct interaction between BMI, polyvascular disease, and long-term outcome was observed. Underweight was an independent predictor of mortality (hazard ratio, 1.65; 95% confidence interval, 1.22-2.22). In contrast, overweight protected for all-cause mortality (hazard ratio, 0.79; 95% confidence interval, 0.700-0.89). Cardioprotective medication usage in underweight patients was the lowest (P < .001), although treatment targets for risk factors were equally achieved within all treated groups. Conclusion Overweight patients referred for vascular surgery were characterized by an increased incidence of polyvascular disease and required more extensive medical treatment for cardiovascular risk factors at discharge. Long-term follow-up showed a paradox of reduced mortality in overweight patients.

Risk factors and peripheral arterial disease; a plea for objective measurements (Article)

2011-01-01T00:00:00Z

Effect of genetic variations in syntaxin-binding protein-5 and syntaxin-2 on von willebrand factor concentration and cardiovascular risk (Article)

2010-12-01T00:00:00Z

Background - Elevated von Willebrand factor (VWF) plasma levels are associated with an increased risk of cardiovascular disease. A meta-analysis of genomewide association studies on VWF identified novel candidate genes, that is, syntaxin-binding protein 5 (STXBP5) and syntaxin 2 (STX2), which are possibly involved in the secretion of VWF. We investigated whether VWF antigen levels (VWF:Ag), VWF collagen-binding activity (VWF:CB) and the risk of arterial thrombosis are affected by common genetic variations in these genes. Methods and Results - In 463 young white subjects (men ≤45 years of age and women ≤55 years of age), who were included 1 to 3 months after a first event of arterial thrombosis, and 406 control subjects, we measured VWF:Ag and VWF:CB. Nine haplotype tagging single-nucleotide polymorphisms of STXBP5 and STX2 were selected and subsequently analyzed using linear regression with additive genetic models adjusted for age, sex, and ABO blood group. The minor alleles of rs9399599 and rs1039084 in STXBP5 were associated with lower VWF plasma levels and activity, whereas the minor allele of rs7978987 in STX2 was associated with higher VWF plasma levels and activity. The minor alleles of the single-nucleotide polymorphisms in STX2 were associated with a reduced risk of arterial thrombosis (rs1236: odds ratio, 0.73 [95% confidence interval, 0.59, 0.89]; rs7978987: odds ratio, 0.81 [95% confidence interval, 0.65, 1.00]; rs11061158: odds ratio, 0.69 [95% confidence interval, 0.55, 0.88]). Conclusions-Genetic variability in STXBP5 and STX2 affects both VWF concentration and activity in young individuals with premature arterial thrombosis. Furthermore, in our study, genetic variability in STX2 is associated with the risk of arterial thrombosis. However, at this point, the underlying mechanism remains unclear.

Timing of Pre-operative beta-blocker treatment in vascular surgery patients: Influence on post-operative outcome (Article)

2010-11-30T00:00:00Z

Objectives This study evaluated timing of β-blocker initiation before surgery and its relationship with: 1) pre-operative heart rate and high-sensitivity C-reactive-protein (hs-CRP) levels; and 2) post-operative outcome. Background Perioperative guidelines recommend β-blocker initiation days to weeks before surgery, on the basis of expert opinions. Methods In 940 vascular surgery patients, pre-operative heart rate and hs-CRP levels were recorded, next to timing of β-blocker initiation before surgery (0 to 1, >1 to 4, >4 weeks). Pre- and post-operative troponin-T measurements and electrocardiograms were performed routinely. End points were 30-day cardiac events (composite of myocardial infarction and cardiac mortality) and long-term mortality. Multivariate regression analyses, adjusted for cardiac risk factors, evaluated the relation between duration of β-blocker treatment and outcome. Results The β-blockers were initiated 0 to 1, >1 to 4, and >4 weeks before surgery in 158 (17%), 393 (42%), and 389 (41%) patients, respectively. Median heart rate at baseline was 74 (±17) beats/min, 70 (±16) beats/min, and 66 (±15) beats/min (p < 0.001; comparing treatment initiation >1 with <1 week pre-operatively), and hs-CRP was 4.9 (±7.5) mg/l, 4.1 (±.6.0) mg/l, and 4.5 (±6.3) mg/l (p = 0.782), respectively. Treatment initiated >1 to 4 or >4 weeks before surgery was associated with a lower incidence of 30-day cardiac events (odds ratio: 0.46, 95% confidence interval [CI]: 0.27 to 0.76, odds ratio: 0.48, 95% CI: 0.29 to 0.79) and long-term mortality (hazard ratio: 0.52, 95% CI: 0.21 to 0.67, hazard ratio: 0.50, 95% CI: 0.25 to 0.71) compared with treatment initiated <1 week pre-operatively. Conclusions Our results indicate that β-blocker treatment initiated >1 week before surgery is associated with lower pre-operative heart rate and improved outcome, compared with treatment initiated <1 week pre-operatively. No reduction of median hs-CRP levels was observed in patients receiving β-blocker treatment >1 week compared with patients in whom treatment was initiated between 0 and 1 week before surgery. © 2010 American College of Cardiology Foundation.

Clinical relevance of hibernating myocardium in ischemic left ventricular dysfunction (Article)

2010-11-01T00:00:00Z

Patients with chronic ischemic left ventricular dysfunction may have a substantial amount of viable, hibernating myocardium, which is a state of chronic contractile dysfunction with reduced blood flow at rest. Coronary revascularization in these patients may result in improvement of left ventricular function; in the absence of viability, left ventricular function will not improve postrevascularization. Various noninvasive imaging techniques are available for detection of viable myocardium, including magnetic resonance imaging, dobutamine stress echocardiography, and nuclear imaging with single photon emission computed tomography or positron emission tomography. Because these techniques probe different characteristics of viable myocardium, the sensitivities and specificities of the techniques are not precisely identical; in general, dobutamine stress echocardiography has the highest specificity, whereas the nuclear techniques have the highest sensitivity. The presence of myocardial viability also is related to prognosis: patients with viable myocardium who undergo revascularization have a good prognosis, whereas patients with viable myocardium who are treated medically have poor outcome. Accordingly, assessment of viability is important in the therapeutic decision-making process of patients with chronic ischemic left ventricular dysfunction.

Optimal medical management around the time of surgery (Article)

2010-11-01T00:00:00Z

Due to technical advancement and improved life expectancy, the surgical patient population is increasing in age and level of comorbidities. In an effort to decrease postoperative cardiac complications and death, optimal medical management is essential. Undergoing surgery has an accelerating effect on coronary atherosclerosis, increases inflammation, and induces a state of hypercoagulability in patients. Therefore, cardioprotective measures should be taken, especially in patients with a high risk of cardiac complications after surgery. Furthermore, increasing numbers of patients scheduled for surgery are treated with antiplatelet and/or anticoagulant therapy. These agents require strict management around the time of surgery, due to their ability to cause haemorrhage on the one hand and increased cardiac risks of withdrawal on the other. As planning for surgery begins, cardioprotective measures are best initiated. Optimally, 30 days before surgery both b-blockade and statin therapy are recommended to start. Especially in high cardiac risk patients, these medications have proven to be beneficial in the perioperative period and in long term follow-up. Additionally, the use of antiplatelet therapy should be assessed. A cardiologist and an anaesthetist should be consulted if the planned procedure has such a high bleeding risk that withdrawal from antiplatelet therapy is considered by the surgeon. Antiplatelet - especially clopidogrel - withdrawal is often hazardous to the patient, and surgery should therefore be postponed until clopidogrel therapy has stopped, if possible. Patients with current anticoagulant treatment should discontinue their therapy 5 days before most types of surgery. This will reduce the risk of bleeding during surgery, but it will increase the risk for thrombosis. In general, LMWH will be used as bridging therapy to reduce the perioperative thrombotic risk. LMWH therapy should commence 1 day after acenocoumarol or 2 days after warfarin, and be continued until 12 h before surgery. One or two days, and certainly no less than 12 h after surgery, LMWH bridging therapy can be continued. One or 2 days after surgery, anticoagulant therapy should be restarted at 150% of the preoperative daily dose for 2 days, and then continued at the preoperative daily dose. Heparin is discontinued when the INR reaches the therapeutic range. This paper provides a comprehensive outline of the optimal perioperative medical management concerning cardiac risk in any surgical population, based on recent guidelines. We emphasise that knowledge of, and adherence to, current guidelines is essential for optimal care and safety of surgical patients.

Statins and postoperative renal function (Article)

2010-11-01T00:00:00Z

Incidence and prediction of major cardiovascular complications in head and neck surgery (Article)

2010-11-01T00:00:00Z

Background. Patients with head and neck squamous cell carcinoma (HNSCC) usually have a history of tobacco and alcohol abuse. These 2 intoxications not only are main oncologic risk factors but also show a strong causal relationship with certain comorbid conditions. Examples are coronary artery disease, stroke, renal dysfunction, and heart failure, which are all proven major risk factors for an adverse postoperative outcome after stressful noncardiac surgery. Preoperative identification of these conditions could lead to preventive measures in patients with HNSCC that undergo extensive surgery. Preventing morbidity and mortality is of medical and economical importance. Methods. All comorbidity of 135 consecutive patients with HNSCC that underwent extensive oncologic and reconstructive surgery as the first form of treatment between 2001 and 2007 was investigated. Based on these data, a Lee Cardiac Risk Index (LCRI) Score and an overall Adult Comorbidity Evaluation (ACE-27) severity score were calculated. The predictive value of these scores and the American Society of Anesthesiologists' (ASA) classification toward major cardiovascular complication development were investigated. Major cardiovascular complications were defined as: cardiac death, nonfatal myocardial infarction, heart failure, and cardiac arrhythmias. The impact of these complications on duration of hospitalization, medical costs, and short-term mortality (defined as death within 6 months after primary tumor diagnosis) were investigated as well. The cardioprotective effect of preoperatively prescribed beta blockers and statins are discussed. Results. Twenty-two patients developed 23 major cardiovascular complications (16.3%). In univariate and multivariate analyses, a higher LCRI score was associated with an increased risk for major cardiovascular complications, as was an age >70 years (all values of p <.01). The area under the receiver operating characteristics (ROC) curve (AUC) for the multivariate model was 0.84, indicating a good prognostic value. In univariate and multivariate analysis, a higher ACE-27 score was associated with an increased risk for major cardiovascular complications, as was as age >70 years (all values of p <.01). The AUC for this model was 0.84, indicating a performance similar to that of the LCRI score model. No statistically significant results were found for the ASA scores (p =.38). Preoperative beta-blocker use showed a significant cardioprotective function in univariate analysis, whereas statins did not. The mean duration of hospitalization was prolonged by 7 days in patients with a major cardiovascular complication. In economic terms, this means a cost increase of at least 3500 euros. None of the patients died during admission because of a major cardiovascular complication. The short-term mortality rate was 11.1%, but no specific cardiovascular cause of death was reported in these patients. Conclusions. Prevention of major complication occurrence after extensive HNSCC surgery is of medical and economic importance. Our results show that the ACE-27 and the LCRI are suitable instruments for preoperative major cardiovascular complication risk assessment. Addition of the variable age >70 years shows an improvement in predictive value of both instruments. Because of its simplicity we advise the implementation of the LCRI into preoperative HNSCC screening protocols. We advise the exploration of low-dose long-acting beta blockers as a preventive treatment strategy.

Prevalence and characteristics of patients with clinical improvement but not significant left ventricular reverse remodeling after cardiac resynchronization therapy (Article)

2010-10-01T00:00:00Z

Background: Although most patients who improve in clinical status after cardiac resynchronization therapy (CRT) also show a significant left ventricular (LV) reverse remodeling, some patients do not show echocardiographic improvement. The aim of the present study was to evaluate the degree of agreement between clinical and echocardiographic response to CRT in a large cohort of heart failure patients, and to evaluate the characteristics of patients with clinical response but without echocardiographic response. Methods: In 440 consecutive heart failure patients (mean age 66 ± 11 years, 81% men) treated with CRT, agreement between clinical and echocardiographic responses at 6 months of follow-up were evaluated. The combined clinical response was defined as: >1-point New York Heart Association functional class improvement or >15% increase in 6-minute walk test. Echocardiographic response was defined by a reduction in LV end-systolic volume (LVESV) >15%. Results: At 6 months of follow-up, clinical response was observed in 84% (n = 370) of the patients. Significant reduction in LVESV was noted in 63% (n = 276). The majority of patients who improved clinically did show LV reverse remodeling (72%, n = 268). Importantly, 28% (n = 102) of patients who improved clinically did not show significant LV reverse remodeling. The patients with clinical response but without echocardiographic response had more often ischemic heart failure as compared to patients with positive clinical and echocardiographic response (69.6% vs 57.5%; P = .021). Moreover, patients with such discordant responses had more narrow QRS complex (148 ± 31 vs 159 ± 31 milliseconds; P = .004), and showed less LV dyssynchrony than patients with concordant positive responses (90 ± 77 vs 171 ± 105 milliseconds; P < .001). Conclusions: Although there is a good concordance between echocardiographic and clinical response to CRT, up to 28% of the population experienced clinical response without significant LV reverse remodeling. Subjects with such discrepant responses have more frequently ischemic heart failure and show more narrow QRS complex and less LV dyssynchrony than patients with both clinical and echocardiographic response.

Prognosis of Vascular Surgery Patients Using a Quantitative Assessment of Troponin T Release: Is the Crystal Ball still Clear? (Article)

2010-09-29T00:00:00Z

Background: Cardiac troponin T (cTnT) assays with increased sensitivity might increase the number of positive tests. Using the area under the curve (AUC) with serial sampling of cTnT an exact quantification of the myocardial damage size can be made. We compared the prognosis of vascular surgery patients with integrated cTnT-AUC values to continuous and standard 12-lead electrocardiography (ECG) changes. Methods: 513 Patients were monitored. cTnT sampling was performed on postoperative days 1, 3, 7, 30 and/or at discharge or whenever clinically indicated. If cTnT release occurred, daily measurements of cTnT were performed, until baseline was achieved. CTnT-AUC was quantified and divided in tertiles. All-cause mortality and cardiovascular events (cardiac death and myocardial infarction) were noted during follow-up. Results: 81/513 (16%) Patients had cTnT release. After adjustment for gender, cardiac risk factors, and site and type of surgery, those in the highest cTnT-AUC tertile were associated with a significantly worse cardiovascular outcome and long-term mortality (HR 20.2; 95% CI 10.2-40.0 and HR 4.0; 95% CI 2.0-7.8 respectively). Receiver operator analysis showed that the best cut-off value for cTnT-AUC was <0.01 days*ng m for predicting long-term cardiovascular events and all-cause mortality. Conclusion: In vascular surgery patients quantitative assessment of cTnT strongly predicts long-term outcome.

Influence of left ventricular dysfunction (Diastolic Versus Systolic) on long-term prognosis in patients with versus without diabetes mellitus having elective peripheral arterial surgery (Article)

2010-09-15T00:00:00Z

Diabetes mellitus (DM) and left ventricular dysfunction (LVD) are often coexistent and invariably associated with increased mortality. Data on long-term prognosis of "isolated" diastolic LVD in diabetics are lacking; therefore, we evaluated these prognostic implications in patients with peripheral arterial disease (PAD) and DM. Using echocardiography, 1321 patients were screened for diastolic, systolic (ejection fraction <50%) or combined LVD. Diastolic LVD was diagnosed based on the ratio of early rapid filling to late filling due to atrial contraction, pulmonary vein flow, and deceleration time. Patients using glucose-lowering drugs or insulin or with a fasting glucose level >6.1 mmol/L were diagnosed with DM. The primary end point was occurrence of cardiovascular death during a mean follow-up of 2.5 ± 1.9 years. In the total population, DM was diagnosed in 518 patients (39%), and diastolic, systolic, or combined LVD was present in 356 patients (27%), 102 patients (8%), or 156 patients (12%), respectively. In diabetic patients, diastolic and systolic LVDs were associated with increased cardiovascular mortality (hazard ratio 1.8, 95% confidence interval 1.03 to 3.03; hazard ratio 3.1, 95% confidence interval 1.46 to 6.38). In nondiabetic patients, the same association between diastolic or systolic LVD and outcome was observed (hazard ratio 2.2, 95% confidence interval 1.30 to 3.74; hazard ratio 3.9, 95% confidence interval 2.00 to 7.52). Combined systolic and diastolic LVD had the worst prognosis. In conclusion, diabetic patients with PAD have an increased prevalence of isolated systolic and combined LVD. In patients with PAD the presence of isolated diastolic, systolic, or combined LVD was independently and equally associated with increased cardiovascular mortality, irrespective of the concomitant presence of DM.

Smoking Cessation has no Influence on Quality of Life in Patients with Peripheral Arterial Disease 5 Years Post-vascular Surgery (Article)

2010-09-01T00:00:00Z

Objectives: Smoking is an important modifiable risk factor in patients with peripheral arterial disease (PAD). We investigated differences in quality of life (QoL) between patients who quitted smoking during follow-up and persistent smokers. Design: Cohort study. Methods: Data of 711 consecutively enrolled patients undergoing vascular surgery were collected in 11 hospitals in the Netherlands. Smoking status was obtained at baseline and at 3-year follow-up. A 5-year follow-up to measure QoL was performed with the EuroQol-5D (EQ-5D) and Peripheral Arterial Questionnaire (PAQ). Results: After adjusting for clinical risk factors, patients, who quit smoking within 3 years after vascular surgery, did not report an impaired QoL (EQ-5D: odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.28-1.43; PAQ: OR = 0.76, 95% CI = 0.35-1.65; visual analogue scale (VAS): OR = 0.88, 95% CI = 0.42-1.84) compared with patients, who continued smoking. Current smokers were significantly more likely to have an impaired QoL (EQ-5D: OR = 1.86, 95% CI = 1.09-3.17; PAQ: OR = 1.63, 95% CI = 1.00-2.65), although no differences in VAS scores were found (OR = 1.17, 95% CI = 0.72-1.90). Conclusions: There was no effect of smoking cessation on QoL in PAD patients undergoing vascular surgery. Nevertheless, given the link between smoking, complications and mortality in this patient group, smoking cessation should be a primary target in secondary prevention.

Response to comment on: Perioperative Blood Glucose Monitoring and Control in Major Vascular Surgery Patients (Article)

2010-09-01T00:00:00Z

Safety of fluvastatin in patients undergoing high-risk non-cardiac surgery (Article)

2010-09-01T00:00:00Z

Importance of the field: In patients undergoing vascular surgery there is a high incidence of adverse cardiac events, due to sudden coronary plaque rupture. The non-lipid lowering or pleiotropic effects of statins can help reduce adverse cardiovascular events associated with vascular surgery. Areas covered in this review: The evidence for perioperative use of fluvastatin, as well as other statins, in high-risk surgery patients is summarized in this review. Data on pharmacokinetics and metabolism is presented, together with considerations on possible drug interactions in the perioperative period. What the reader will gain: The reader will gain a comprehensive understanding of the existing safety and efficacy data for fluvastatin and other statins in the perioperative period. The practical considerations of perioperative fluvastatin therapy will be presented, including potential side-effects and management of the early non-oral phase immediately post surgery. Finally, advice on when to initiate therapy and safety recommendations are offered. Take home message: In patients scheduled for high-risk vascular surgery, fluvastatin improves postoperative outcome, reducing the incidence of myocardial damage by ∼ 50% in the first 30 days following vascular surgery. In comparison with placebo, fluvastatin was not associated with a rise in liver enzymes or creatine kinase levels. To bridge the non-oral phase, an extended-release formula is recommended.

Screening value of N-terminal pro-B-type natriuretic peptide as a predictor of perioperative cardiac events after noncardiac surgery (Article)

2010-09-01T00:00:00Z

Preoperative cardiac risk assessment is the cornerstone of rationale perioperative management that guides invasive surgical interventions. In addition to clinical risk factors, a simple screening biomarker would be useful for identifying those surgical patients who might benefit from additional cardiac testing or therapeutic interventions. Preoperative plasma levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) are predictors of cardiac events after noncardiac surgery. NT-proBNP is synthesized in the ventricular myocardium in response to ventricular wall stress. To further increase the diagnostic accuracy of NT-proBNP for preoperative screening, it is important to identify confounding factors that influence NT-proBNP levels and their interaction with identifying risks for adverse cardiac events. Moreover, until now the available data from previous studies has been unable to consistently recognize the optimal discriminatory threshold for NT-proBNP. Currently, the ongoing DECREASE-VI study is conducted to evaluate whether current preoperative risk stratification can be improved by incorporating NT-proBNP measurements.

The efficacy and safety of clopidogrel in vascular surgery patients with immediate postoperative asymptomatic troponin T release for the prevention of late cardiac events: Rationale and design of the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo-VII (DECREASE-VII) trial (Article)

2010-09-01T00:00:00Z

Background: Major vascular surgery patients are at high risk for developing asymptomatic perioperative myocardial ischemia reflected by a postoperative troponin release without the presence of chest pain or electrocardiographic abnormalities. Long-term prognosis is severely compromised and characterized by an increased risk of long-term mortality and cardiovascular events. Current guidelines on perioperative care recommend single antiplatelet therapy with aspirin as prophylaxis for cardiovascular events. However, as perioperative surgical stress results in a prolonged hypercoagulable state, the postoperative addition of clopidogrel to aspirin within 7 days after perioperative asymptomatic cardiac ischemia could provide improved effective prevention for cardiovascular events. Study design: DECREASE-VII is a phase III, randomized, double-blind, placebo-controlled, multicenter clinical trial designed to evaluate the efficacy and safety of early postoperative dual antiplatelet therapy (aspirin and clopidogrel) for the prevention of cardiovascular events after major vascular surgery. Eligible patients undergoing a major vascular surgery (abdominal aorta or lower extremity vascular surgery) who developed perioperative asymptomatic troponin release are randomized 1:1 to clopidogrel or placebo (300-mg loading dose, followed by 75 mg daily) in addition to standard medical treatment with aspirin. The primary efficacy end point is the composite of cardiovascular death, stroke, or severe ischemia of the coronary or peripheral arterial circulation leading to an intervention. The evaluation of long-term safety includes bleeding defined by TIMI criteria. Recruitment began early 2010. The trial will continue until 750 patients are included and followed for at least 12 months. Summary: DECREASE-VII is evaluating whether early postoperative dual antiplatelet therapy for patients developing asymptomatic cardiac ischemia after vascular surgery reduces cardiovascular events with a favorable safety profile.

Process of Care Partly Explains the Variation in Mortality Between Hospitals After Peripheral Vascular Surgery (Article)

2010-08-01T00:00:00Z

Objectives: The aim of this study is to investigate whether variation in mortality at hospital level reflects differences in quality of care of peripheral vascular surgery patients. Design: Observational study. Materials: In 11 hospitals in the Netherlands, 711 consecutive vascular surgery patients were enrolled. Methods: Multilevel logistic regression models were used to relate patient characteristics, structure and process of care to mortality at 1 year. The models were constructed by consecutively adding age, sex and Lee index, then remaining risk factors, followed by structural measures for quality of care and finally, selected process of care parameters. Results: Total 1-year mortality was 11%, ranging from 6% to 26% in different hospitals. Large differences in patient characteristics and quality indicators were observed between hospitals (e.g., age > 70 years: 28-58%; beta-blocker therapy: 39-87%). Adjusted analyses showed that a large part of variation in mortality was explained by age, sex and the Lee index (Akaike's information criterion (AIC) = 59, p< 0.001). Another substantial part of the variation was explained by process of care (AIC = 5, p=0.001). Conclusions: Differences between hospitals exist in patient characteristics, structure of care, process of care and mortality. Even after adjusting for the patient population at risk, a substantial part of the variation in mortality can be explained by differences in process measures of quality of care.

Influence of polyvascular disease on cardiovascular event rates. Insights from the REACH registry (Article)

2010-08-01T00:00:00Z

Cardiovascular event rates have been shown to increase substantially with the number of symptomatic disease locations. We sought to assess the risk profile, management and subsequent event rates of polyvascular disease patients. Consecutive outpatients were assessed for atherosclerotic risk factors and medications in the REACH Registry. A total of 19,117 symptomatic patients in Europe completed a 2-year follow-up: 77.2% with single arterial bed disease (coronary artery or cerebrovascular or peripheral arterial disease) and 22.8% with polyvascular disease (≥ 1 disease location). Polyvascular disease patients were older (68.5 ± 9.4 vs 66.3 ± 9.9 years, p < 0.0001), more often current or former smokers (64.9% vs 58.7%, p < 0.0001), and more often suffered from hypertension (59.5% vs 46.6%, p < 0.0001) and diabetes (34.5% vs 25.9%, p < 0.0001) than single arterial bed disease patients. Despite more intense medical therapy, risk factors (smoking, hypertension, low fasting glucose, and low fasting total cholesterol) were less often controlled in polyvascular disease patients. This was associated with substantially more events over 2 years compared with single arterial bed disease patients (cMACCE [cardiovascular death/non-fatal stroke/non-fatal MI] odds ratio, 1.63 [95% CI, 1.45-1.83], p < 0.0001). In conclusion, polyvascular disease patients have more cardiovascular risk factors, and the prognosis for these patients is significantly worse than for patients with single arterial bed disease. This suggests a need to improve detection and consequent medical treatment of polyvascular disease.

Detection of coronary artery disease in patients with a permanent pacemaker (Article)

2010-08-01T00:00:00Z

Elevated Preoperative Phosphorus Levels Are an Independent Risk Factor for Cardiovascular Mortality (Article)

2010-07-01T00:00:00Z

Background/Aims: Serum phosphorus levels have been associated with adverse long-term outcome in several populations, however, no prior studies evaluated short-term postoperative outcome. The present study evaluated the predictive value of phosphorus levels on 30-day outcome after vascular surgery. Methods: The study included patients scheduled for major vascular surgery (aortic aneurysm repair, lower extremity revascularization or carotid surgery), divided into four quartiles based on the preoperative fasting phosphorus level. The endpoints of the analyses were all-cause and cardiovascular mortality during the first 30 postoperative days and during long-term follow-up (median 3.6 years, interquartile range 1.8-8.0). Results: Prior to surgery, 1,798 patients were categorized into the following quartiles: <2.9 mg/dl (n = 459), 2.9-3.4 mg/dl (n = 456), 3.4-3.8 mg/dl (n = 444) and >3.8 mg/dl (n = 439), respectively. During the first 30 postoperative days, 81 (4.5%) patients died of which 66 (81%) secondary to a cardiovascular cause. In multivariate analyses, an independent association was observed between phosphorus level >3.8 mg/dl and all-cause (OR 2.53, 95% CI 1.2-5.4) or cardiovascular mortality (OR 2.37, 95% CI 1.1-5.7). Baseline serum phosphorus >3.8 mg/dl was also significantly associated with long-term all-cause mortality (HR 1.38, 95% CI 1.1-1.7). Conclusions: Preoperative elevated serum phosphorus demonstrated an independent relationship with the occurrence of all-cause and cardiovascular mortality during the first 30 days after major vascular surgery. In addition, an elevated serum phosphorus was independently associated with long-term mortality.

Predicting Patient-Specific Expansion of Abdominal Aortic Aneurysms (Article)

2010-07-01T00:00:00Z

Objective: Local anatomy and the patient's risk profile independently affect the expansion rate of an abdominal aortic aneurysm. We describe a hybrid method that combines finite element modelling and statistical methods to predict patient-specific aneurysm expansion. Methods: The 3-D geometry of the aneurysm was imaged with computed tomography. We used finite element methods to calculate wall stress and aneurysm expansion. Expansion rate was adjusted by risk factors obtained from a database of 80 patients. Aneurysm diameters predicted with and without the risk profiles were compared with diameters measured with ultrasound for 11 patients. Results: For this specific group of patients, local anatomy contributed 62% and the risk profile 38% to the aneurysmal expansion rate. Predictions with risk profiles resulted in smaller root mean square errors than predictions without risk profiles (2.9 vs. 4.0 mm, p < 0.01). Conclusions: This hybrid approach predicted aneurysmal expansion for a period of 30 months with high accuracy.

Perioperative Cardiac Damage in Vascular Surgery Patients (Article)

2010-07-01T00:00:00Z

Background: Patients undergoing vascular surgery are at increased risk for developing cardiac complications. Majority of patients with perioperative myocardial damage are asymptomatic. Our objective is to review the available literature addressing the prevalence and prognostic implications of perioperative myocardial damage in vascular surgery patients. Methods: An Internet-based literature search was performed using MEDLINE to identify all published reports on perioperative myocardial damage in vascular surgery patients. Only those studies published from 2000 to 2010 evaluating myocardial damage using troponin I or T, with or without symptoms of angina pectoris were included. Results: Thirteen studies evaluating the prevalence of perioperative myocardial ischaemia or infarction were included in the study. The incidence of perioperative myocardial ischaemia ranged from 14% to 47% and the incidence of perioperative myocardial infarction ranged from 1% to 26%. In addition, 10 studies evaluating the prognostic value of perioperative myocardial ischaemia towards postoperative mortality or the occurrence of major adverse cardiac events were included. In the retrieved studies, hazard ratios varied from 1.9 to 9.0. Conclusion: The high prevalence and asymptomatic nature of perioperative myocardial damage, combined with a substantial influence on postoperative mortality of vascular surgery patients, underline the importance of early detection and adequate management of perioperative myocardial damage.This article provides an extended overview regarding the prevalence and prognostic value of perioperative myocardial ischaemia and infarction in vascular surgery patients. In addition, treatment options to reduce the risk of perioperative myocardial damage are provided based on the current available literature.

Prognosis of Atrial Fibrillation in Patients with Symptomatic Peripheral Arterial Disease: Data from the REduction of Atherothrombosis for Continued Health (REACH) Registry (Article)

2010-07-01T00:00:00Z

Background: Atrial fibrillation (AF) is a significant risk factor for cardiovascular (CV) mortality. This study aims to evaluate the prognostic implication of AF in patients with peripheral arterial disease (PAD). Methods: The International Reduction of Atherothrombosis for Continued Health (REACH) Registry included 23,542 outpatients in Europe with established coronary artery disease, cerebrovascular disease (CVD), PAD and/or ≥3 risk factors. Of these, 3753 patients had symptomatic PAD. CV risk factors were determined at baseline. Study end point was a combination of cardiac death, non-fatal myocardial infarction (MI) and stroke (CV events) during 2 years of follow-up. Cox regression analysis adjusted for age, gender and other risk factors (i.e., congestive heart failure, coronary artery re-vascularisation, coronary artery bypass grafting (CABG), MI, hypertension, stroke, current smoking and diabetes) was used. Results: Of 3753 PAD patients, 392 (10%) were known to have AF. Patients with AF were older and had a higher prevalence of CVD, diabetes and hypertension. Long-term CV mortality occurred in 5.6% of patients with AF and in 1.6% of those without AF (p<0.001). Multivariable analyses showed that AF was an independent predictor of late CV events (hazard ratio (HR): 1.5; 95% confidence interval (CI): 1.09-2.0). Conclusion: AF is common in European patients with symptomatic PAD and is independently associated with a worse 2-year CV outcome.

The management of combined coronary artery disease and peripheral vascular disease (Article)

2010-07-01T00:00:00Z

Coronary artery disease (CAD) and peripheral vascular disease (PVD) remain highly prevalent in the population due to population ageing, smoking, diabetes, unhealthy lifestyles, and the epidemic of obesity, and frequently coexist. The management of combined CAD and PVD is a common challenge and brings with it numerous clinical dilemmas. The goal of this article is to review the prevalence of PVD and its major impact upon prognosis in patients with known CAD and in turn to review the impact of CAD upon the prognosis of patients with PVD. This review will also highlight issues related to the peri-operative evaluation and management of patients going to vascular surgery, including medical optimization as well as the performance and timing of coronary revascularization. Published on behalf of the European Society of Cardiology. All rights reserved.

Temporary perioperative decline of renal function is an independent predictor for chronic kidney disease (Article)

2010-07-01T00:00:00Z

Background and objectives: Acute kidney injury is an independent predictor of short- and long-term survival; however, data on the relationship between reversible transitory decline of kidney function and chronic kidney disease (CKD) are lacking. We assessed the prognostic value of temporary renal function decline on the development of long-term CKD. Design, setting, participants, & measurements: The study included 1308 patients who were undergoing major vascular surgery (aortic aneurysm repair, lower extremity revascularization, or carotid surgery), divided into three groups on the basis of changes in Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated GFR (eGFR) on days 1, 2, and 3 after surgery, compared with baseline: Group 1, improved or unchanged (change in CKD-EPI eGFR ±10%); group 2, temporary decline (decline >10% at day 1 or 2, followed by complete recovery within 10% to baseline at day 3); and group 3, persistent decline (>10% decrease). Primary end point was the development of incident CKD during a median follow-up of 5 years. Results: Perioperative renal function was classified as unchanged, temporary decline, and persistent decline in 739 (57%), 294 (22%), and 275 (21%) patients, respectively. During follow-up, 272 (21%) patients developed CKD. In multivariate logistic regression analyses, temporary and persistent declines in renal function both were independent predictors of long-term CKD, compared with unchanged renal function. Conclusion: Vascular surgery patients have a high incidence of temporary and persistent perioperative renal function declines, both of which were independent predictors for development of long-term incident CKD. Copyright

Preoperative evaluation of patients with possible coronary artery disease (Article)

2010-07-01T00:00:00Z

During noncardiac surgery, patients may be at risk for developing cardiac events, related to underlying coronary artery disease. Therefore, perioperative cardiac complications remain an area of clinical interest and concern in patients undergoing noncardiac surgery. Over the years, perioperative risk assessment has evolved significantly to detect surgical patients with myocardium at risk due the coronary artery disease. In addition, many efforts have been made to reduce the cardiac risk of patients undergoing noncardiac surgery. The present review article will focus on the definition of high cardiac risk surgery and will discuss patient-related cardiac risk factors. In addition, the preoperative cardiac tests available to detect patients with coronary artery disease and strategies to reduce perioperative cardiac risk, as recommended in most recent perioperative guidelines, will be outlined.

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.

Risk factors and outcome of new-onset cardiac arrhythmias in vascular surgery patients (Article)

2010-06-01T00:00:00Z

Background: The pathophysiology of new-onset cardiac arrhythmias is complex and may bring about severe cardiovascular complications. The relevance of perioperative arrhythmias during vascular surgery has not been investigated. The aim of this study was to assess risk factors and prognosis of new-onset arrhythmias during vascular surgery. Methods: A total of 513 vascular surgery patients, without a history of arrhythmias, were included. Cardiac risk factors, inflammatory status, and left ventricular function (LVF; N-terminal pro-B-type natriuretic peptide and echocardiography) were assessed. Continuous electrocardiography (ECG) recordings for 72 hours were used to identify ischemia and new-onset arrhythmias: atrial fibrillation, sustained ventricular tachycardia, supraventricular tachycardia, and ventricular fibrillation. Logistic regression analysis was applied to identify preoperative risk factors for arrhythmias. Cox regression analysis assessed the impact of arrhythmias on cardiovascular event-free survival during 1.7 years. Results: New-onset arrhythmias occurred in 55 (11%) of 513 patients: atrial fibrillation, ventricular tachycardia, supraventricular tachycardia, and ventricular fibrillation occurred in 4%, 7%, 1%, and 0.2%, respectively. Continuous ECG showed myocardial ischemia and arrhythmias in 17 (3%) of 513 patients. Arrhythmia was preceded by ischemia in 10 of 55 cases. Increased age and reduced LVF were risk factors for the development of arrhythmias. Multivariate analysis showed that perioperative arrhythmias were associated with long-term cardiovascular events, irrespective of the presence of perioperative ischemia (hazard ratio 2.2, 95% CI 1.3-3.8, P = .004). Conclusion: New-onset perioperative arrhythmias are common after vascular surgery. The elderly and patients with reduced LVF show arrhythmias. Perioperative continuous ECG monitoring helps to identify this high-risk group at increased risk of cardiovascular events and death.

Metabolic syndrome is an independent predictor of cardiovascular events in high-risk patients with occlusive and aneurysmatic peripheral arterial disease (Article)

2010-06-01T00:00:00Z

Objective: Metabolic syndrome (MetSyn) is a well-known risk factor for cardiovascular (CV) disease in the general population; however, the additional predictive value for CV events in high-risk patients with peripheral arterial disease (PAD) is unknown. The aims of the current study were to assess and compare: (1) prevalence of MetSyn, and (2) predictive value of MetSyn for CV events, in patients with either occlusive or aneurysmatic PAD. Methods: We screened 2069 patients scheduled for lower occlusive arterial revascularization (n=1031) or abdominal aortic aneurysm repair (n=1038) for the presence of MetSyn. Adult Treatment Panel III report (ATP III) was used for defining MetSyn. Central obesity was defined as body-mass-index >30kg/m2. Main outcomes were the occurrence of CV events and CV mortality during a median follow-up of 6 years (IQR 2-9 years). Results: Metabolic syndrome was diagnosed in 421 (41%) and 432 (42%) patients with occlusive and aneurysmatic PAD, respectively (p= 0.72). Patients with occlusive or aneurysmatic PAD and MetSyn had an increased risk for the development of CV events, when compared to patients without MetSyn (27% vs. 18% and 27% vs. 19%, p<. 0.001, respectively). In occlusive and aneurysmatic PAD, MetSyn was independently associated with an increased risk of CV events (HR = 1.6; 95%CI 1.2-2.1 and HR = 1.4; 95%CI 1.1-1.8). No significant association between the presence of MetSyn and CV mortality was observed. Conclusions: Metabolic syndrome is highly prevalent in high-risk PAD patients. In occlusive and aneurysmatic PAD patients, MetSyn is an independent predictor of long-term CV events.

Prognostic implications of asymptomatic left ventricular dysfunction in patients undergoing vascular surgery (Article)

2010-06-01T00:00:00Z

Background: The prognostic value of heart failure symptoms on postoperative outcome is well acknowledged in perioperative guidelines. The prognostic value of asymptomatic left ventricular (LV) dysfunction remains unknown. This study evaluated the prognostic implications of asymptomatic LV dysfunction in vascular surgery patients assessed with routine echocardiography. Methods: Echocardiography was performed preoperatively in 1,005 consecutive vascular surgery patients. Systolic LV dysfunction was defined as LV ejection fraction less than 50%. Ratio of mitral-peak velocity during early and late filling, pulmonary vein flow, and deceleration time was used to diagnose diastolic LV dysfunction. Troponin-T measurements and electrocardiograms were performed routinely perioperatively. Multivariate regression analyses evaluated the relation between LV function and the study endpoints, 30-day cardiovascular events, and long-term cardiovascular mortality. Results: Left ventricular dysfunction was diagnosed in 506 (50%) patients of which 80% were asymptomatic. In open vascular surgery (n = 649), both asymptomatic systolic and isolated diastolic LV dysfunctions were associated with 30-day cardiovascular events (odds ratios 2.3, 95% confidence interval [CI] 1.4-3.6 and 1.8, 95% CI 1.1-2.9, respectively) and long-term cardiovascular mortality (hazard ratios 4.6, 95% CI 2.4-8.5 and 3.0, 95% CI 1.5-6.0, respectively). In endovascular surgery (n = 356), only symptomatic heart failure was associated with 30-day cardiovascular events (odds ratio 1.8, 95% CI 1.1-2.9) and long-term cardiovascular mortality (hazard ratio 10.3, 95% CI 5.4-19.3). Conclusions: This study demonstrated that asymptomatic LV dysfunction is predictive for 30-day and long-term cardiovascular outcome in open vascular surgery patients. These data suggest that preoperative risk stratification should include not only solely heart failure symptoms but also routine preoperative echocardiography to risk stratify open vascular surgery patients. Copyright

The prevalence and prognostic implications of polyvascular atherosclerotic disease in patients with chronic kidney disease (Article)

2010-06-01T00:00:00Z

Background. Atherosclerotic disease is often extended to multiple affected vascular beds (AVB). Polyvascular disease (PVD) and chronic kidney disease (CKD) have both separately been associated with an adverse cardiovascular outcome. We assessed the prevalence of PVD in vascular surgery patients with preoperative CKD and studied the influence on long-term cardiovascular survival.Methods. Consecutive patients (2933) were preoperatively screened for PVD, defined as 1-, 2-or 3-AVB. Preoperative glomerular filtration rate (GFR in ml/min/1.73 m2body-surface area) was estimated by the Modification of Diet in Renal Disease (MDRD) prediction equation, and patients were categorized according their estimated GFR. Primary end point was (cardiovascular) mortality during a median follow-up of 6.0 years (IQR 2-9).Results. Preoperative MDRD-GFR was classified as normal kidney function (GFR ≥ 90) or mild (GFR 60-89), moderate (GFR 30-59) and severe (GFR < 30) kidney disease in 779 (27%), 1423 (48%), 605 (21%) and 124 (4%) patients, respectively. One-vessel disease was present in 54% of the patients with normal kidney function, while 62% of the patients with CKD (GFR < 60) had PVD. In patients with moderate or severe kidney disease, the presence of PVD was independently associated with even higher cardiovascular mortality rates (2-AVB: HR 1.65 95%CI 1.09-2.48; 3-AVB: 2.07 95%CI 1.08-3.99), compared to 1-AVB.Conclusion. Patients with CKD had a high prevalence of PVD, which was independently associated with increased all-cause and cardiovascular mortality.

Health-related quality of life predicts long-term survival in patients with peripheral artery disease (Article)

2010-06-01T00:00:00Z

We examined whether health-related quality of life (HRQoL) predicts long-term survival in patients with peripheral artery disease (PAD) independent of established prognostic risk factors. In 2004, data on 711 consecutive patients with PAD undergoing vascular surgery were collected from 11 hospitals in The Netherlands. After 1 year, patients were contacted to complete the EuroQol Questionnaire (EQ-5D), of which 503 complied. HRQoL assessed by the EQ-5D was divided into tertiles (i.e. poor, intermediate and good HRQoL). Mortality was subsequently assessed 3 years after surgery. Of the 503 patients, 55 (11%) patients died during follow-up. Mortality was 21% in patients with poor HRQoL, 8% in patients with intermediate HRQoL, and 5% in patients with good HRQoL. Patients with poor HRQoL (HR = 5.4; 95% CI 2.3-12.5) had a worse survival compared to patients with a good HRQoL, after adjusting for established prognostic factors. In conclusion, the study indicates that poor HRQoL predicts long-term survival in patients with PAD, and provides prognostic value above established risk factors.

Postoperative mortality in the Netherlands: A population-based analysis of surgery-specific risk in sdults (Article)

2010-05-01T00:00:00Z

BACKGROUND: Few data are available that systematically describe rates and trends of postoperative mortality for fairly large, unselected patient populations. METHODS: This population-based study uses a registry of 3.7 million surgical procedures in 102 hospitals in The Netherlands during 1991-2005. Patients older than 20 yr who underwent an elective, nonday case, open surgical procedure were enrolled. Patient data included main (discharge) diagnosis, secondary diagnoses, dates of admission and discharge, death during admission, operations, age, sex, and a limited number of comorbidities classified according to the International Classification of Diseases 9th revision Clinical Modification. The main outcome measure was postoperative all-cause mortality. Univariable and multivariable logistic regression analyses were applied to evaluate the relationship between type of surgery and the main outcome. RESULTS: Postoperative all-cause death was observed in 67,879 patients (1.85%). In a model based on a classification into 11 main surgical categories, breast surgery was associated with lowest mortality (adjusted incidence, 0.07%), and vascular surgery was associated with highest mortality (adjusted incidence, 5.97%). In a model based on 36 surgical subcategories, the adjusted mortality ranged from 0.07% for hernia nuclei pulposus surgery to 18.5% for liver transplant. The c-index of the 36-category model was 0.88, which was significantly (P < 0.001) higher than the c-index that was associated with the simple surgical classification (low vs. high risk) in the commonly used Revised Cardiac Risk Index (c-index, 0.83). CONCLUSIONS: This population-based study provided a detailed and contemporary overview of postoperative mortality for the entire surgical spectrum, which may act as reference standard for surgical outcome in Western populations. Copyright

Association of COPD with carotid wall intima-media thickness in vascular surgery patients (Article)

2010-05-01T00:00:00Z

Introduction: There is increasing evidence that non-invasive imaging modalities such as ultrasonography may be able to detect subclinical atherosclerotic lesions, and as such may be useful tools for risk-stratification. However, the clinical relevance of these observations remains unknown in patients with COPD. Therefore we investigated the association between COPD and carotid wall intima-media thickness (IMT) in patients undergoing vascular surgery and its relationship with mortality in these patients. Methods: Carotid wall IMT was measured in 585 patients who underwent lower extremity, aortic aneurysm or stenosis repair. Primary study endpoint was increased carotid wall IMT which was defined as IMT ≥ 1.25 mm. Secondary study endpoints included total and cardiovascular mortality over a mean follow-up of 1.5 years. Results: Thirty-two percent of patients with mild COPD and 36% of the patients with moderate/severe COPD had increased carotid wall IMT, while only 23% had an increased carotid wall IMT in patients without COPD (p < 0.01). COPD was independently associated with an increased carotid wall IMT (OR 1.60; 95% CI 1.08-2.36). Among patients with COPD, increased carotid wall IMT was associated with an increased risk of total (HR, 3.18 95% CI 1.93-5.24) and cardiovascular mortality (HR 7.28, 95% CI 3.76-14.07). Conclusions: COPD is associated with increased carotid wall IMT independent of age and smoking status. Increased carotid wall IMT is associated with increased total and cardiovascular mortality in patients with COPD suggesting that carotid wall measurements may be a good biomarker for morbidity and mortality in these patients.

Co-existence of COPD and left ventricular dysfunction in vascular surgery patients (Article)

2010-05-01T00:00:00Z

Background: The co-existence between chronic obstructive pulmonary disease (COPD) and heart failure has been previously described. However, the co-existence between COPD and subclinical left ventricular (LV) dysfunction, without the presence of heart failure symptoms, is less well understood. This study determined the relationship and clinical relevance of COPD and subclinical LV dysfunction in vascular surgery patients. Methods: 1005 consecutive vascular surgery patients were included in which COPD was determined using spirometry and LV function using echocardiography. Mild COPD was defined as FEV1≥ 80% of predicted + FEV1/FVC-ratio < 0.70. Moderate/severe COPD was defined as FEV1< 80% of predicted + FEV1/FVC-ratio < 0.70. Systolic LV dysfunction was defined as LV ejection fraction <50% and diastolic LV dysfunction was diagnosed based on E/A-ratio, pulmonary vein flow and deceleration time. Multivariate regression analyses were used to evaluate the impact of COPD and LV dysfunction on all-cause mortality. The mean follow-up time was 2.2 ± 1.8 years. Results: Both, mild and moderate/severe COPD were associated with increased risk for subclinical LV dysfunction with odds ratio of 1.6 (95%-CI = 1.1-2.3) and 1.7 (95%-CI = 1.2-2.4), respectively. Mild- or moderate/severe COPD in combination with LV dysfunction was associated with increased risk for all-cause mortality (mild: hazard ratio 1.7; 95%-CI = 1.1-3.6, moderate/severe: hazard ratio 2.5; 95%-CI = 1.5-4.7). Conclusions: COPD was associated with increased risk for subclinical LV dysfunction. COPD + subclinical LV dysfunction was associated with increased risk for all-cause mortality compared to patients with COPD + normal LV function. Echocardiography may be useful to detect subclinical cardiovascular disease and risk-stratify COPD patients undergoing vascular surgery.

Clinical review: Practical recommendations on the management of perioperative heart failure in cardiac surgery (Article)

2010-04-28T00:00:00Z

Acute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF, significant arrhythmias and valvular disease. Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high-risk surgery. EuroSCORE reliably predicts perioperative cardiovascular alteration in patients aged less than 80 years. Preoperative B-type natriuretic peptide level is an additional risk stratification factor. Aggressively preserving heart function during cardiosurgery is a major goal. Volatile anaesthetics and levosimendan seem to be promising cardioprotective agents, but large trials are still needed to assess the best cardioprotective agent(s) and optimal protocol(s). The aim of monitoring is early detection and assessment of mechanisms of perioperative cardiovascular dysfunction. Ideally, volume status should be assessed by 'dynamic' measurement of haemodynamic parameters. Assess heart function first by echocardiography, then using a pulmonary artery catheter (especially in right heart dysfunction). If volaemia and heart function are in the normal range, cardiovascular dysfunction is very likely related to vascular dysfunction. In treating myocardial dysfunction, consider the following options, either alone or in combination: low-to-moderate doses of dobutamine and epinephrine, milrinone or levosimendan. In vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure. Exclude hypovolaemia in patients under vasopressors, through repeated volume assessments. Optimal perioperative use of inotropes/vasopressors in cardiosurgery remains controversial, and further large multinational studies are needed. Cardiosurgical perioperative classification of cardiac impairment should be based on time of occurrence (precardiotomy, failure to wean, postcardiotomy) and haemodynamic severity of the patient's condition (crash and burn, deteriorating fast, stable but inotrope dependent). In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended. A ventricular assist device should be considered before end organ dysfunction becomes evident. Extra-corporeal membrane oxygenation is an elegant solution as a bridge to recovery and/or decision making. This paper offers practical recommendations for management of perioperative HF in cardiosurgery based on European experts' opinion. It also emphasizes the need for large surveys and studies to assess the optimal way to manage perioperative HF in cardiac surgery.

Long-term prognosis of patients with peripheral arterial disease with or without polyvascular atherosclerotic disease (Article)

2010-04-01T00:00:00Z

AimsPatients with peripheral atherosclerotic disease often have multiple affected vascular beds (AVB), however, data on long-term follow-up and medical therapy are scarce. We assessed the prevalence and prognostic implications of polyvascular disease on long-term outcome in symptomatic peripheral arterial disease (PAD) patients.Methods and resultsTwo thousand nine hundred and thirty-three consecutive patients were screened prior to surgery for concomitant documented cerebrovascular disease and coronary artery disease. The number of AVB was determined. Cardiovascular medication as recommended by guidelines was noted at discharge. Single, two, and three AVB were detected in 1369 (46), 1249 (43), and 315 (11) patients, respectively. During a median follow-up of 6 years, 1398 (48) patients died, of which 54 secondary to cardiovascular cause. After adjustment for baseline cardiac risk factors and discharge-medication, the presence of 2-AVB or 3-AVB was associated with all-cause mortality (HR 1.3 95 CI 1.2-1.5; HR 1.8 95 CI 1.5-2.2) and cardiovascular mortality (HR 1.5 95 CI 1.2-1.7; HR 2.0 95 CI 1.6-2.5) during long-term follow-up, respectively. Patients with 2-and 3-AVB received extended medical treatment compared with 1-AVB at the time of discharge.ConclusionPolyvascular atherosclerotic disease in PAD patients is independently associated with an increased risk for all-cause and cardiovascular mortality during long-term follow-up.

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

Relation between preoperative and intraoperative new wall motion abnormalities in vascular surgery patients: A transesophageal echocardiographic study (Article)

2010-03-01T00:00:00Z

Background: Coronary revascularization of the suspected culprit coronary lesion assessed by preoperative stress testing is not associated with improved outcome in vascular surgery patients. Methods: Fifty-four major vascular surgery patients underwent preoperative dobutamine echocardiography and intraoperative transesophageal echocardiography. The locations of left ventricular rest wall motion abnormalities and new wall motion abnormalities (NWMAs) were scored using a seven-wall model. During 30-day follow-up, postoperative cardiac troponin release, myocardial infarction, and cardiac death were noted. Results: Rest wall motion abnormalities were noted by dobutamine echocardiography in 17 patients (31%), and transesophageal echocardiography was noted in 16 (30%). NWMAs were induced during dobutamine echocardiography in 17 patients (31%), whereas NWMAs were observed by transesophageal echocardiography in 23 (43%), κ value = 0.65. Although preoperative and intraoperative rest wall motion abnormalities showed an excellent agreement for the location (κ value = 0.92), the agreement for preoperative and intraoperative NWMAs in different locations was poor (κ value = 0.26-0.44). The composite cardiac endpoint occurred in 14 patients (26%). Conclusions: There was a poor correlation between the locations of preoperatively assessed stress-induced NWMAs by dobutamine echocardiography and those observed intraoperatively using transesophageal echocardiography. However, the composite endpoint of outcome was met more frequently in relation with intraoperative NWMAs.

Prevalence and pharmacological treatment of left-ventricular dysfunction in patients undergoing vascular surgery (Article)

2010-03-01T00:00:00Z

AimsThis study evaluated the prevalence of left-ventricular (LV) dysfunction in vascular surgery patients and pharmacological treatment, according ESC guidelines.Methods and resultsEchocardiography was performed pre-operatively in 1005 consecutive patients. Left ventricular ejection fraction (LVEF) ≤50 defined systolic LV dysfunction. Diastolic LV dysfunction was diagnosed based on E/A-ratio, pulmonary vein flow, and deceleration time. Optimal pharmacological treatment to improve LV function was considered as: (i) angiotensin-blocking agent (ACE-I/ARB) in patients with LVEF ≤40; (ii) ACE-I/ARB and-blocker in patients with LVEF ≤40 + heart failure symptoms or previous myocardial infarction; and (iii) a diuretic in patients with symptomatic heart failure, regardless of LVEF. Left-ventricular dysfunction was present in 506 patients (50), of whom 209 (41) had asymptomatic diastolic LV dysfunction, 194 (39) had asymptomatic systolic LV dysfunction, and 103 (20) had symptomatic heart failure. Treatment with ACE-I/ARB and/or-blocker could be initiated/improved in 67 (34) of the 199 patients with (a)symptomatic LVEF ≤40. A diuretic could be initiated in 32 patients (31) with symptomatic heart failure (regardless of LVEF).ConclusionsThis study demonstrates a high prevalence of LV dysfunction in vascular surgery patients and under-utilization of ESC recommended pharmacological treatment. Standard pre-operative evaluation of LV function could be argued based on our results to reduce this observed care gap.

A comparative study of myocardial injury during conventional and endovascular aortic aneurysm repair: Measurement of cardiac troponin T and plasma cytokine release (Article)

2010-03-01T00:00:00Z

Background: Major aortic surgery results in significant haemodynamic and oxidative stress to the myocardium. Cytokine release is a major factor in causing cardiac injury during aortic surgery. Endovascular aortic aneurysm repair (EVAR) has the potential to reduce the severity of the ischaemia reperfusion syndrome and its systemic consequences. Aim: The aim of this study was to investigate the occurrence of myocardial injury during conventional and endovascular abdominal aortic aneurysm repair using measurement of the myocardial-specific protein, cardiac troponin T. Interleukin-6 was also measured in both groups and haemodynamic responses to surgery assessed. Methods: Nine consecutive patients undergoing conventional infra-renal aortic aneurysm surgery were compared with 13 patients who underwent EVAR. Patients were allocated on the basis of aneurysm morphology and suitability for endovascular repair. Results: Patients undergoing open repair had significantly more haemodynamic disturbance than those having endovascular repair (mean arterial pressure at 5 min following unclamping or balloon deflation: open (69.6 + 3.3 mmHg); endovascular (86 + 4.4 mmHg), P < 0.05 vs. pre-op). Troponin T levels at 48 h post-operatively were higher in patients who underwent open repair (open 0.164 + 0.1 ng/ml; endovascular 0.008 + 0.0005 ng/ml, P < 0.04). Significantly more patients in the open repair group had troponin T levels > 0.1 ng/l when compared with the endovascular group (P < 0.01, χ 2 test) Conclusion: Endovascular aortic surgery produces significantly less myocardial injury than the open technique of aortic aneurysm repair.

Comparing endovascular and open repair of abdominal aortic aneurysm [2] (Article)

2010-02-10T00:00:00Z

Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The task force for preoperative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery of the European society of Cardiology (ESC) and endorsed by the European society of anaesthesiology (ESA) (Article)

2010-02-01T00:00:00Z

The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines.

Sudden death during follow-up after new-onset ventricular tachycardias in vascular surgery patients (Article)

2010-01-01T00:00:00Z

Background: Vascular surgery patients are at increased risk for late sudden cardiac death. Identification of patients at risk during surgery offers the opportunity for focused therapy. Methods: We monitored 483 vascular surgery patients who had no documented history of arrhythmias to identify perioperative new-onset ventricular tachyarrhythmia (VT) and myocardial ischemia using a continuous electrocardiographic (ECG) device for 72 hours. Cardiac risk factors, left ventricular ejection fraction (LVEF), medical therapy, inflammation status, and perioperative ischemia in relation to arrhythmia were noted in all patients. During follow-up, event-based outcomes analysis was used to describe survival. Results: New-onset perioperative VT was detected in 33 patients (6.8%). A higher percentage of patients experiencing perioperative VT had reduced LVEF preoperatively than those without VT (24% vs 12%; P = .04). Additionally, fewer patients experiencing VT were receiving statins than those without (70% vs 85%; P = .02). Patients experiencing VT had a higher incidence of myocardial ischemia (30% vs 18%; P = .10). Perioperative VT was preceded by ischemia in only 60% of the cases. The overall cohort survival was 83% at 24-month follow-up (interquartile range [IQR], 1.1-1.3). Sudden cardiac death free survival among patients experiencing VT was less than in those without (79% vs 92%; P = .02). After adjusting for gender, cardiac risk factors, and type of surgery, new-onset perioperative VT was associated with sudden cardiac death (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.1-5.8). Conclusion: Perioperative VT is likely to be associated with late sudden cardiac death and decreased survival. Continuous perioperative ECG is an effective method to identify VT and may allow improved management of these patients.

Impact of Prophylactic β-Blocker Therapy to Prevent Stroke After Noncardiac Surgery (Article)

2010-01-01T00:00:00Z

β Blockers are widely used to improve the postoperative cardiac outcome in patients with coronary artery disease scheduled for noncardiac surgery. However, recently serious concerns regarding the safety of perioperative β blockers have emerged. To assess the incidence, risk factors, and β-blocker use associated with postoperative stroke in the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) trials, we evaluated all 3,884 patients of the DECREASE trials for postoperative stroke. All cardiac risk factors and medication use were assessed. The incidence of stroke within 30 days after surgery was recorded. The incidence of postoperative stroke in the DECREASE trials was 0.46% (18 of 3,884). For the β-blocker users, the incidence was 0.5%. All the strokes had an ischemic origin. A history of stroke was associated with a greater incidence of postoperative stroke (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.2 to 11.6). Statins and anticoagulants were not associated with postoperative stroke (OR 0.85, 95% CI 0.3 to 2.4; and OR 1.27, 95% CI 0.4 to 4.6, respectively). No association with bisoprolol therapy was found (OR 1.16, 95% CI 0.4 to 3.4). In conclusion, with a low-dose bisoprolol regimen started ≥30 days before surgery, no association was observed between β-blocker use and postoperative stroke.

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.

New Guidelines from the European Society of Cardiology for Perioperative Cardiac Care: A Summary of Implications for Elective Vascular Surgery Patients (Article)

2010-01-01T00:00:00Z

Asymptomatic Low Ankle-Brachial Index in Vascular Surgery Patients: A Predictor of Perioperative Myocardial Damage (Article)

2010-01-01T00:00:00Z

Objectives: This study evaluated the prognostic value of asymptomatic low ankle-brachial index (ABI) to predict perioperative myocardial damage, incremental to conventional cardiac risk factors imbedded in cardiac risk indices (Revised Cardiac index and Adapted Lee index). Materials and methods: Preoperative ABI measurements were performed in 627 consecutive vascular surgery patients (carotid artery or abdominal aortic aneurysm repair). An ABI < 0.90 was considered abnormal. Patients with ABI > 1.40 or (a history of) intermittent claudication were excluded. Serial troponin-T measurements were performed routinely before and after surgery. The main study endpoint was perioperative myocardial damage, the composite of myocardial ischaemia and infarction. Multivariate regression analyses, adjusted for conventional risk factors, evaluated the relation between asymptomatic low ABI and perioperative myocardial damage. Results: In total, 148 (23%) patients had asymptomatic low ABI (mean 0.73, standard deviation ± 0.13). Perioperative myocardial damage was recorded in 107 (18%) patients. Multivariate regression analyses demonstrated that asymptomatic low ABI was associated with an increased risk of perioperative myocardial damage (odds ratio (OR): 2.4, 95% CI: 1.4-4.2). Conclusions: This study demonstrated that asymptomatic low ABI has a prognostic value to predict perioperative myocardial damage in vascular surgery patients, incremental to risk factors imbedded in conventional cardiac risk indices.

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.

Prognosis of Transient New-Onset Atrial Fibrillation During Vascular Surgery (Article)

2009-12-01T00:00:00Z

Background: Chronic atrial fibrillation (AF) in a non-surgical setting is associated with cardiovascular events. However, the prognosis of transient new-onset AF during vascular surgery is unknown. Objective: The purpose of this study is to investigate the prognosis of new-onset AF during vascular surgery using continuous electrocardiographic monitoring (continuous-ECG). Methods: In this study, 317 patients, all in sinus rhythm, scheduled for major vascular surgery were screened for cardiac risk factors. Continuous-ECG recordings for 72 h and standard ECG on days 3, 7 and 30 were used to identify new-onset AF. Cardiac troponin T (cTnT) was measured routinely after surgery. Study endpoint was a composite of cardiac death, myocardial infarction, unstable angina and stroke (cardiovascular events) at 30 days after surgery and during late follow-up. Median follow-up was 12 (interquartile range 2-28) months. Results: New-onset AF was noted in 15 (4.7%) patients. All but three patients returned spontaneously to sinus rhythm. The composite endpoint of cardiovascular events within 30 days and during late follow-up occurred in 34 (11%) and 62 (20%) patients, respectively. Multivariate regression analysis showed that new-onset AF was associated with perioperative (hazard ratio (HR) 6.0; 95% CI: 2.4-15) and late cardiovascular events (HR 4.2, 95% CI: 2.1-8.8). Conclusion: New-onset AF during vascular surgery is associated with an increased incidence of 30-day and late cardiovascular events.

Reducing cardiac risk in non-cardiac surgery: Evidence from the DECREASE studies (Article)

2009-12-01T00:00:00Z

Ischaemic cardiac events are a major cause of perioperative morbidity and mortality in non-cardiac surgery; 10-40% of the perioperative deaths are due to myocardial infarction (MI). Drugs that influence myocardial oxygen balance (e.g. beta-blockers) or improve plaque stability (e.g. statins) would be expected to reduce perioperative MI. Evidence for the benefit of beta-blockers in high-risk patients undergoing non-cardiac surgery comes from various studies including the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) study, in which perioperative bisoprolol significantly reduced short- and long-term cardiac death and MI. DECREASE IV found that bisoprolol also significantly reduced 30-day cardiac death and MI in intermediate-risk patients, with a non-significant trend towards a beneficial effect of fluvastatin XL. DECREASE III showed that in high-risk patients undergoing major vascular surgery, fluvastatin XL reduced myocardial ischaemia and the combined endpoint of cardiovascular death and MI. DECREASE II showed that patients identified as intermediate risk on the basis of clinical assessment did not need pre-operative echocardiographic cardiac stress testing, provided that they received bisoprolol to maintain tight heart rate control. DECREASE V found that in high-risk patients with extensive stress-induced ischaemia, coronary revascularization (added to tight heart rate control with bisoprolol) did not produce any additional reduction in death and MI.

Remote ischemic preconditioning in vascular surgery patients: The additional value to medical treatment (Article)

2009-12-01T00:00:00Z

Lower levels of ADAMTS13 are associated with cardiovascular disease in young patients (Article)

2009-11-01T00:00:00Z

ADAMTS13 may play a role in arterial thrombosis by cleaving the highly active and thrombogenic ultralarge Von Willebrand Factor (VWF) multimers into less active VWF multimers. The aim was to investigate the relationship between plasma levels of ADAMTS13, VWF and genetic variation in the ADAMTS13 gene with cardiovascular disease. We performed a case-control study in 374 patients with a first-ever arterial thrombosis before the age of 45 years in males and 55 years in women. We included 218 patients with coronary heart disease (CHD), 109 patients with ischemic stroke (IS) and 47 patients with peripheral arterial disease (PAD) and 332 healthy population-based controls. ADAMTS13 and VWF levels were measured 1-3 months after the event. ADAMTS13 levels were associated with cardiovascular disease (OR antigen 5.1 (95% CI 3.1-8.5, p < 0.001) and OR activity 4.4 (95% CI 2.5-7.5, p < 0.001), in the lowest quartiles). VWF levels were associated with cardiovascular disease (OR antigen 2.1 (95% CI 1.3-3.3, p = 0.001) and OR activity 2.0 (95% CI 1.3-3.1, p = 0.003), in the highest quartile). Patients with combined low ADAMTS13 levels and high VWF levels had an odds ratio of 7.7 (95% CI 3.3-17.7) (p for trend <0.0001). No association was found between genetic variation in the ADAMTS13 gene with levels of ADAMTS13 or with risk of cardiovascular disease. In conclusion, levels of ADAMTS13 and VWF are strongly associated with the risk of cardiovascular disease.

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.

The interrelationship between preoperative anemia and N-terminal pro-B-type natriuretic peptide: The effect on predicting postoperative cardiac outcome in vascular surgery patients (Article)

2009-11-01T00:00:00Z

INTRODUCTION: N-terminal pro-B-type natriuretic peptide (NT-proBNP) predicts adverse cardiac outcome in patients undergoing vascular surgery. However, several conditions might influence this prognostic value, including anemia. In this study, we evaluated whether anemia confounds the prognostic value of NT-proBNP for predicting cardiac events in patients undergoing vascular surgery. METHODS:: A detailed cardiac history, resting echocardiography, and hemoglobin and NT-proBNP levels were obtained in 666 patients before vascular surgery. Anemia was defined as serum hemoglobin <13 g/dL for men and <12 g/dL for women. Troponin T measurements and 12-lead electrocardiograms were performed on postoperative days 1, 3, 7, and 30 and whenever clinically indicated. The primary end point of the study was the composite of 30-day postoperative cardiovascular death, nonfatal myocardial infarction, and troponin T release. Receiver operating characteristic curve analysis was used to assess the optimal cutoff value of NT-proBNP for the prediction of the composite end point. Multivariable regression analysis was used to assess the additional value of NT-proBNP for the prediction of postoperative cardiac events in nonanemic and anemic patients. RESULTS:: Anemia was present in 206 patients (31%) before surgery. Hemoglobin level was inversely related with the NT-proBNP levels (β coefficient = -2.242; P = 0.025). The optimal predictive cutoff value of NT-proBNP for predicting the composite cardiovascular outcome was 350 pg/mL. After adjustment for clinical cardiac risk factors, both anemia (odds ratio [OR] 1.53; 95% confidence interval [CI]: 1.07-2.99) and increased levels of NT-proBNP (OR 4.09; 95% CI: 2.19-7.64) remained independent predictors for postoperative cardiac events. However, increased levels of NT-proBNP were not predictive for the risk of adverse cardiac events in the subgroup of anemic patients (OR 2.16; 95% CI: 0.90-5.21). CONCLUSIONS:: Both anemia and NT-proBNP are independently associated with an increased risk for postoperative cardiac events in patients undergoing vascular surgery. NT-proBNP has less predictive value in anemic patients. Copyright

Statins and noncardiac surgery: Current evidence and practical considerations (Article)

2009-11-01T00:00:00Z

Vascular surgery is associated with a high risk of perioperative morbidity and mortality that is partly attributable to inflammatory stress induced by the surgical procedure. Preoperative initiation of a long-acting statin is a strategy intended to reduce the inflammatory stress response and the excess risk associated with vascular surgery. The Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo III demonstrated significant reductions in perioperative myocardial ischemia and the composite end point of myocardial infarction or cardiovascular death with extended-release fluvastatin (relative to placebo) initiated 30 days prior to vascular surgery. These benefits were achieved with no increase in liver dysfunction, evidence of myopathy, or other side effects. Observational data suggest that perioperative statin use is associated with improved recovery from acute kidney injury after high-risk vascular surgery and with improved long-term survival in patients undergoing such surgery.

The experts debate: Perioperative beta-blockade for noncardiac surgery-proven safe or not? (Article)

2009-11-01T00:00:00Z

Guidelines on perioperative management of patients undergoing noncardiac surgery recommend the use of prophylactic perioperative beta-blockers in high-risk patients who are not already taking them, and their continuance in patients on chronic beta-blockade prior to surgery. These recommendations were challenged recently by results of the Perioperative Ischemic Evaluation (POISE), a large randomized trial of extended-release metoprolol succinate started immediately before noncardiac surgery in patients at high risk for atherosclerotic disease. While metoprolol significantly reduced myocardial infarctions relative to placebo in POISE, it also was associated with signifi cant excesses of both stroke and mortality. The merits and limitations of POISE and its applicability in light of other trials of perioperative beta-blockade are debated here by two experts in the field-Dr. Don Poldermans and Dr. P. J. Devereaux (co-principal investigator of POISE).

Perioperative Blood Glucose Monitoring and Control in Major Vascular Surgery Patients (Article)

2009-11-01T00:00:00Z

Diabetes mellitus (DM) is an independent predictor for morbidity and mortality in the general population, which is even more apparent in patients with concomitant cardiovascular risk factors. As the prevalence of DM is increasing, with an ageing general population, it is expected that the number of diabetic patients requiring surgical interventions will increase. Perioperative hyperglycaemia, without known DM, has been identified as a predictor for morbidity and mortality in patients undergoing surgery. Moreover, early studies showed that intensive blood-glucose-lowering therapy reduced both morbidity and mortality among patients admitted to the postoperative intensive care unit (ICU). However, later studies have doubted the benefit of intensive glucose control in medical-surgical ICU patients. This article aims to comprehensively review the evidence on the use of perioperative intensive glucose control, and to provide recommendations for current clinical practice. A systematic review was performed of the literature on perioperative intensive glucose control. Based on this literature review, we observed that intensive glucose control in the perioperative period has no clear benefit on short-term mortality. Intensive glucose control may even have a net harmful effect in selected patients. In addition, concerns on the external validity of some studies are important barriers for widespread recommendation of intensive glucose control in the perioperative setting. We propose that guidelines recommending intensive glucose control should be re-evaluated. In addition, moderate tight glucose control should currently be regarded as the safest and most efficient approach to patients undergoing major vascular surgery.

Perioperative strokes and β-blockade (Article)

2009-11-01T00:00:00Z

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.

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.

The Prevalence of Polyvascular Disease in Patients Referred for Peripheral Arterial Disease (Article)

2009-10-01T00:00:00Z

Objective: To objectively assess the presence of polyvascular disease in patients with peripheral arterial disease and its relation to inflammation and clinical risk factors. Methods: A total of 431 vascular surgery patients (mean age 68 years, men 77%) with atherosclerotic disease were enrolled. The presence of atherosclerosis was assessed using ultrasonography. Affected territories were defined as: (1) carotid, stenosis of common or internal carotid artery of ≥50%, (2) cardiac, left ventricular wall motion abnormalities, (3) abdominal aorta, diameter ≥30 mm and (4) lower limb, ankle-brachial pressure index <0.9. Cardiovascular risk factors and high-sensitivity C-reactive protein (hs-CRP) levels were noted in all. Results: One vascular territory was affected in 29% of the patients, whereas polyvascular disease was found in 71%: two affected territories in 45%, three in 23% and four in 3% of patients. Levels of hs-CRP increased with the number of affected vascular territories (p < 0.001). Multivariable logistic regression analysis showed age ≥70 years, male gender, body mass index (BMI) ≥ 25 kg m-2, and hs-CRP to be independently associated with polyvascular disease. Conclusion: Polyvascular disease is a common condition in patients who have undergone vascular surgery. The level of systemic inflammation, reflected by hs-CRP levels, is moderately associated with the extent of polyvascular disease.

Perioperative asymptomatic cardiac damage after endovascular abdominal aneurysm repair is associated with poor long-term outcome (Article)

2009-10-01T00:00:00Z

Background: Endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is associated with a decreased incidence of perioperative cardiac complications compared with open repair. However, EVAR is not associated with long-term survival benefit. This study assessed the effect of perioperative asymptomatic cardiac damage after EVAR on long-term prognosis. Methods: In 220 patients undergoing elective EVAR, routine sampling for levels of cardiac troponin T and electrocardiography (ECG) were performed on days 1, 3, and 7 during the patient's hospital stay. Elevated cardiac troponin T was defined as serum concentrations ≥0.01 ng/mL. Asymptomatic cardiac damage was defined as cardiac troponin T release without symptoms or ECG changes. The median follow-up was 2.9 years. Survival status was obtained by contacting the Office of Civil Registry. Results: Release of cardiac troponin T (median, 0.08 ng/mL) occurred in 24 of 220 patients, of whom 20 (83%) were asymptomatic and without ECG changes. Patients with asymptomatic cardiac damage had a mortality rate of 85% after 2.9 years vs 51% for patients without perioperative cardiac damage (P < .001). Also after adjustment for clinical risk factors and medication use applying multivariate Cox regression analysis, asymptomatic cardiac damage was associated with a 2.3-fold increased risk for death (95% confidence interval, 1.1-5.1). Statin use was associated with a reduced long-term risk for death (hazard ratio, 0.5; 95% confidence interval, 0.3-0.9). Conclusion: Asymptomatic cardiac damage in patients undergoing EVAR is associated with poor long-term outcome. Routine perioperative cardiac screening after EVAR might be warranted.

Three-dimensional speckle tracking echocardiography: A novel approach in the assessment of left ventricular volume and function? (Article)

2009-10-01T00:00:00Z

Asymptomatic perioperative cardiac damage: Long-term prognosis (Article)

2009-09-23T00:00:00Z

Fluvastatin and perioperative events in patients undergoing vascular surgery (Article)

2009-09-03T00:00:00Z

BACKGROUND: Adverse cardiac events are common after vascular surgery. We hypothesized that perioperative statin therapy would improve postoperative outcomes. METHODS: In this double-blind, placebo-controlled trial, we randomly assigned patients who had not previously been treated with a statin to receive, in addition to a beta-blocker, either 80 mg of extended-release fluvastatin or placebo once daily before undergoing vascular surgery. Lipid, interleukin-6, and C-reactive protein levels were measured at the time of randomization and before surgery. The primary end point was the occurrence of myocardial ischemia, defined as transient electrocardiographic abnormalities, release of troponin T, or both, within 30 days after surgery. The secondary end point was the composite of death from cardiovascular causes and myocardial infarction. RESULTS: A total of 250 patients were assigned to fluvastatin, and 247 to placebo, a median of 37 days before vascular surgery. Levels of total cholesterol, low-density lipoprotein cholesterol, interleukin-6, and C-reactive protein were significantly decreased in the fluvastatin group but were unchanged in the placebo group. Postoperative myocardial ischemia occurred in 27 patients (10.8%) in the fluvastatin group and in 47 (19.0%) in the placebo group (hazard ratio, 0.55; 95% confidence interval [CI], 0.34 to 0.88; P=0.01). Death from cardiovascular causes or myocardial infarction occurred in 12 patients (4.8%) in the fluvastatin group and 25 patients (10.1%) in the placebo group (hazard ratio, 0.47; 95% CI, 0.24 to 0.94; P=0.03). Fluvastatin therapy was not associated with a significant increase in the rate of adverse events. CONCLUSIONS: In patients undergoing vascular surgery, perioperative fluvastatin therapy was associated with an improvement in postoperative cardiac outcome. (Current Controlled Trials number, ISRCTN83738615.) Copyright

Prevalence of (A)Symptomatic Peripheral Arterial Disease; the Additional Value of Ankle-Brachial Index on Cardiovascular Risk Stratification (Article)

2009-09-01T00:00:00Z

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.

Intima media thickness of the common carotid artery in vascular surgery patients: A predictor of postoperative cardiovascular events (Article)

2009-08-01T00:00:00Z

Background: Cardiovascular (CV) complications are the leading cause of morbidity and mortality in vascular surgery patients. The Revised Cardiac Risk (RCR) index, identifying cardiac risk factors, is commonly used for preoperative risk stratification. However, a more direct marker of the underlying atherosclerotic disease, such as the common carotid artery intimamedia thickness (CCA-IMT) may be of predictive value as well. The current study evaluated the prognostic value of the CCA-IMT for postoperative CV outcome. Methods: In 508 vascular surgery patients, the CCA-IMT was measured using high-resolution B-mode ultrasonography. We recorded the RCR factors: ischemic heart disease, heart failure, cerebrovascular disease, diabetes mellitus, and renal dysfunction. Repeated Troponin T measurements and electrocardiograms were performed postoperatively. The study end point was the composite of 30-day CV events and long-term CV mortality. Multivariable regression analyses were used to assess the additional value of CCA-IMT for the prediction of cardiac events. Results: In total, 30-day events and long-term cardiovascular mortality were noted in 122 (24%) and 81 (16%) patients, respectively. The optimal predictive value of CCA-IMT, using receiver-operating characteristic curve analysis, for the prediction of CV events was calculated to be 1.25 mm (sensitivity 70%, specificity 80%). An increased CCA-IMT was independently associated with 30-day CV events (OR 2.20, 95% CI 1.38-3.52) and long-term CV mortality (HR 6.88, 95% CI 4.11-11.50), respectively. Conclusions: This study shows that an increased CCA-IMT has prognostic value in vascular surgery patients to predict 30-day CV events and long-term CV mortality, incremental to the RCR index.

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 with ischaemic cardiomyopathy after coronary revascularisation: Relation to viability and improvement in left ventricular ejection fraction (Article)

2009-08-01T00:00:00Z

Background: In patients with ischaemic cardiomyopathy and viable myocardium, left ventricular ejection fraction (LVEF) does not always improve after revascularisation. Whether this may affect prognosis is unclear. Objective: To evaluate the prognosis of viable patients with and without improvement of LVEF after coronary revascularisation. Methods: Before revascularisation, radionuclide ventriculography (RNV) and dobutamine stress echocardiography were performed to assess LVEF and myocardial viability, respectively. Nine to 12 months after revascularisation, LVEF improvement was assessed by RNV. Patients were divided into three groups: group 1, viable patients with LVEF improvement (n=27); group 2, viable patients without LVEF improvement (n=15), group 3, non-viable patients (n=48). Cardiac events were evaluated during a 4-year follow-up. Results: After revascularisation, the mean (SD) LVEF improved from 32 (9)% to 42 (10)% in group 1, but did not change significantly in group 2 and in group 3, p<0.001 by analysis of variance (ANOVA). Heart failure symptoms improved in both groups 1 (mean (SD) NYHA class from 3.1 (0.9) to 1.7 (0.7)) and 2 (from 3.2 (0.7) to 1.7 (0.9)), but not in group 3 (from 2.8 (1.0) to 2.7 (0.5)), p<0.001 by ANOVA. During follow-up, the cardiac event rate was low (4%) in group 1, intermediate (21%) in group 2 and high (33%) in group 3 (p=0.01). Conclusion: The best prognosis after revascularisation may be expected in those viable patients whose LVEF improves. Conversely, viable patients without functional improvement have an intermediate prognosis.

Screening for abdominal aortic aneurysms using a dedicated portable ultrasound system: Early results (Article)

2009-07-01T00:00:00Z

AimsAbdominal aortic aneurysms (AAA) are often diagnosed at time of (impending) rupture leading to a dramatic increase of morbidity and mortality. A simple screening device might be the key solution for widespread AAA screening. This study evaluated the diagnostic accuracy of a new portable ultrasound scanner (Aortascan BVI 9600) developed for automatic AAA detection.Methods and resultsA total of 150 patients with presumed aneurysmatic peripheral atherosclerotic disease were included in the study. Patients were first scanned with conventional ultrasound (US), serving as reference technique. An infra-renal abdominal aorta diameter of ≥30 mm was defined as an AAA. Hereafter, the aorta was scanned using the Aortascan BVI 9600. Statistical analyses were performed using SPSS version 15.0 statistical software. Abdominal aortic aneurysms were detected with conventional US in 78 (52) patients, compared with 74 (49) AAA's detected with Aortascan BVI 9600. The Aortascan BVI 9600 demonstrated a sensitivity, specificity, positive and negative predictive value of 90, 94, 95, and 89, respectively, in the detection of AAA's.ConclusionThe Aortascan BVI 9600 automatically detects the aortic diameter with a 90 sensitivity without the need for a trained operator. Because of these unique capabilities, it can be used for AAA screening outside the hospital.

Medication underuse during long-term follow-up in patients with peripheral arterial disease (Article)

2009-07-01T00:00:00Z

Background-Patients with peripheral arterial disease constitute a high-risk population. Guideline-recommended medical therapy use is therefore of utmost importance. The aims of our study were to establish the patterns of guidelinerecommende medication use in patients with PAD at the time of vascular surgery and after 3 years of follow up, and to evaluate the effect of these therapies on long-term mortality in this patient group. Methods and Results-Data on 711 consecutive patients with peripheral arterial disease undergoing vascular surgery were collected from 11 hospitals in the Netherlands (enrollment between May and December 2004). After 3.1=0.1 years of follow-up, information on medication use was obtained by a questionnaire (n<465; 84% response rate among survivors). Guideline-recommended medical therapy use for the combination of aspirin and statins in all patients and β-blockers in patients with ischemic heart disease was 41% in the perioperative period. The use of perioperative evidence-based medication was associated with a reduction of 3-year mortality after adjustment for clinical characteristics (hazard ratio, 0.65; 95% CI, 0.45 to 0.94). After 3 years of follow-up, aspirin was used in 74%, statins in 69%, and β-blockers in 54% of the patients respectively. Guideline-recommended medical therapy use for the combination of aspirin, statins, and β-blockers was 50%. Conclusions-The use of guideline recommended therapies in the perioperative period was associated with reduction in long-term mortality in patients with peripheral arterial disease. However, the proportion of patients receiving these evidence-based treatments- both at baseline and 3 years after vascular surgery-was lower than expected based on the current guidelines. These data highlight a clear opportunity to improve the quality of care in this high-risk group of patients. (Circ Cardiovasc Qual Outcomes. 2009;2:338-343.)

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.

Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: A randomized controlled trial (DECREASE-IV) (Article)

2009-06-01T00:00:00Z

Objective: This study evaluated the effectiveness and safety of beta-blockers and statins for the prevention of perioperative cardiovascular events in intermediate-risk patients undergoing noncardiovascular surgery. SUMMARY BACKGROUND DATA:: Beta-blockers and statins reduce perioperative cardiac events in high-risk patients undergoing vascular surgery by restoring the myocardial oxygen supply/demand balance and/or stabilizing coronary plaques. However, their effects in intermediate-risk patients remained ill-defined. METHODS:: In this randomized open-label 2 × 2 factorial design trial 1066 intermediate cardiac risk patients were assigned to bisoprolol, fluvastatin, combination treatment, or control therapy before surgery (median: 34 days). Intermediate risk was defined by an estimated risk of perioperative cardiac death and myocardial infarction (MI) of 1% to 6%, using clinical data and type of surgery. Starting dose of bisoprolol was 2.5 mg daily, titrated to a perioperative heart rate of 50 to 70 beats per minute. Fluvastatin was prescribed in a fixed dose of 80 mg. The primary end point was the composite of 30-day cardiac death and MI. This study is registered in the ISRCTN registry and has the ID number ISRCTN47637497. RESULTS:: Patients randomized to bisoprolol (N = 533) had a lower incidence of perioperative cardiac death and nonfatal MI than those randomized to bisoprolol-control (2.1% vs. 6.0% events; hazard ratios: 0.34; 95% confidence intervals: 0.17-0.67; P = 0.002). Patients randomized to fluvastatin experienced a lower incidence of the end point than those randomized to fluvastatin-control therapy (3.2% vs. 4.9% events; hazard ratios: 0.65; 95% confidence intervals: 0.35-1.10), but statistical significance was not reached (P = 0.17). CONCLUSION:: Bisoprolol was associated with a significant reduction of 30-day cardiac death and nonfatal MI, while fluvastatin showed a trend for improved outcome. Copyright

Cardiovascular risk assessment of the diabetic patient undergoing major noncardiac surgery (Article)

2009-06-01T00:00:00Z

Noncardiac surgery is associated with an increased risk for cardiovascular morbidity and mortality. It is important to stratify the risk of these patients for perioperative cardiac events. Diabetes, a presently rapidly expanding disease, is a major risk factor for cardiovascular morbidity and mortality. Importantly, silent ischemia is more common in diabetic patients than in the general population. When preoperative risk assessment identifies an increased risk, further cardiac testing is warranted. The most commonly used stress tests for detecting cardiac ischemia is treadmill or bicycle ergometry. However, patients undergoing noncardiac surgery frequently have limited exercise capacity due to co-morbidities. Pharmacologic testing, such as dobutamine stress echocardiography and dipyridamole myocardial perfusion scintigraphy can be performed in patients with limited exercise capacity. Non-invasive stress testing should be considered, especially in diabetic patients, to detect asymptomatic coronary artery disease. Furthermore, when an increased cardiac risk is assessed, two strategies could be used to reduce the incidence of perioperative cardiac events: 1) prophylactic coronary revascularization from which the value is still controversial, and 2) pharmacological treatment (with beta-blockers, statins and aspirin), associated with improved post-operative outcome.

The role of thrombin activatable fibrinolysis inhibitor in arterial thrombosis at a young age: The ATTAC study (Article)

2009-05-29T00:00:00Z

Background and objectives: Thrombin activatable fibrinolysis inhibitor (TAFI) attenuates fibrinolysis and may therefore contribute to the pathophysiology of arterial thrombosis. The aim of the present study was to elucidate the pathogenetic role of TAFI levels and genotypes in young patients with arterial thrombosis. Patients and methods: In a case-control study, 327 young patients with a recent first-ever event of coronary heart disease (CHD subgroup) or cerebrovascular disease (ischemic stroke subgroup) and 332 healthy young controls were included. TAFI levels [intact TAFI, activation peptide (TAFI-AP) and (in)activated TAFI (TAFIa(i)] and TAFI activity were measured and genetic variations in the TAFI gene (-438G/A, 505G/A and 1040C/T) were determined. Results: In the total group of patients, TAFIa(i) levels were higher (145.1 ± 37.5%) than in controls (137.5 ± 31.3%, P = 0.02). Plasma levels of intact TAFI, TAFI-AP and TAFI activity were similar in patients and controls. In the CHD subgroup (n = 218), intact TAFI levels were higher (109.4 ± 23.0%) than in controls (102.8 ± 20.7%, P = 0.02). In 325Ile/Ile homozygotes, lower TAFI levels and a decreased risk of arterial thrombosis were observed (OR 0.58, 95% CI 0.34-0.99) compared with patients with the common 325Thr/Thr genotype. This association was most evident in CHD patients (OR 0.48, 95% CI 0.26-0.90). Haplotype analyses supported a role for the Thr325Ile polymorphism. Conclusions: TAFIa(i) levels were higher in patients with cardiovascular disease. Furthermore, the TAFI 325Thr/Ile polymorphism was associated with lower TAFI levels and with the risk of cardiovascular disease in young patients, especially in CHD.

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.

Incremental value of high-sensitivity C-reactive protein and N-terminal pro-B-type natriuretic peptide for the prediction of postoperative cardiac events in noncardiac vascular surgery patients (Article)

2009-05-01T00:00:00Z

OBJECTIVES: High-sensitivity C-reactive protein (hs-CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are associated with the presence of coronary artery disease. The aim of this study was to assess the prognostic value of hs-CRP and NT-proBNP for postoperative cardiac events in noncardiac vascular surgery patients. METHODS: In 592 patients, cardiac history, hs-CRP, and NT-proBNP levels were assessed preoperatively. Levels of hs-CRP of at least 6.5 mg/l and NT-proBNP of at least 350 pg/ml were defined as the optimal cut-off values for the prediction of postoperative cardiac events. The end point was the composite of 30-day cardiovascular death, Q-wave myocardial infarction, and troponin T release. Multivariable regression analysis was used to evaluate the association between hs-CRP, NT-proBNP and the end point. The performance of the risk models based on cardiac risk factors alone and the addition of both biomarkers was determined using C statistics. RESULTS: After adjustment for cardiac risk factors, site of surgery and type of procedure, elevated levels of hs-CRP (odds ratio 2.54; 95% confidence interval 1.50-4.30) and NT-proBNP (odds ratio 4.78; 95% confidence interval 2.71-8.42) remained independent predictors for postoperative cardiac events. When hs-CRP and NT-proBNP were added to the cardiac risk score, the C statistic improved from 0.79 to 0.84. A combined elevation of hs-CRP and NT-proBNP provided a seven-fold higher risk for postoperative cardiac events. CONCLUSION: Both hs-CRP and NT-proBNP have additional value in the prediction of postoperative cardiac events in vascular surgery patients. Their integrated use improves cardiac risk stratification.

Prevention of acute coronary events in noncardiac surgery: β-blocker therapy and coronary revascularization (Article)

2009-05-01T00:00:00Z

During major vascular surgery, patients are at high risk for developing myocardial infarction and myocardial ischemia, and two risk-reduction strategies can be considered prior to surgery: pharmacological treatment and prophylactic coronary revascularization. β-blockers are established therapeutic agents for patients with hypertension, heart failure and coronary artery disease. There is still considerable debate concerning the protective effect of β-blocker therapy towards perioperative coronary events, which will be outlined in this article. Two randomized, controlled trials suggest that coronary revascularization of cardiac-stable patients provides no benefits in the postoperative outcomes. In the current American College of Cardiology/ American Heart Association guidelines for 'Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery', routine prophylactic coronary revascularization is not recommended in patients with stable coronary artery disease. However, a recent retrospective, observational study suggests that intermediate-risk patients may benefit from preoperative coronary revascularization. The present article provides an extended overview of leading observational studies, randomized, controlled trials, meta-analyses and guidelines assessing perioperative β-blocker therapy and prophylactic coronary revascularization.

Hypofibrinolysis is a risk factor for arterial thrombosis at young age (Article)

2009-04-01T00:00:00Z

The relationship between defective fibrinolysis and arterial thrombosis is uncertain. The evaluation of the plasma fibrinolytic potential might provide stronger evidence linking fibrinolysis to arterial thrombosis than the evaluation of the individual fibrinolytic factors. We determined the plasma fibrinolytic potential of 335 young survivors of a first arterial thrombosis, including coronary artery disease (n = 198), ischaemic stroke (n = 103) and peripheral artery disease (n = 34), enrolled in a population-based case-control study and of 330 healthy individuals. Patients had significantly higher clot lysis times (CLTs) than the controls. Odds ratios (ORs) were calculated as a measure of relative risk. The OR for arterial thrombosis was determined in these subjects who had a CLT above the 60th, 70th, 80th, 90th and 95th percentiles of the values found in the control subjects. We found a progressive increase in risk of arterial thrombosis in subjects with hypofibrinolysis (OR: 1·7, 2·0, 2·3, 2·3 and 2·9, respectively). Relative risk estimates obtained in the whole group were comparable those obtained in the event-subgroups. In conclusion, a low plasma fibrinolytic potential, found in 10% of the population, increases the relative risk of arterial thrombosis twofold. This points to an important contribution of hypofibrinolysis to the burden of arterial thrombosis.

Long-Term Outcome of Prophylactic Coronary Revascularization in Cardiac High-Risk Patients Undergoing Major Vascular Surgery (from the Randomized DECREASE-V Pilot Study) (Article)

2009-04-01T00:00:00Z

Prophylactic coronary revascularization in vascular surgery patients with extensive coronary artery disease was not associated with an improved immediate postoperative outcome. However, the potential long-term benefit was unknown. This study was performed to assess the long-term benefit of prophylactic coronary revascularization in these patients. Of 1,880 patients scheduled for major vascular surgery, 430 had ≥3 risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, diabetes mellitus, and renal failure). All underwent cardiac testing using dobutamine echocardiography or nuclear stress imaging. Patients with extensive stress-induced ischemia (≥5 segments or ≥3 walls) were randomly assigned to additional revascularization. In total, 101 patients showed extensive ischemia and were assigned to revascularization (n = 49) or no revascularization (n = 52). After 2.8 years, the overall survival rate was 64% for patients randomly assigned to no preoperative coronary revascularization versus 61% for patients assigned to preoperative coronary revascularization (hazard ratio [HR] 1.18, 95% confidence interval [CI] 0.63 to 2.19, p = 0.61). Rates for survival free of all-cause death, nonfatal myocardial infarction, and coronary revascularization were similar in both groups at 49% and 42% for patients allocated to medical treatment or coronary revascularization, respectively (HR 1.51, 95% CI 0.89 to 2.57, p = 0.13). Only 2 patients assigned to medical treatment required coronary revascularization during follow-up. Also, in patients who survived the first 30 days after surgery, there was no apparent benefit of revascularization on cardiac events (HR 1.35, 95% CI 0.72 to 2.52, p = 0.36). In conclusion, preoperative coronary revascularization in high-risk patients undergoing major vascular surgery was not associated with improved postoperative or long-term outcome compared with the best medical treatment.

Clinical validity of a disease-specific health status questionnaire: The Peripheral Artery Questionnaire (Article)

2009-02-01T00:00:00Z

Background: Measuring patient-centered outcomes is becoming increasingly important in patients with peripheral arterial disease (PAD), both as a means of determining the benefits of treatment and as an aid for disease management. In order to monitor health status in a reliable and sensitive way, the disease-specific measure Peripheral Artery Questionnaire (PAQ) was developed. However, to date, its correlation with traditional clinical indices is unknown. The primary aim of this study was to better establish the clinical validity of the PAQ by examining its association with functional indices related to PAD. Furthermore, we hypothesized that the clinical validity of this disease-specific measure is better as compared with the EuroQol-5-dimensional (EQ-5D), a standardized generic instrument. Methods: Data on 711 consecutive PAD patients undergoing surgery were collected from 11 Dutch hospitals in 2004. At 3-year follow-up, questionnaires including the PAQ, EQ-5D, and EuroQol-Visual Analogue Scale (EQ VAS) were completed in 84% of survivors. The PAQ was analyzed according to three domains, as established by a factor analyses in the Dutch population, and the summary score. Baseline clinical indices included the presence and severity of claudication intermittent (CI) and the Lee Cardiac Risk Index. Results: All three PAQ domains (Physical Function, Perceived Disability, and Treatment Satisfaction) were significantly associated with CI symptoms (P values < .001-.008). Patients with claudication had significant lower PAQ summary scores as compared with asymptomatic patients (58.6 ± 27.8 vs 68.6 ± 27.8, P = < .001). Furthermore, the PAQ summary score and the subscale scores for Physical Functioning and Perceived Disability demonstrated a clear dose-response relation for walking distance and the Lee Risk Index (P values < .001-.031). With respect to the generic EQ-5D, the summary EQ-5D index was associated with CI (0.81 ± 0.20 vs 0.76 ± 0.24, P = .031) but not with walking distance (P = .128) nor the Lee Risk Index (P = .154). The EQ VAS discriminated between the clinical indices (P values = .003-.008), although a clear dose-response relation was lacking. Conclusion: The clinical validity of the PAQ proved to be good as the PAQ subscales discriminated well between patients with or without symptomatic PAD and its severity as defined by walking distance. Furthermore, the PAQ subscales were directly proportional to the presence and number of risk factors relevant for PAD. For studying outcomes in PAD patients, the disease-specific PAQ is likely to be a more sensitive measure of treatment benefit as compared with the generic EQ VAS, although the latter may still be of value when comparing health status across different diseases. Regarding disease management, we advocate the use of the disease-specific PAQ as its greater sensitivity and validity will assist its translation into clinical practice.

Stress Echocardiography Expert Consensus Statement - Executive Summary: European Association of Echocardiography (EAE) (a registered branch of the ESC) (Article)

2009-02-01T00:00:00Z

Treatment recommendations to prevent myocardial ischemia and infarction in patients undergoing vascular surgery (Article)

2009-01-29T00:00:00Z

During major vascular surgery (MVS), patients are at high risk for developing unrecognized myocardial infarction (MI) and myocardial ischemia. In reducing postoperative morbidity and mortality, preoperative cardiac risk stratification and adequate medical therapy play a pivotal role. Based on literature and current opinions, medical treatment should comprise at least a combination of β-blockers, aspirin, and statins. β-Blockers exert their beneficial effects predominantly through heart rate control, leading to reduced oxygen demand during surgery. A heart rate between 65 and 70 bpm should be achieved. Irrespective of their lipid-lowering effects, statins seem to improve postoperative cardiac outcome by stabilizing coronary artery plaques, thereby preventing atherosclerotic plaque rupture. Aspirin reduces platelet activation and vasoconstriction, thereby limiting ischemic events and reducing nonfatal MI by 34%. Adding clopidogrel to low-dose aspirin might be beneficial toward postoperative cardiac outcomes; however, the effect on the incidence of postoperative bleeding complications may be a problem for future studies to resolve. Whereas β-blockers inhibit the effect of catecholamines, α2-agonists inhibit catecholamine release and may be used in the perioperative setting when β-blockers are contraindicated. Despite the blood pressure-lowering effect and anti-inflammatory properties of angiotensin-converting enzyme inhibitors, the literature does not support their use in patients undergoing MVS. The possible use of calcium antagonists before MVS should be further evaluated in high-risk patients with contraindications to β-blockers, such as asthma, conduction abnormalities, or a history of stroke. Although nitrates are widely used for treating angina pectoris, the beneficial effect of their use in patients undergoing MVS remains controversial. Therefore, nitrates are not routinely used in the perioperative setting. The current American College of Cardiology/American Heart Association guidelines do not recommend prophylactic coronary revascularization before noncardiac surgery in patients with stable coronary artery disease.

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.

Highlights of the 2008 Scientific Sessions of the European Society of Cardiology. Munich, Germany, August 30 to September 3, 2008 (Article)

2008-12-09T00:00:00Z

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.

Reply (Article)

2008-12-01T00:00:00Z

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.

β blockers in non-cardiac surgery: haemodynamic data needed (Article)

2008-11-12T00:00:00Z

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

Further Validation of the Peripheral Artery Questionnaire: Results from a Peripheral Vascular Surgery Survey in the Netherlands (Article)

2008-11-01T00:00:00Z

Objectives: Peripheral arterial disease (PAD) is associated with adverse cardiovascular events and can significantly impair patients' health status. Recently, marked methodological improvements in the measurement of PAD patients' health status have been made. The Peripheral Artery Questionnaire (PAQ) was specifically developed for this purpose. We validated a Dutch version of the PAQ in a large sample of PAD patients. Design: Cross-sectional study. Methods: The Dutch PAQ was completed by 465 PAD patients (70% men, mean age 65 ± 10 years) participating in the Euro Heart Survey Programme. Principal components analysis and reliability analyses were performed. Convergent validity was documented by comparing the PAQ with EQ-5D scales. Results: Three factors were discerned; Physical Function, Perceived Disability, and Treatment Satisfaction (factor loadings between 0.50 and 0.90). Cronbach's α values were excellent (mean α = 0.94). Shared variance of the PAQ domains with EQ-5D scales ranged from 3 to 50%. Conclusions: The Dutch PAQ proved to have good measurement qualities; assessment of Physical Function, Perceived Disability, and Treatment Satisfaction facilitates the monitoring of patients' perceived health in clinical research and practice. Measuring disease-specific health status in a reliable way becomes essential in times were a wide array of treatment options are available for PAD patients.

Safety of contrast-enhanced echocardiography within 24 h after acute myocardial infarction (Article)

2008-11-01T00:00:00Z

Aims: Contrast-enhanced echocardiography is widely used to enhance left ventricular (LV) endocardial border delineation in stable patients with known or suspected coronary artery disease. In patients with acute myocardial infarction, accurate assessment of LV function and size is important, but data on the safety of contrast-enhanced echocardiography in the early stage of myocardial infarction (within 24 h) are lacking. In the current study, the experience on the safety of contrast-enhanced echocardiography within 24 h of acute myocardial infarction is reported. Methods and results: A total of 115 consecutive patients (58 ± 11 years; 77% male) admitted to the coronary care unit for ST-elevation acute myocardial infarction underwent clinically indicated contrast-enhanced echocardiography within 24 h of hospital admission to assess LV size and function. Perflutren (Luminity®, Bristol-Myers Squibb Pharma, Bruxelles, Belgium) was used as contrast agent. Safety was determined evaluating vital signs, physical examination, ECG, and adverse events. On contrast-enhanced echocardiography, the mean LV ejection fraction was 44 ± 11%, and 56% of patients had an LV ejection fraction ≤45%. Administration of echo contrast did not induce any significant change in vital signs, physical examination, and ECG. Major adverse events were not observed whereas minor events occurred in 4% of patients (hypersensitivity at the injection site in three and transient back pain in two). Conclusion: These data provide evidence on the safety of contrast-enhanced echocardiography in the first 24 h of myocardial infarction; larger patient cohorts are needed to confirm these findings.

Perioperative β blockade - Authors' reply (Article)

2008-10-06T00:00:00Z

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.

Statin use in the elderly: Results from a peripheral vascular survey in The Netherlands (Article)

2008-10-01T00:00:00Z

Background: The prevalence of death due to cardiovascular disease increases steeply in vascular surgery patients with increasing age. Observational data in coronary heart disease and heart failure patients suggest that elderly patients are less optimally treated compared to younger patients. The aim of this study was to examine the differences in clinical characteristics and medical therapy of the elderly compared to younger patients in vascular surgery. Furthermore, we assessed the effect of statins on 1-year mortality in an unselected patient population. Methods: Data on 711 consecutive peripheral vascular surgery patients were collected from 11 hospitals in The Netherlands in 2004. Elderly patients were defined as patients with an age above 70 years. Multivariable logistic regression analysis was used to identify clinical characteristics and medical therapy associated with older age. The effect of statins on 1-year mortality was assessed with Cox proportional hazard regression analysis. Results: The mean age was 67 ± 10 years and 299 (42%) patients were older than 70 years of age. Elderly patients showed a significant higher cardiac risk profile according to the Lee Cardiac Risk Index (Lee-Index) (≥2 risk factors: 50% vs 32% in younger patients, P < .001). Multivariable analysis showed that older patients presented with a significant higher Lee-Index, a higher incidence of cardiac arrhythmias (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.1-3.3) and chronic obstructive pulmonary disease (COPD) (OR = 2.8; 95% CI = 1.7-4.7). However, smoking (OR = 0.5; 95% CI = 0.3-0.7) was less common in the elderly. Statins were significantly less often prescribed in the elderly (OR = 0.6; 95% CI = 0.4-0.8), although a beneficial effect of statins on 1-year mortality (HR = 0.3, 95% CI = 0.1-0.7) was observed. Conclusion: Elderly patients undergoing vascular surgery had a higher cardiac risk profile than younger patients. Despite this high cardiac risk and the beneficial effect, our study demonstrated that statins were less often used in elderly patients.

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.

Cardiovascular risk profile and outcome of patients with abdominal aortic aneurysm in out-patients with atherothrombosis: Data from the Reduction of Atherothrombosis for Continued Health (REACH) Registry (Article)

2008-10-01T00:00:00Z

Objective: Datasets regarding patients with abdominal aortic aneurysm (AAA) have almost universally been restricted to single geographic regions. We aimed to obtain data on the risk factor profile and cardiovascular (CV) co-morbidity among multi-ethnic patients with known AAA in the global REACH (REduction of Atherothrombosis for Continued Health) Registry. Methods: The REACH Registry is an international, prospective, observational out-patient registry enrolling out-patients ≥45 years of age with established coronary artery disease (CAD), cerebrovascular disease (CVD) or peripheral arterial disease (PAD) or with at least three atherothrombotic risk factors. This report includes observations pertaining to 68,236 out-patients enrolled in 44 countries. Main outcome measures: Gender, ethnic origin, CV risk factors, established atherosclerotic disease (CAD, CVD and PAD) at baseline, and CV outcome events at 1-year were compared in patients with and without AAA. Results: An AAA was reported in 1722 (2.5%) of 68,236 out-patients enrolled in the REACH Registry. Older age (73 ± 8 vs 68 ± 10, P < .0001), male gender (81% vs 63%, P < .0001), White ethnicity (79% vs 67%, P < .0001) and a history of smoking (81% vs 55%, P < .0001) were independently related to the diagnosis of AAA. There was a weaker association with hypertension or hypercholesterolemia, and an inverse relation with diabetes. Fatal and non-fatal coronary and cerebrovascular event rates were not different between the AAA and non-AAA cohorts, but individuals with AAA suffered increased rates of other cardiovascular deaths (1.39% vs 0.94%, P = .0135), hospitalizations for atherothrombotic events (14.1% vs 9.3%, P < .0001) due to increased rates of revascularization procedures, and new or worsening PAD (3.7% vs 1.3%, P < .0001) at 1-year follow-up. Conclusion: This study, the largest published to date, presents the CV risk profile and outcome of patients with an established diagnosis of AAA from a cohort of patients with either overt manifestations of CV disease or multiple risk factors, and further defines these patients in a multi-ethnic, global context.

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.

Stress echocardiography expert consensus statement (Article)

2008-07-01T00:00:00Z

Stress echocardiography is the combination of 2D echocardiography with a physical, pharmacological or electrical stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding - coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operator's training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.

A numerical model to predict abdominal aortic aneurysm expansion based on local wall stress and stiffness (Article)

2008-06-03T00:00:00Z

Aneurysms of the abdominal aorta enlarge until rupture occurs. We assume that this is the result of remodelling to restore wall stress. We developed a numerical model to predict aneurysm expansion based on this assumption. In addition, we obtained aneurysm geometry of 11 patients from computed tomography angiographic images to obtain patient specific calculations. The assumption of a wall stress related expansion indeed resulted in a series of local expansions, adjusting global geometry in an exponential fashion similar as in patients. Furthermore, it revealed that location of peak wall stress changed over time. The assumptions of this model are discussed in detail in this manuscript, and the implications are related to literature findings.

Pre-Operative Risk Assessment and Risk Reduction Before Surgery (Article)

2008-05-20T00:00:00Z

Perioperative myocardial infarctions are the predominant cause of morbidity and mortality in patients undergoing noncardiac surgery. The pathophysiology of perioperative myocardial infarction is complex. Prolonged myocardial ischemia due to the stress of surgery in the presence of a hemodynamically significant coronary lesion, leading to subendocardial ischemia, and acute coronary artery occlusion after plaque rupture and thrombus formation contribute equally to these devastating events. Perioperative management aims at optimizing the patient's condition by identification and modification of underlying cardiac risk factors and diseases. During recent decades there has been a shift from the assessment and treatment of the underlying culprit coronary lesion toward a systemic medical therapy aiming at prevention of myocardial oxygen supply demand mismatch and coronary plaque stabilization. Beta-blockers, statins, and aspirin are widely used in this setting. The role of prophylactic coronary revascularization has been restricted to the same indications as the nonoperative setting. Therefore pre-operative cardiac testing is recommended only if test results will change perioperative management. In addition to the limited perioperative period, physicians should benefit from this opportunity to initiate lifestyle changes and medical therapy to lessen the impact of cardiac risk factors, as patients should live long enough after the operation to enjoy the benefits of surgery.

Perioperative β blockade: where do we go from here? (Article)

2008-05-14T00:00:00Z

Transthoracic Doppler echocardiography assessment of left anterior descending artery flow in patients with previous anterior myocardial infarction (Article)

2008-05-01T00:00:00Z

Aim: We tested the hypothesis that shortening of diastolic pressure half time (PHT) of left anterior descending (LAD) coronary flow in patients with old reperfused anterior myocardial infarction (MI) is related to the presence of permanent myocardial damage of the reperfused area. Methods and results: We studied 49 patients divided into: group A: 15 patients with previous anterior MI and evidence of myocardial scar; group B: 10 patients with previous anterior MI and no evidence of myocardial scar and group C: 24 patients without anterior MI. All patients underwent coronary angiography at least 6 months after an index event and any reperfusion procedure. Group A patients had lower PHT (199 ± 62 ms) than group C (377 ± 103 ms, p = 0.0001) and group B (316 ± 154 ms, p = 0.029) patients. No other LAD flow velocity parameter differed among the 3 groups. A PHT value of 265 ms discriminated patients with scarred anteriorwallwith a sensitivity of 79% and a specificity of 94% (0.88, p < 0.001). Conclusion: Shortening of the LAD flow diastolic PHT in patients with remote, reperfused anterior MI reflects scarred myocardial tissue in the anteroapical wall while patients who maintain diastolic wall thickness after an acute coronary syndrome have PHT similar to patients without anterior MI.

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.

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.

Long Term Risk Prediction in Patients Undergoing Abdominal Aortic Aneurysm Repair: The Ultimate Stress Test of Open Repair (Article)

2008-04-01T00:00:00Z

Impaired glucose regulation, elevated glycated haemoglobin and cardiac ischaemic events in vascular surgery patients (Article)

2008-03-01T00:00:00Z

Aims: Cardiac morbidity and mortality is high in patients undergoing high-risk surgery. This study investigated whether impaired glucose regulation and elevated glycated haemoglobin (HbA1c) levels are associated with increased cardiac ischaemic events in vascular surgery patients. Methods: Baseline glucose and HbA1cwere measured in 401 vascular surgery patients. Glucose < 5.6 mmol/l was defined as normal. Fasting glucose 5.6-7.0 mmol/l or random glucose 5.6-11.1 mmol/l was defined as impaired glucose regulation. Fasting glucose ≥ 7.0 or random glucose ≥ 11.1 mmol/l was defined as diabetes. Perioperative ischaemia was identified by 72-h Holter monitoring. Troponin T was measured on days 1, 3 and 7 and before discharge. Cardiac death or Q-wave myocardial infarction was noted at 30-day and longer-term follow-up (mean 2.5 years). Results: Mean (± sd) level for glucose was 6.3 ± 2.3 mmol/l and for HbA1c6.2 ± 1.3%. Ischaemia, troponin release, 30-day and long-term cardiac events occurred in 27, 22, 6 and 17%, respectively. Using subjects with normal glucose levels as the reference category, multivariate analysis revealed that patients with impaired glucose regulation and diabetes were at 2.2- and 2.6-fold increased risk of ischaemia, 3.8- and 3.9-fold for troponin release, 4.3- and 4.8-fold for 30-day cardiac events and 1.9- and 3.1-fold for long-term cardiac events. Patients with HbA1c> 7.0% (n = 63, 16%) were at 2.8-fold, 2.1-fold, 5.3-fold and 5.6-fold increased risk for ischaemia, troponin release, 30-day and long-term cardiac events, respectively. Conclusions: Impaired glucose regulation and elevated HbA1care risk factors for cardiac ischaemic events in vascular surgery patients.

Intermittent acute aortic valve regurgitation: A case report of a prosthetic valve dysfunction (Article)

2008-03-01T00:00:00Z

Complications of any mechanical prosthesis include thrombus or pannus formation. In our case report we demonstrate that prosthetic aortic valve regurgitation due to pannus formation may be intermittent and non-cyclic in pattern and therefore not obvious at the time of original clinical examination. Under these conditions and as transesophageal echocardiography cannot be repeated promptly, transthoracic 2-D and Doppler echocardiography should be available at any time when symptoms occur and present the method of choice for acute patient evaluation. Thrombolysis seems to be the first treatment of choice in case of thrombus formation and re-do surgery in case of pannus formation.

Usefulness of Preoperative Oral Glucose Tolerance Testing for Perioperative Risk Stratification in Patients Scheduled for Elective Vascular Surgery (Article)

2008-02-15T00:00:00Z

Patients scheduled for major vascular surgery are screened for cardiac risk factors using standardized risk indexes, including diabetes mellitus (DM). Screening in patients without a history of DM includes fasting glucose measurement. However, an oral glucose tolerance test (OGTT) could significantly improve the detection of DM and impaired glucose tolerance (IGT) and the prediction of perioperative cardiac events. In a prospective study, 404 consecutive patients without signs or histories of IGT or DM were included and subjected to OGTT. The primary study end point was the composite of perioperative myocardial ischemia, assessed by 72-hour Holter monitoring using ST-segment analysis and troponin release. The primary end point was noted in 21% of the patients. IGT was diagnosed in 104 patients (25.7%), and new-onset DM was detected in 43 patients (10.6%). The OGTT detected 75% of the patients with IGT and 72% of the patients with DM. Preoperative glucose levels significantly predicted the risk for perioperative cardiac ischemia; odds ratios for DM and IGT were, respectively, 3.2 (95% confidence interval 1.3 to 8.1) and 1.4 (95% confidence interval 0.7 to 3.0). In conclusion, the prevalence of undiagnosed IGT and DM is high in vascular patients and is associated with perioperative myocardial ischemia. Therefore, an OGTT should be considered for all patients who undergo elective vascular surgery.

Preoperative cardiac risk assessment in vascular surgery patients: Seeing beyond the perioperative period (Article)

2008-02-01T00:00:00Z

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.

Influence of Renal Function on the Usefulness of N-Terminal Pro-B-Type Natriuretic Peptide as a Prognostic Cardiac Risk Marker in Patients Undergoing Noncardiac Vascular Surgery (Article)

2008-01-01T00:00:00Z

N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is related to stress-induced myocardial ischemia and/or volume overload, both common in patients with renal dysfunction. This might compromise the prognostic usefulness of NT-pro-BNP in patients with renal impairment before vascular surgery. We assessed the prognostic value of NT-pro-BNP in the entire strata of renal function. In 356 patients (median age 69 years, 77% men), cardiac history, glomerular filtration rate (GFR, ml/min/1.73 m2), and NT-pro-BNP level (pg/ml) were assessed preoperatively. Troponin T and electrocardiography were assessed postoperatively on days 1, 3, 7, and 30. The end point was the composite of cardiovascular death, Q-wave myocardial infarction, and troponin T release. Multivariate analysis was used to evaluate the interaction between GFR, NT-pro-BNP and their association with postoperative outcome. Median GFR was 78 ml/min/1.73 m2and the median concentration of NT-pro-BNP was 197 pg/ml. The end point was reached in 64 patients (18%); cardiac death occurred in 7 (2.0%), Q-wave myocardial infarction in 34 (9.6%), and non-Q-wave myocardial infarction in 23 (6.5%). After adjustment for confounders, NT-pro-BNP levels and GFR remained significantly associated with the end point (p = 0.005). The prognostic value of NT-pro-BNP was most pronounced in patients with GFR ≥90 (odds ratio [OR] 1.18, 95% confidence interval [CI] 0.80 to 1.76) compared with patients with GFR 60 to 89 (OR 1.04, 95% CI 1.002 to 1.07), and with GFR 30 to 59 (OR 1.12, 95% CI 1.03 to 1.21). In patients with GFR <30 ml/min/1.73 m2, NT-pro-BNP levels have no prognostic value (OR 1.00, 95% CI 0.99 to 1.01). In conclusion, the discriminative value of NT-pro-BNP is most pronounced in patients with GFR ≥90 ml/min/1.73 m2and has no prognostic value in patients with GFR <30 ml/min/1.73 m2.

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

Re: Secondary Medical Prevention in Patients with Peripheral Arterial Disease (Article)

2008-01-01T00:00:00Z

Imaging Highlights From the European Society of Cardiology, American Society of Nuclear Cardiology, and Heart Failure Society of America (Article)

2008-01-01T00:00:00Z

Cardiac imaging has become an integrated part in the diagnostic and prognostic work-up of patients with cardiovasular disease. In this article, highlights of scientific abstracts on cardiac imaging presented at the European Society of Cardiology (ESC), the American Society of Nuclear Cardiology (ASNC), and the Heart Failure Society of America (HFSA) are summarized.

Highlights of the 2007 Scientific Sessions of the European Society of Cardiology. Vienna, Austria, September 1-5, 2007 (Article)

2007-12-18T00:00:00Z

Comparison With Computed Tomography of Two Ultrasound Devices for Diagnosis of Abdominal Aortic Aneurysm (Article)

2007-12-15T00:00:00Z

Screening for abdominal aortic aneurysms (AAAs) in patients at risk will become more cost effective if a simple, inexpensive, and reliable ultrasound device is available. The aim of this study was to compare a 2-dimensional, handheld ultrasound device and a newly developed ultrasound volume scanner (based on bladder scan technology) with computed tomography (CT) for diagnosing AAA. A total of 146 patients (mean age 69 ± 10 years; 127 men) were screened for the presence of AAAs (diameter >3 cm) using CT. All patients were examined with the handheld ultrasound device and the volume scanner. Maximal diameters and volumes were used for the analyses. AAAs were diagnosed by CT in 116 patients (80%). The absolute difference of aortic diameter between ultrasound and CT was <5 mm in 88% of patients. Limits of agreement between ultrasound and CT (-6.6 to 9.4 mm) exceeded the limits of clinical acceptability (±5 mm). An excellent correlation between ultrasound and CT was observed (r = 0.98). The correlation coefficient between the volume scanner and CT was 0.86, with agreement of 90% and κ value of 0.73. Using an optimal cut-off value of >56 ml, defined by receiver-operating characteristic curve analysis, sensitivity, specificity, and the positive and negative predictive values of the volume scanner for detecting AAA were 90%, 90%, 97%, and 71%, respectively. In conclusion, this study shows that a 2-dimensional, handheld ultrasound device and a newly developed ultrasound volume scanner can effectively identify patients with AAAs confirmed by CT.

A prognostic risk index for long-term mortality in patients with peripheral arterial disease (Article)

2007-12-10T00:00:00Z

Background: Prognostic information in peripheral arterial disease (PAD) may provide the basis for optimal management strategies at an early stage. This study aimed to develop a prognostic risk index for long-term mortality in patients with PAD. Methods: In a single-center observational cohort study, 2642 patients with an ankle-brachial index of 0.90 or lower were randomly divided into derivation (n=1332) and validation (n=1310) cohorts. Cox regression analysis with stepwise backward elimination identified predictors of 1-year, 5-year, and 10-year mortality in the derivation cohort. Weighted points were assigned to each predictor. Index discrimination was determined in both the derivation and validation cohorts. Results: During 10 years of follow-up, 42.2% and 40.4% of patients died in the derivation and validation cohorts, respectively. The risk index for 10-year mortality (+points) included renal dysfunction (+12), heart failure (+7), ST-segment changes (+5), age greater than 65 years (+5), hypercholesterolemia (+5), ankle-brachial index lower than 0.60 (+4), Q-waves (+4), diabetes (+3), cerebrovascular disease (+3), and pulmonary disease (+3). Statins (-6), aspirin (-4), and β-blockers (-4) were associated with reduced 10-year mortality. Patients were stratified into low (<0 points), low-intermediate (0-5 points), high-intermediate (6-9 points), and high (>9 points) risk categories, according to risk score. Ten-year mortality rates were 22.1%, 32.2%, 45.8%, and 70.4%, respectively (P < .001) and comparable to mortality in the validation cohort. C statistics demonstrated good discrimination in both the derivation (0.72) and validation cohorts (0.73). Conclusions: A prognostic risk index for long-term mortality stratified patients with PAD into different risk categories. This may be useful for risk stratification, patient counseling, and medical decision making.

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.

Baseline natriuretic peptide levels in relation to myocardial ischemia, troponin T release and heart rate variability in patients undergoing major vascular surgery (Article)

2007-12-01T00:00:00Z

BACKGROUND: This study was conducted to determine the association between baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP) and myocardial ischemia, troponin T release and heart rate variability (HRV) in patients undergoing major vascular surgery. METHODS: In a prospective study, 182 vascular surgery patients were evaluated by clinical risk factors, dobutamine stress echocardiography and baseline NT-proBNP levels. Myocardial ischemia was detected by continuous 12-lead electrocardiographic monitoring starting 1 day before to 2 days after surgery. Troponin T (>0.03 ng/ml) was measured on day 1, 3 and 7 postoperatively and before discharge. HRV was measured at the day prior to surgery. RESULTS: The median NT-proBNP level was 184 ng/l (interquartile range: 79-483 ng/l). Myocardial ischemia was detected in 21% and troponin T release in 17% of patients. After adjustment for clinical risk factors and stress echocardiography results, higher NT-proBNP levels (per 1 ng/l increase in the natural logarithm of NT-proBNP) were associated with a higher incidence of myocardial ischemia (odds ratio: 1.59, 95% confidence interval: 1.21-2.08, P<0.001) and troponin T release (odds ratio: 1.76, 95% confidence interval: 1.33-2.34, P<0.001). The optimal cutoff value of NT-proBNP to predict ischemia and/or troponin T release was 270 ng/l (area under the curve: 0.70). Higher baseline NT-proBNP levels were also associated with a larger ischemic burden at electrocardiographic monitoring (r=0.22, P=0.03). No significant correlation, however, was found between NT-proBNP and preoperative HRV (r=-0.024, P=0.78). CONCLUSION: Elevated baseline NT-proBNP levels are significantly associated with perioperative myocardial ischemia and troponin T release, but not with preoperative HRV in patients undergoing major 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.

Can tissue Doppler imaging detect myocardial viability in patients with left ventricular dysfunction? Commentary (Article)

2007-12-01T00:00:00Z

Should troponin and creatinine kinase be routinely measured after vascular surgery? (Article)

2007-11-14T00:00:00Z

The current guidelines for the evaluation and prediction of adverse cardiovascular events (CVEs) following vascular surgery in high-risk patients recommends serial electrocardiograms (ECGs) but not biomarkers such as cTn-I and CK-MB. The objective of this study was to determine whether biomarkers should be routinely measured in high-risk patients undergoing vascular surgery. A multicenter, prospective study with investigators blinded to core laboratory results was conducted, cTn-I and CK-MB were obtained on the day of surgery, as well as 24 hours, 72 hours and 120 hours after surgery, 24 hours prior to planned hospital discharge and at the onset of symptoms of a suspected CVE. The CVE was adjudicated by an endpoint committee using ECG, biomarker and symptoms data and was defined as cardiac death or myocardial infarction (MI) occurring up to 30 days after surgery. A total of 784 patients, with a mean age of 70.1 (SD ± 9.8), underwent vascular surgery. Of the 83 patients with a CVE, cTn-I was positive in 42 and CK-MB was positive in 29 on or before the day of the CVE. The number of patients not classified as having a CVE but positive for elevation of cTn-I or CK-MB was 64 and 20, respectively, cTn-I was more sensitive than CK-MB (50.6% versus 34.9%) for predicting a CVE. The optimum time for measuring cTn-I after surgery with the highest positive predictive value was 24 hours. In conclusion, these data support routine serial measurement of cTn-I after vascular surgery.

Comparison of the Incidences of Cardiac Arrhythmias, Myocardial Ischemia, and Cardiac Events in Patients Treated With Endovascular Versus Open Surgical Repair of Abdominal Aortic Aneurysms (Article)

2007-11-01T00:00:00Z

This study examines differences in cardiac arrhythmias, perioperative myocardial ischemia, troponin T release, and cardiovascular events between endovascular and open repair of abdominal aortic aneurysms (AAAs). Of 175 patients, 126 underwent open AAA repair and 49 underwent endovascular AAA repair. Continuous 12-lead electrocardiographic monitoring, starting 1 day before surgery and continuing through 2 days after surgery, was used for cardiac arrhythmia and myocardial ischemia detection. Troponin T was measured on postoperative days 1, 3, and 7 and before discharge. Cardiac events (cardiac death or Q-wave myocardial infarction) were noted at 30 days and at follow-up (mean 2.3 years). New-onset atrial fibrillation, nonsustained ventricular tachycardia, sustained ventricular tachycardia, and ventricular fibrillation occurred in 5%, 17%, 2%, and 1% of patients, respectively. Myocardial ischemia, troponin T release, and 30-day and long-term cardiac events occurred in 34%, 29%, 6%, and 10% of patients, respectively. Significantly higher heart rates and less heart rate variability were observed in the open AAA repair group. Cardiac arrhythmias were less prevalent in the endovascular AAA repair group (14% vs 29%, p = 0.04). Endovascular repair was also significantly associated with less myocardial ischemia (odds ratio 0.14, 95% confidence interval 0.05 to 0.40, p <0.001) and troponin T release (odds ratio 0.10, 95% confidence interval 0.02 to 0.32, p <0.001) and lower 30-day mortality (zero vs 8.7%, p = 0.03) and 30-day cardiac event rates (zero vs 7.9%, p = 0.04). Long-term mortality and cardiac event rates were not significantly lower in the endovascular AAA repair group. In conclusion, endovascular AAA repair is associated with a lower incidence of perioperative cardiac arrhythmias, myocardial ischemia, troponin T release, cardiac events, and all-cause mortality compared with open AAA repair.

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.

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.

Preoperative cardiac testing before major vascular surgery (Article)

2007-11-01T00:00:00Z

Risk Models in Abdominal Aortic Aneurysm Surgery; Useful for Policy Makers or Patients? (Article)

2007-11-01T00:00:00Z

Intensity of Statin Therapy in Relation to Myocardial Ischemia, Troponin T Release, and Clinical Cardiac Outcome in Patients Undergoing Major Vascular Surgery (Article)

2007-10-23T00:00:00Z

Objectives: This study sought to examine whether higher statin doses and lower low-density lipoprotein (LDL) cholesterol are associated with improved cardiac outcome in vascular surgery patients. Background: Statins may have cardioprotective effects during major vascular surgery. Methods: In a prospective study of 359 vascular surgery patients, statin dose and cholesterol levels were recorded preoperatively. Myocardial ischemia and heart rate variability were assessed by 72-h 12-lead electrocardiography starting 1 day before to 2 days after surgery. Troponin T was measured on postoperative day 1, 3, 7, and before discharge. Cardiac events included cardiac death or nonfatal Q-wave myocardial infarction at 30 days and follow-up (mean 2.3 years). Results: Perioperative myocardial ischemia, troponin T release, 30-day events, and late cardiac events occurred in 29%, 23%, 4%, and 18%, respectively. In multivariate analysis, lower LDL cholesterol (per 10 mg/dl) correlated with lower myocardial ischemia (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.80 to 0.95), troponin T release (OR 0.89, 95% CI 0.82 to 0.96), and 30-day (OR 0.89, 95% CI 0.78 to 1.00) and late cardiac events (hazard ratio 0.91, 95% CI 0.84 to 0.96). Higher statin doses (per 10% of maximum recommended dose) correlated with lower myocardial ischemia (OR 0.85, 95% CI 0.76 to 0.93), troponin T release (OR 0.84, 95% CI 0.76 to 0.93), and 30-day (OR 0.62, 95% CI 0.40 to 0.96) and late cardiac events (hazard ratio 0.76, 95% CI 0.65 to 0.89), even after adjusting for LDL cholesterol. Significantly higher perioperative heart rate variability was observed in patients with higher statin doses. Conclusions: Higher statin doses and lower LDL cholesterol correlate with lower perioperative myocardial ischemia, perioperative troponin T release, and 30-day and late cardiac events in major vascular surgery.

Guidelines for cardiac management in noncardiac surgery are poorly implemented in clinical practice: Results from a peripheral vascular survey in The Netherlands (Article)

2007-10-01T00:00:00Z

BACKGROUND: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery recommend an algorithm for a stepwise approach to preoperative cardiac assessment in vascular surgery patients. The authors' main objective was to determine adherence to the ACC/AHA guidelines on perioperative care in daily clinical practice. METHODS: Between May and December 2004, data on 711 consecutive peripheral vascular surgery patients were collected from 11 hospitals in The Netherlands. This survey was conducted within the infrastructure of the Euro Heart Survey Programme. The authors retrospectively applied the ACC/AHA guideline algorithm to each patient in their data set and subsequently compared observed clinical practice data with these recommendations. RESULTS: Although 185 of the total 711 patients (26%) fulfilled the ACC/AHA guideline criteria to recommend preoperative noninvasive cardiac testing, clinicians had performed testing in only 38 of those cases (21%). Conversely, of the 526 patients for whom noninvasive testing was not recommended, guidelines were followed in 467 patients (89%). Overall, patients who had not been tested, irrespective of guideline recommendation, received less cardioprotective medications, whereas patients who underwent noninvasive testing were significantly more often treated with cardiovascular drugs (β-blockers 43% vs. 77%, statins 52% vs. 83%, platelet inhibitors 80% vs. 85%, respectively; all P < 0.05). Moreover, the authors did not observe significant differences in cardiovascular medical therapy between patients with a normal test result and patients with an abnormal test result. CONCLUSION: This survey showed poor agreement between ACC/AHA guideline recommendations and daily clinical practice. Only one of each five patients underwent noninvasive testing when recommended. Furthermore, patients who had not undergone testing despite recommendations received as little cardiac management as the low-risk population.

Cardiac risk in non-cardiac surgery (Article)

2007-10-01T00:00:00Z

Comparison of Myocardial Infarct Size Assessed With Contrast-Enhanced Magnetic Resonance Imaging and Left Ventricular Function and Volumes to Predict Mortality in Patients With Healed Myocardial Infarction (Article)

2007-09-15T00:00:00Z

Currently, left ventricular (LV) ejection fraction (EF) and/or LV volumes are the established predictors of mortality in patients with coronary artery disease (CAD) and severe LV dysfunction. With contrast-enhanced magnetic resonance imaging (MRI), precise delineation of infarct size is now possible. The relative merits of LVEF/LV volumes and infarct size to predict long-term outcome are unknown. The purpose of this study was to determine the predictive value of infarct size assessed with contrast-enhanced MRI relative to LVEF and LV volumes for long-term survival in patients with healed myocardial infarction. Cine MRI and contrast-enhanced MRI were performed in 231 patients with healed myocardial infarction. LVEF and LV volumes were measured and infarct size was derived from contrast-enhanced MRI. Nineteen patients (8.2%) died during a median follow-up of 1.7 years (interquartile range 1.1 to 2.9). Cox proportional hazards analysis revealed that infarct size defined as spatial extent (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.1 to 1.6, chi-square 6.7, p = 0.010), transmurality (HR 1.5, 95% CI 1.1 to 1.9, chi-square 8.9, p = 0.003), or total scar score (HR 6.2, 95% CI 1.7 to 23, chi-square 7.4, p = 0.006) were stronger predictors of all-cause mortality than LVEF and LV volumes. In conclusion, infarct size on contrast-enhanced MRI may be superior to LVEF and LV volumes for predicting long-term mortality in patients with healed myocardial infarction.

Carotid artery stenting versus endarterectomy in relation to perioperative myocardial ischemia, troponin T release and major cardiac events (Article)

2007-09-01T00:00:00Z

BACKGROUND: Carotid artery stenting (CAS) is less invasive than endarterectomy. This study examined differences in perioperative myocardial ischemia, troponin T release and clinical cardiac events in patients undergoing CAS compared with endarterectomy. METHODS: In an observational study, CAS was performed in 24 and carotid endarterectomy in 44 patients. Before surgery, clinical risk factors were noted and dobutamine stress echocardiography was performed for cardiac risk assessment. Perioperative continuous 72-h 12-lead electrocardiographic monitoring was used for myocardial ischemia detection. Troponin T (>0.03 ng/ml) was measured on postoperative days 1, 3, 7 or before discharge. Cardiac events (cardiac death or Q-wave myocardial infarction) were noted during hospital stay and during follow-up (mean: 1.2 years). RESULTS: No significant differences were observed between patients with CAS and endarterectomy in terms of baseline clinical characteristics, dobutamine stress echocardiography results and cardiovascular medication. Perioperative myocardial ischemia was detected in nine patients (13%), perioperative troponin T release in seven patients (10%), early cardiac events in one patient (1%) and late cardiac events in three patients (4%). Significantly less perioperative myocardial ischemia was observed in patients with CAS compared with endarterectomy (0 versus 21%, P=0.02). Troponin T release was also significantly lower in CAS, compared with endarterectomy (0 versus 16%, P=0.04). Early (0 versus 2%, P=0.5) and late (0 versus 7%, P=0.2) cardiac events were lower after CAS, compared with endarterectomy, although these differences were not significant. CONCLUSION: CAS is associated with a lower incidence of perioperative myocardial ischemia and troponin T release, compared with endarterectomy.

Reply (Article)

2007-08-01T00:00:00Z

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.

Prognostic Significance of Declining Ankle-brachial Index Values in Patients with Suspected or Known Peripheral Arterial Disease (Article)

2007-08-01T00:00:00Z

Background: Peripheral arterial disease (PAD) is a risk factor for cardiovascular events. This study assessed the prognostic significance of repeated ankle-brachial index (ABI) measurements at rest and after exercise in patients with PAD receiving conservative treatment. Methods: In a cohort study of 606 patients (mean age 62 ± 12 years, 68% male), ABI at rest and after exercise was measured at baseline and after 1 year. Patients with reductions in ABI were divided into three equally-sized groups (minor, intermediate and major reductions) and were compared to patients without reductions. During a mean follow-up of 5 ± 3 years, all-cause mortality, cardiac events, stroke and progression to kidney failure were noted. Results: Death was recorded in 83 patients (14%) of which 49% were due to cardiac causes. Non-fatal myocardial infarction occurred in 38 patients (6%), stroke in 46 (8%) and progression to kidney failure in 35 (6%). By multivariate analysis, patients with major declines in resting (>20%) and post-exercise (>30%) ABI were at increased risk of all-cause mortality (HR: 3.3, 95% CI: 1.5-7.2, HR: 3.0, 95% CI: 1.4-6.4, respectively), cardiac events (HR: 3.1, 95% CI: 1.3-7.2, HR: 2.4, 95% CI: 1.1-5.6, respectively), stroke (HR: 4.2, 95% CI: 1.6-10.4, HR: 3.9, 95% CI: 1.4-10.2, respectively) and kidney failure (HR: 2.7, 95% CI: 1.1-7.5, HR: 6.9, 95% CI: 1.5-31.5, respectively), compared to patients with no declines in ABI. Conclusions: This study shows that major 1-year declines in resting and post-exercise ABI are associated with all-cause mortality, cardiac events, stroke and kidney failure in patients with PAD.

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.

Perioperative β-blockade: Still not enough for adequate cardioprotection! [2] (Article)

2007-07-01T00:00:00Z

Assessment of myocardial viability in patients with heart failure (Article)

2007-07-01T00:00:00Z

The prognosis for patients with chronic ischemic left ventricular dysfunction is poor, despite advances in different therapies. Noninvasive assessment of myocardial viability may guide patient management. Multiple imaging techniques have been developed to assess viable and nonviable myocardium by evaluating perfusion, cell membrane integrity, mitochondria, glucose metabolism, scar tissue, and contractile reserve. PET,201Tl and99mTc scintigraphy, and dobutamine stress echocardiography have been extensively evaluated for assessment of viability and prediction of clinical outcome after coronary revascularization. In general, nuclear imaging techniques have a high sensitivity for the detection of viability, whereas techniques evaluating contractile reserve have a somewhat lower sensitivity and a higher specificity. MRI has a high diagnostic accuracy for assessment of the transmural extent of myocardial scar tissue. Patients with a substantial amount of dysfunctional but viable myocardium are likely to benefit from coronary revascularization and may show improvements in regional and global contractile function, symptoms, exercise capacity, and long-term prognosis. Copyright

Safety and tolerability of prolonged-release nicotinic acid in statin-treated patients (Article)

2007-07-01T00:00:00Z

Objective: To evaluate the safety and tolerability of prolonged-release nicotinic acid (Niaspan*) added to statin therapy in patients at increased cardiovascular risk. Methods: This was a 6-month, prospective, observational, multicentre, open-label evaluation of prolonged-release nicotinic acid (maximum dose 2000 mg/day) in statin-treated patients with cardiovascular disease and/ or type 2 diabetes. The primary endpoint was the safety and tolerability of prolonged-release nicotinic acid, with special regard to treatment-related adverse drug reactions (ADRs). Secondary endpoints were changes in lipids and 10-year cardiovascular risk (Prospective Cardiovascular Münster (PROCAM) score). Results: The study population included 1053 patients: 50% had hypertension, diabetes and/or metabolic syndrome (National Cholesterol Education Program/Adult Treatment Panel III criteria) and 80% had cardiovascular disease. Flushing (mostly mild or moderate) occurred in 430 patients (40.8%). Other ADRs occurred in 125 patients (12.5%), most commonly pruritus (2.7%), gastrointestinal symptoms (3.8%) and nervous system-related complaints (3.8%). Serious ADRs were uncommon (0.6%). All patients recovered completely from these ADRs after treatment discontinuation. In total, 11.1 % of the patients discontinued study medication for flushing and 8.4% for other ADRs. There was no evidence of hepatotoxicity or myopathy. New-onset hyperglycaemia was negligible. Overall tolerability of prolonged-release nicotinic acid treatment (n = 734 patients at closeout) was 'very good' in 130 (17.7%), 'good' in 262 (35.7%), and 'acceptable' in 144 (19.6%) patients. High-density lipoprotein (HDL) cholesterol increased by 23%, triglycerides decreased by 15% and LDL-C decreased by 4%. Conclusions: Prolonged-release nicotinic acid was safe and generally well tolerated and effective in combination with statin therapy in patients at high risk of cardiovascular events, with a side-effect profile consistent with previous clinical experience.

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.

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.

Perioperative medical management of ischemic heart disease in patients undergoing noncardiac surgery (Article)

2007-06-01T00:00:00Z

PURPOSE OF REVIEW: Cardiovascular disease is the leading cause of death after anesthesia and surgery. The preoperative identification of patients with underlying coronary artery disease is important to initiate appropriate treatment strategies in order to reduce the risk of perioperative complications. The current review will discuss new insights in the field of perioperative medicine that can be applied to clinical practice or stimulate further investigation. RECENT FINDINGS: Recent findings in the past year have developed preoperative risk stratification in terms of simplicity, safety, accuracy and cost-effectiveness. Natriuretic peptides have been demonstrated to be promising new preoperative risk markers. Although recommended in high-risk patients, noninvasive cardiac stress testing may be safely omitted in patients at intermediate risk. The antiischemic properties of β-blockers have been well described. In clinical practice, however, adequate β-blocker dosage, tight perioperative heart rate control and continuation of β-blockers after surgery may also be important factors. Statins have emerged as promising drugs with perioperative cardioprotective properties. Before recommending routine administration of statin therapy, however, more clinical trials are needed. SUMMARY: New perceptions in perioperative medical management and novel developments in surgical and anesthesiology techniques continue to improve the cardiovascular outcome of patents undergoing major noncardiac surgery.

Management of patients with cardiac stents undergoing noncardiac surgery (Article)

2007-06-01T00:00:00Z

PURPOSE OF REVIEW: Coronary stenting is performed in over 4 million patients annually. Approximately 5% of these patients undergo a noncardiac surgical procedure within 1 year after stenting. Surgery might induce hypercoagulability. This causes increased concern about the effects of previous coronary stenting on postoperative cardiac outcome, particularly in-stent thrombosis. On the other hand, patients with multiple cardiac risk factors are at high risk for postoperative adverse cardiac events and might even benefit from preoperative prophylactic coronary revascularization. RECENT FINDINGS: Early noncardiac surgery after coronary stent placement is associated with an increased risk of major adverse cardiac events. The majority of these events are attributable to in-stent thrombosis. Antiplatelet therapy interruption in the perioperative period seems to be associated with an increase in adverse cardiac events, particularly in patients who undergo noncardiac surgery early after coronary stenting. Furthermore, prophylactic coronary revascularization for high cardiac risk patients is not associated with an improved outcome. SUMMARY: Early noncardiac surgery after coronary stenting increases the risk of postoperative cardiac events. Interruption of antiplatelet therapy seems to play an important role in this increased event rate. Prophylactic coronary revascularization in cardiac stable, but high-risk patients does not seem to improve outcome.

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

Cardiac Troponins as a Risk Stratification Tool for Patients with Chronic Critical Limb Ischemia (Article)

2007-06-01T00:00:00Z

Cardiac Risk Reduction in Patients with Intermittent Claudication (Article)

2007-06-01T00:00:00Z

A Clinical Randomized Trial to Evaluate the Safety of a Noninvasive Approach in High-Risk Patients Undergoing Major Vascular Surgery. The DECREASE-V Pilot Study (Article)

2007-05-01T00:00:00Z

Objectives: The purpose of this research was to perform a feasibility study of prophylactic coronary revascularization in patients with preoperative extensive stress-induced ischemia. Background: Prophylactic coronary revascularization in vascular surgery patients with coronary artery disease does not improve postoperative outcome. If a beneficial effect is to be expected, then at least those with extensive coronary artery disease should benefit from this strategy. Methods: One thousand eight hundred eighty patients were screened, and those with ≥3 risk factors underwent cardiac testing using dobutamine echocardiography (17-segment model) or stress nuclear imaging (6-wall model). Those with extensive stress-induced ischemia (≥5 segments or ≥3 walls) were randomly assigned for additional revascularization. All received beta-blockers aiming at a heart rate of 60 to 65 beats/min, and antiplatelet therapy was continued during surgery. The end points were the composite of all-cause death or myocardial infarction at 30 days and during 1-year follow-up. Results: Of 430 high-risk patients, 101 (23%) showed extensive ischemia and were randomly assigned to revascularization (n = 49) or no revascularization. Coronary angiography showed 2-vessel disease in 12 (24%), 3-vessel disease in 33 (67%), and left main in 4 (8%). Two patients died after revascularization, but before operation, because of a ruptured aneurysm. Revascularization did not improve 30-day outcome; the incidence of the composite end point was 43% versus 33% (odds ratio 1.4, 95% confidence interval 0.7 to 2.8; p = 0.30). Also, no benefit during 1-year follow-up was observed after coronary revascularization (49% vs. 44%, odds ratio 1.2, 95% confidence interval 0.7 to 2.3; p = 0.48). Conclusions: In this randomized pilot study, designed to obtain efficacy and safety estimates, preoperative coronary revascularization in high-risk patients was not associated with an improved outcome.

The effect of intensified lipid-lowering therapy on long-term prognosis in patients with peripheral arterial disease (Article)

2007-05-01T00:00:00Z

Background: The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are associated with improved outcome in patients with peripheral arterial disease. Statins may also have beneficial properties beyond their lipid-lowering effect. Methods: A prospective, observational cohort study was conducted at a university hospital from 1990 to 2005 to examine whether higher doses of statins and lower low-density lipoprotein (LDL) cholesterol levels are both independently associated with improved outcome in peripheral arterial disease. Enrolled were 1374 consecutive patients (age, 61 ± 10 years, 73% male) with peripheral arterial disease (ankle-brachial index ≤0.90). They were screened for clinical risk factors, statin therapy, and LDL cholesterol levels. Serial LDL cholesterol levels were measured at 6 months and yearly after enrollment. The mean follow-up time was 6.4 ± 3.6 years, and no patients were lost to follow-up. The primary end points were all-cause and cardiac mortality. The secondary end point was the progression to kidney failure. Results: Overall mortality, cardiac death, and progression to kidney failure occurred in 29%, 20%, and 5% of patients, respectively. Multivariate analysis revealed that higher doses of statins (per 10% increase) and lower 6-month LDL cholesterol levels (per 10 mg/dL decrease) were both independently associated with lower all-cause mortality (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.62 to 0.80; and HR, 0.96; 95% CI, 0.93 to 0.98, respectively) and cardiac death (HR, 0.76; 95% CI, 0.67 to 0.86; and HR, 0.95; 95% CI, 0.92 to 0.98, respectively). Higher high-density lipoprotein cholesterol levels also correlated significantly with lower all-cause and cardiac mortality. Higher doses of statins (per 10% increase) were associated with less progression to kidney failure (HR, 0.69; 95% CI, 0.54 to 0.89). Conclusions: Higher doses of statins and lower LDL cholesterol levels are both independently associated with improved outcome in patients with peripheral arterial disease. These results support the view that statins have beneficial effects beyond their lipid-lowering properties and should be considered in all patients with PAD, irrespective of LDL cholesterol levels.

Coronary artery stent placement immediately before noncardiac surgery: A potential risk? [11] (Article)

2007-05-01T00:00:00Z

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.

Myocardial Damage in High-risk Patients Undergoing Elective Endovascular or Open Infrarenal Abdominal Aortic Aneurysm Repair (Article)

2007-05-01T00:00:00Z

Objective: Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results. Methods: Consecutive patients with ≥3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death. Results: All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p = 0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p = 0.02) was significantly lower in patients receiving endovascular repair. Conclusion: In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.

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.

Indications of prophylactic coronary revascularization in patients undergoing major vascular surgery: The saga continues (Article)

2007-03-01T00:00:00Z

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.

Scar tissue on contrast-enhanced MRI predicts left ventricular remodelling after acute infarction (Article)

2007-03-01T00:00:00Z

Mitral Valve Repair and Replacement in Endocarditis: A Systematic Review of Literature (Article)

2007-02-01T00:00:00Z

Background: Several observational studies have suggested a superior survival after mitral valve repair compared with replacement in patients undergoing surgery for infective endocarditis. The objective of this study was to systematically review the rate of morbidity and mortality associated with mitral valve repair or replacement in infective endocarditis. Methods: A Medline search was conducted for literature and a systematic review of 24 studies, reporting prognosis of patients who underwent surgery for mitral valve endocarditis, was performed. Information on the patients, type of surgery, and follow-up was abstracted using standardized protocols. Results: A total of 470 patients (39%) underwent mitral valve repair and 724 patients (61%) underwent valve replacement. Lower in-hospital mortality (2.3% versus 14.4%, relative risk: 0.16, 95% confidence interval: 0.09 to 0.30, p < 0.0001) and long-term mortality (7.8% versus 40.5%, relative risk: 0.19, 95% confidence interval: 0.13 to 0.29, p < 0.0001) were observed among patients undergoing mitral valve repair compared with replacement. In addition, the rates of early reoperation (2.2% versus 12.7%, p < 0.0001), early cerebrovascular events (4.7% versus 11.5%, p = 0.045), late reoperation (4.7% versus 8.7%, p = 0.039), late recurrent endocarditis (1.8% versus 7.3%, p = 0.0013), and late cerebrovascular events (1.6% versus 24.4%, p < 0.0001) were significantly lower after mitral valve repair. Meta-regression analysis demonstrated that mitral valve repair over replacement was associated with a better early and late prognosis after surgery. Male sex and acute surgery were (nonsignificantly) predictive of worse early outcome. Conclusions: A systematic review of literature showed that mitral valve repair is associated with good clinical in-hospital and long-term results among patients undergoing surgery for infective endocarditis.

Tolerability and blood pressure-lowering efficacy of the combination of amlodipine plus valsartan compared with lisinopril plus hydrochlorothiazide in adult patients with stage 2 hypertension (Article)

2007-02-01T00:00:00Z

Background: Most patients with hypertension in the United States and Europe fail to achieve the recomended target blood pressure (BP) of <140/90 mm Hg. Combination therapy is required in approximately two thirds of all patients whose BP is >20/10 mm Hg above the goal. Combination therapy with agents having complernentary mechanisms of action, such as a calcium channel blocker and an angiotensin II-receptor blacker, would be a potentially useful therapeutic option. Objectives: This study evaluated the overall safetyprofile of combination therapy with amlodipine plus valsartan compared with a combination of lisinopril plus hydrochlorothiazide (HCTZ) in patients with stage 2 hypertension (mean sitting diastolic BP [MSDBP] ≥110 and <120 mm Hg) over the short term (6 weeks). A secondary objective was to evaluate the efficacy of the 2 regimens in achieving BP reduction. Methods: This was an international, multicenter, randomized, double-blind, active-controlled, parallel-group study. Patients were randomized to receive once-daily treatment with amlodipine 5 to 10 mg + valsartan 160 mg or lisinopril 10 to 20 mg + HCTZ 12.5 rig for 6 weeks. Safety assessments included monitoring of all adverse events, vital signs, and hematology and biochemistry variables. Efficacy variables included the changes from baseline in MSDBP and mean sitting systolic BP (MSSBP), the response rate (MSDBP <90 mm Hg, or a ≥ 10-mm Hg reduction from baseline), and the rate of DBP control (<90 mm Hg). The overall rate of BP control (proportion of patients with MSSBP/MSDBP <140/90 mm Hg) was evaluated in a post hoc analysis. Efficacy variables were summasized at each visit and at the end of the study (week 6, applying last-observation-carried-forward methodology) using descriptive statistics for the intent-to-treat population (all randomized patients with a baseline BP measurement and at least 1 postbaseline BP measurement). Subgroup analyses of BP changes were performed in prespecified age groups (<65 and ≥65 years) and post hoc in patients with a baseline systolic BP <180 and ≥180 mm Hg. Results: Of 130 patients who were randomized totreatment, 128 completed the study: 63 in the amlodipine + valsartan group and 65 in the lisinopril + HCTZ group. The majority of patients in both groups were white (amlodipine + valsartan: 59.4% lisinopril + HCTZ: 60.6%) and female (57.8% and 54.5%, respectively). The mean age was similar in the 2 groups (56.5 and 57.6 years), as was the mean weight (85.1 and 82.0 kg). Both regimens were generally well tolerated. Adverse events were mild to moderate in severity, and most were not considered related to study drug. At the 6-week end point, both the amlodipine + valsartan and hsinopril + HCTZ groups had achieved significant reductions from baseline in MSSBP (-35.8 [11.8] and -31.8 [14.7] mm Hg, respectively; both, P < 0.001) and MSDBP (-28.6 [7.7] and -27.6 [8.6] mm Hg; both, P < 0.001). Response rates were similar for the 2 treatment groups (100% and 95.5%), as were rates of DBP control (79.7% and 77.3%). Conclusions: The combinations of amlodipine 5 to 10 rug + valsartan 160 mg and lisinopril 10 to 20 mg + HCTZ 12.5 mg were well tolerated and efficacious, and both treatments were associated with achievement of BP goals in the majority of these adult patients with stage 2 hypertension.

Beta-blockers and statins are individually associated with reduced mortality in patients undergoing noncardiac, nonvascular surgery (Article)

2007-02-01T00:00:00Z

BACKGROUND: Patients undergoing noncardiac, nonvascular surgery are at risk for perioperative mortality owing to underlying (a)symptomatic coronary artery disease. We hypothesized that β-blocker and statin use are associated with reduced perioperative mortality. METHODS: We performed a case-control study in 75 581 patients who underwent 108 593 noncardiac, nonvascular surgery at the Erasmus Medical Center between 1991 and 2001. Cases were the 989 patients who died during hospital stay after surgery. From the remaining patients, 1879 matched controls (age, sex, calendar year and type of surgery) were selected. Information was then obtained regarding the use of β-blockers and statins and the presence of cardiac risk factors. RESULTS: The median age of the study population was 63 years; 61% were men. β-blockers were less often used in cases than in controls (6.2 vs. 8.2%; P=0.05), as were statins (2.4 vs. 5.5%; P<0.001). After adjustment for the propensity of β-blocker use and cardiovascular risk factors, β-blockers were associated with a 59% mortality reduction (odds ratio 0.41; 95% confidence interval 0.28-0.59). Statins were associated with a 60% mortality reduction (adjusted odds ratio 0.40; 95% confidence interval 0.24-0.68). A significant interaction between β-blockers and statins was observed (P<0.001). In the presence of each other, statins and β-blockers were not associated with reduced mortality (adjusted odds ratio 2.0 and 95% confidence interval 0.74-5.7 and adjusted odds ratio 1.3 and 95% confidence interval 0.52-3.2). It should be, however, noted that only nine cases and 29 controls used both agents simultaneously. CONCLUSION: This case-control study provides evidence that β-blockers and statins are individually associated with a reduction of perioperative mortality in patients undergoing noncardiac, nonvascular surgery.

Assessment of right ventricular infarction with contrast-enhanced magnetic resonance imaging (Article)

2007-02-01T00:00:00Z

OBJECTIVE: Evaluation of contrast-enhanced magnetic resonance imaging to assess right ventricular infarction in patients with acute inferior myocardial infarction. BACKGROUND: Contrast-enhanced magnetic resonance imaging has been used for assessing scar tissue after left ventricular infarction. The value of contrast-enhanced magnetic resonance imaging to assess right ventricular infarction is unknown and was evaluated. METHODS: Consecutive patients (n=18) with first acute inferior infarction were included. Resting electrocardiogram and right-sided electrocardiogram were acquired to assess right ventricular involvement. Resting cine magnetic resonance imaging was performed to evaluate right ventricular function and volumes, whereas the extent of right ventricular scar tissue was assessed by contrast-enhanced magnetic resonance imaging. Cine magnetic resonance imaging was repeated at 6-months follow-up to re-assess right ventricular function and volumes. RESULTS: Sensitivity and specificity of magnetic resonance imaging were 100 and 78%, respectively, to detect right ventricular infarction (using the right-sided electrocardiogram as the gold standard). At 6 months follow-up, patients with scar tissue on contrast-enhanced magnetic resonance imaging showed right ventricular dilatation. Moreover, the extent of right ventricular scar tissue was linearly related to the severity of right ventricular dilatation. CONCLUSIONS: Contrast-enhanced magnetic resonance imaging permits accurate assessment of right ventricular scar tissue. Patients with extensive right ventricular infarction demonstrate right ventricular dilatation at 6 months follow-up.

Outcome after redo coronary artery bypass grafting in patients with ischaemic cardiomyopathy and viable myocardium (Article)

2007-02-01T00:00:00Z

Background: Repeat coronary artery bypass grafting (redo-CABG) in patients with ischaemic cardiomyopathy is associated with high perioperative risk and worse long-term outcome compared with patients undergoing their first CABG. Objective: To assess whether patients with viable myocardium undergoing redo-CABG have a better outcome. Methods: 18 patients with ischaemic cardiomyopathy underwent redo-CABG and 34 underwent their first CABG; all had substantial viability (≥25% of the left ventricle) on dobutamine stress echocardiography (DSE). Left ventricular ejection fraction (LVEF) and heart failure symptoms were assessed before and 9-12 months after revascularisation. Cardiac event rate was assessed during the follow-up period (median 4 years, 25-75th centile 2.8-4.9 years). Results: The extent of viable myocardium on DSE was comparable in the two groups (11.3 (3.9) segments in patients who underwent redo-CABG v 12.8 (3.0) in patients who underwent their first CABG; p = NS). LVEF improved from 32% (9%) to 39% (12%); p = 0.01, in patients who underwent redo-CABG and from 30% (7%) to 36% (7%); p<0.01, in those who underwent their first CABG; New York Heart Association class improved from 2.5 (1.1) to 1.9 (0.8); p = 0.03, and from 2.7 (1.0) to 1.8 (0.70); p<0.01, respectively. In patients who underwent redo-CABG, the perioperative mortality was 0, post-surgery inotropic support was needed in 11% of the patients and mid-term (4-year) survival was 100%, with a total event rate of 28%. All these variables were not statistically different from patients who underwent their first CABG (p = 0.50, 0.90, 0.08 and 0.81, respectively). Conclusion: Patients with ischaemic cardiomyopathy and substantial viability undergoing redo-CABG benefit from revascularisation in terms of improvement in LVEF, heart failure symptoms, angina and mid-term prognosis.

Plasma N-terminal pro-B-type natriuretic peptide as long-term prognostic marker after major vascular surgery (Article)

2007-02-01T00:00:00Z

Objective: To assess the long-term prognostic value of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) after major vascular surgery. Design: A single-centre prospective cohort study. Patients: 335 patients who underwent abdominal aortic aneurysm repair or lower extremity bypass surgery. Interventions: Prior to surgery, baseline NT-proBNP level was measured. Patients were also evaluated for cardiac risk factors according to the Revised Cardiac Risk Index. Dobutamine stress echocardiography (DSE) was performed to detect stress-induced myocardial ischaemia. Main outcome measures: The prognostic value of NT-proBNP was evaluated for the endpoints all-cause mortality and major adverse cardiac events (MACE) during long-term follow-up. Results: In this patient cohort (mean age: 62 years, 76% male), median NT-proBNP level was 186 ng/l (interquartile range: 65-444 ng/l). During a mean follow-up of 14 (SD 6) months, 49 patients (15%) died and 50 (15%) experienced a MACE. Using receiver operating characteristic curve analysis for 6-month mortality and MACE, NT-proBNP had the greatest area under the curve compared with cardiac risk score and DSE. In addition, an NT-proBNP level of 319 ng/l was identified as the optimal cut-off value to predict 6-month mortality and MACE. After adjustment for age, cardiac risk score, DSE results and cardioprotective medication, NT-proBNP ≥319 ng/l was associated with a hazard ratio of 4.0 for all-cause mortality (95% CI: 1.8 to 8.9) and with a hazard ratio of 10.9 for MACE (95% CI: 4.1 to 27.9). Conclusion: Preoperative NT-proBNP level is a strong predictor of long-term mortality and major adverse cardiac events after major non-cardiac vascular surgery.

Pro: Beta-blockers are indicated for patients at risk for cardiac complications undergoing noncardiac surgery (Article)

2007-01-01T00:00:00Z

Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery (Article)

2007-01-01T00:00:00Z

Objective: To determine the relationship between preoperative glucose levels and perioperative mortality in noncardiac, nonvascular surgery. Research design and methods: We performed a case-control study in a cohort of 108 593 patients who underwent noncardiac surgery at the Erasmus MC during 1991-2001. Cases were 989 patients who underwent elective noncardiac, nonvascular surgery and died within 30 days during hospital stay. From the remaining patients, 1879 matched controls (age, sex, calendar year, and type of surgery) were selected. Information was obtained regarding the presence of cardiac risk factors, medication, and preoperative laboratory results. Preoperative random glucose levels < 5.6 mmol/l (110 mg/dl) were normal. Impaired glucose levels in the range of 5.6-11.1 mmol/l were prediabetes. Glucose levels ≥ 11.1 mmol/l (200 mg/dl) were diabetes. Results: Preoperative glucose levels were available in 904 cases and 1247 controls. A cardiovascular complication was the primary cause of death in 207 (23%) cases. Prediabetes glucose levels were associated with a 1.7-fold increased mortality risk compared with normoglycernic levels (adjusted odds ratio (OR) 1.7 and 95% confidence interval (CI) 1.4-2.1; P<0.001). Diabetes glucose levels were associated with a 2.1-fold increased risk (adjusted OR 2.1 and 95% CI 1.3-3.5; P<0.001). In cases with cardiovascular death, prediabetes glucose levels had a threefold increased cardiovascular mortality risk (adjusted OR 3.0 and 95% CI 1.7-5.1) and diabetes glucose levels had a fourfold increased cardiovascular mortality risk (OR 4.0 and 95% CI 1.3-12). Conclusions: Preoperative hyperglycemia is associated with increased (cardiovascular) mortality in patients undergoing noncardiac, nonvascular surgery.

Increase of 1-year Mortality After Perioperative Beta-blocker Withdrawal in Endovascular and Vascular Surgery Patients (Article)

2007-01-01T00:00:00Z

Objectives: To assess the relation between beta-blocker use, underlying cardiac risk, and 1-year outcome in vascular surgery patients, including the effect of beta-blocker withdrawal. Design: Prospective survey. Materials: 711 consecutive peripheral vascular surgery patients from 11 hospitals in the Netherlands between May and December 2004. Methods: Patients were evaluated for cardiac risk factors, beta-blocker use and 1-year mortality. Low and high risk was defined according to the Revised Cardiac Risk Index. Propensity scores for the likelihood of beta-blocker use were calculated and regression models were used to study the relation between beta-blocker use and mortality. Results: 285 patients (40%) received beta-blockers throughout the perioperative period (continuous users). Only 52% of the 281 high risk patients received continuous beta-blocker therapy. Beta-blocker therapy was started in 29 and stopped in 21 patients, respectively. One-year mortality was 11%. After adjustment for potential confounders and the propensity of its use, continuous beta-blocker use remained significantly associated with a lower 1-year mortality compared to non-users (HR = 0.4; 95%CI = 0.2-0.7). In contrast, beta-blocker withdrawal was associated with an increased risk of 1-year mortality compared to non-users (HR = 2.7; 95%CI = 1.2-5.9). Conclusions: We demonstrated an under-use of beta-blockers in vascular surgery patients, even in high-risk patients. Perioperative beta-blocker use was independently associated with a lower risk of 1-year mortality compared to non-use, while perioperative withdrawal of beta-blocker therapy was associated with a higher 1-year mortality.

Evaluation of a hand carried cardiac ultrasound device in an outpatient cardiology clinic (Article)

2005-01-01T00:00:00Z

OBJECTIVE: To determine the diagnostic potential of a hand carried cardiac ultrasound (HCU) device (OptiGo, Philips Medical Systems) in a cardiology outpatient clinic and to compare the HCU diagnosis with the clinical diagnosis and diagnosis with a full featured standard echocardiography (SE) system. METHODS: 300 consecutive patients took part in the study. The HCU examination was performed by an experienced echocardiographer before patients visited the cardiologist. The echocardiographer noted whether the HCU device was able to confirm or reject the referral diagnosis, which abnormality was detected, and whether SE investigation was necessary. Physical examination by a cardiologist followed and thereafter, whenever required, a complete study with an SE was carried out. The HCU data were compared with the clinical diagnosis of the cardiologist and the SE diagnosis in a blinded manner. RESULTS: The cardiologist referred 203 of 300 patients for an SE study and 13 patients for transoesophageal echocardiography. In 84 patients no further examination was considered necessary. HCU echocardiography was able to confirm or reject the suspected clinical diagnosis in 159 of 203 (78%) patients. In 44 of 203 (22%) patients SE Doppler was needed. Agreement between the HCU device and the SE system for the detection of major abnormalities was excellent (98%). The HCU device missed 4% of the major findings. Among the 84 patients not referred for an SE, the HCU device detected unsuspected major abnormalities missed with the physical examination in 14 (17%). CONCLUSION: Integration of an HCU device with the physical examination augments the yield of information.

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.

Clinical assessment of myocardial hibernation (Article)

2005-01-01T00:00:00Z

Perioperatieve cardiovasculaire zorg: risico en zorg op maat (Inaugural Lecture)

2004-06-11T00:00:00Z

Pulsed wave tissue Doppler imaging for the quantification of contractile reserve in stunned, hibernating, and scarred myocardium (Article)

2004-01-01T00:00:00Z

OBJECTIVES: To assess whether quantification of myocardial systolic velocities by pulsed wave tissue Doppler imaging can differentiate between stunned, hibernating, and scarred myocardium. DESIGN: Observational study. SETTING: Tertiary referral centre. PATIENTS: 70 patients with reduced left ventricular function caused by chronic coronary artery disease. METHODS: Pulsed wave tissue Doppler imaging was done close to the mitral annulus at rest and during low dose dobutamine; systolic ejection velocity (Vs) and the difference in Vs between low dose dobutamine and the resting value (DeltaVs) were assessed using a six segment model. Assessment of perfusion (with Tc-99m-tetrofosmin SPECT) and glucose utilisation (by 18F-fluorodeoxyglucose SPECT) was used to classify dysfunctional regions (by resting cross sectional echocardiography) as stunned, hibernating, or scarred. RESULTS: 253 of 420 regions (60%) were dysfunctional. Of these, 132 (52%) were classified as stunned, 25 (10%) as hibernating, and 96 (38%) as scarred. At rest, Vs in stunned, hibernating, and scar tissue was, respectively, 6.3 (1.8), 6.6 (2.2), and 5.5 (1.5) cm/s (p = 0.001 by ANOVA). There was a gradual decline in Vs during low dose dobutamine infusion between stunned, hibernating, and scar tissue (8.3 (2.6) v 7.8 (1.5) v 6.8 (1.9) cm/s, p < 0.001 by ANOVA). DeltaVs was higher in stunned (2.1 (1.9) cm/s) than in hibernating (1.2 (1.4) cm/s, p < 0.05) or scarred regions (1.3 (1.2) cm/s, p = 0.001). CONCLUSIONS: Quantitative tissue Doppler imaging showed a gradual reduction in regional velocities between stunned, hibernating, and scarred myocardium. Dobutamine induced contractile reserve was higher in stunned regions than in hibernating and scarred myocardium, reflecting different severities of myocardial damage

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 (

Relation between left ventricular contractile reserve during low dose dobutamine echocardiography and plasma concentrations of natriuretic peptides (Article)

2004-01-01T00:00:00Z

BACKGROUND: In ischaemic cardiomyopathy, raised plasma concentrations of natriuretic peptides are associated with a poor long term prognosis, while the presence of contractile reserve is a favourable sign. OBJECTIVE: To assess the relation between plasma natriuretic peptides and contractile reserve. DESIGN: Prospective observational study. SETTING: Tertiary referral centre. PATIENTS: 66 consecutive patients undergoing low dose dobutamine stress echocardiography to evaluate contractile reserve in regions with contractile dysfunction at rest, divided into two groups: group 1, 31 patients with ischaemic cardiomyopathy (left ventricular ejection fraction < or = 40%) and heart failure symptoms; group 2, 35 patients with normal left ventricular function. MAIN OUTCOME MEASURES: Plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), measured using immunoradiometric assays. Contractile reserve was defined as an improvement in segmental wall motion score during infusion of low dose dobutamine. RESULTS: Plasma ANP and BNP concentrations were higher in group 1 than in group 2 (mean (SD): ANP, 17.8 (32.8) v 7.2 (9.7), p < 0.005; BNP, 24.4 (69.0) v 5.0 (14.3) pmol/l, respectively; p < 0.001). In group 1, the presence of contractile reserve was inversely related to ANP and BNP levels; however, patients with contractile reserve had lower ANP and BNP concentrations than patients without contractile reserve (ANP, 14.2 (9.1) v 24.2 (44.2), p < 0.05; BNP, 20.2 (25.5) v 37.5 (93.8) pmol/l, respectively; p < 0.05). CONCLUSIONS: Plasma natriuretic peptide concentrations are raised in patients with left ventricular dysfunction, but in the presence of preserved myocardial contractile reserve, relatively low levels of ANP and BNP are present.

Catheter-based intramyocardial injection of autologous skeletal myoblasts as a primary treatment of ischemic heart failure: clinical experience with six-month follow-up. (Article)

2003-12-17T00:00:00Z

Objectives We report on the procedural and six-month results of the first percutaneous and stand-alone study on myocardial repair with autologous skeletal myoblasts. Background Preclinical studies have shown that skeletal myoblast transplantation to injured myocardium can partially restore left ventricular (LV) function. Methods In a pilot safety and feasibility study of five patients with symptomatic heart failure (HF) after an anterior wall infarction, autologous skeletal myoblasts were obtained from the quadriceps muscle and cultured in vitro for cell expansion. After a culturing process, 296 ± 199 million cells were harvested (positive desmin staining 55 ± 30%). With a NOGA-guided catheter system (Biosense-Webster, Waterloo, Belgium), 196 ± 105 million cells were transendocardially injected into the infarcted area. Electrocardiographic and LV function assessment was done by Holter monitoring, LV angiography, nuclear radiography, dobutamine stress echocardiography, and magnetic resonance imaging (MRI). Results All cell transplantation procedures were uneventful, and no serious adverse events occurred during follow-up. One patient received an implantable cardioverter-defibrillator after transplantation because of asymptomatic runs of nonsustained ventricular tachycardia. Compared with baseline, the LV ejection fraction increased from 36 ± 11% to 41 ± 9% (3 months, P = 0.009) and 45 ± 8% (6 months, P = 0.23). Regional wall analysis by MRI showed significantly increased wall thickening at the target areas and less wall thickening in remote areas (wall thickening at target areas vs. 3 months follow-up: 0.9 ± 2.3 mm vs. 1.8 ± 2.4 mm, P = 0.008). Conclusions This pilot study is the first to demonstrate the potential and feasibility of percutaneous skeletal myoblast delivery as a stand-alone procedure for myocardial repair in patients with post-infarction HF. More data are needed to confirm its safety.

Noninvasive evaluation of ischaemic heart disease: myocardial perfusion imaging or stress echocardiography? (Article)

2003-05-01T00:00:00Z

Stress echocardiography and myocardial perfusion imaging are commonly used noninvasive imaging modalities for the evaluation of ischaemic heart disease. Both modalities have proved clinically useful in the entire spectrum of coronary artery disease. Both techniques can detect coronary artery disease and provide prognostic information. Both techniques can identify low-risk and high-risk subsets among patients with known or suspected coronary artery disease and thus guide patient management decisions. In patients with acute myocardial infarction, both techniques have been used to identify residual viable tissue and predict improvement of function over time. In patients with chronic ischaemic left ventricular (LV) dysfunction, viability assessment with either modality can be used to predict improvement of function after revascularisation and thus guide patient treatment.

Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery. (Article)

2003-04-15T00:00:00Z

BACKGROUND: Patients undergoing major vascular surgery are at increased risk of perioperative mortality due to underlying coronary artery disease. Inhibitors of the 3-hydroxy-3-methylglutaryl coenzyme A (statins) may reduce perioperative mortality through the improvement of lipid profile, but also through the stabilization of coronary plaques on the vascular wall. METHODS AND RESULTS: To evaluate the association between statin use and perioperative mortality, we performed a case-controlled study among the 2816 patients who underwent major vascular surgery from 1991 to 2000 at the Erasmus Medical Center. Case subjects were all 160 (5.8%) patients who died during the hospital stay after surgery. From the remaining patients, 2 controls were selected for each case and were stratified according to calendar year and type of surgery. For cases and controls, information was obtained regarding statin use before surgery, the presence of cardiac risk factors, and the use of other cardiovascular medication. A vascular complication during the perioperative phase was the primary cause of death in 104 (65%) case subjects. Statin therapy was significantly less common in cases than in controls (8% versus 25%; P<0.001). The adjusted odds ratio for perioperative mortality among statin users as compared with nonusers was 0.22 (95% confidence interval 0.10 to 0.47). Similar results were obtained in subgroups of patients according to the use of cardiovascular therapy and the presence of cardiac risk factors. CONCLUSIONS: This case-controlled study provides evidence that statin use reduces perioperative mortality in patients undergoing major vascular surgery.

Acute myocardial infardion (Article)

2003-03-08T00:00:00Z

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.

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.

A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery (Article)

2003-01-01T00:00:00Z

OBJECTIVE: To evaluate the discriminatory value and compare the predictive performance of six non-invasive tests used for perioperative cardiac risk stratification in patients undergoing major vascular surgery. DESIGN: Meta-analysis of published reports. METHODS: Eight studies on ambulatory electrocardiography, seven on exercise electrocardiography, eight on radionuclide ventriculography, 23 on myocardial perfusion scintigraphy, eight on dobutamine stress echocardiography, and four on dipyridamole stress echocardiography were selected, using a systematic review of published reports on preoperative non-invasive tests from the Medline database (January 1975 and April 2001). Random effects models were used to calculate weighted sensitivity and specificity from the published results. Summary receiver operating characteristic (SROC) curve analysis was used to evaluate and compare the prognostic accuracy of each test. The relative diagnostic odds ratio was used to study the differences in diagnostic performance of the tests. RESULTS: In all, 8119 patients participated in the studies selected. Dobutamine stress echocardiography had the highest weighted sensitivity of 85% (95% confidence interval (CI) 74% to 97%) and a reasonable specificity of 70% (95% CI 62% to 79%) for predicting perioperative cardiac death and non-fatal myocardial infarction. On SROC analysis, there was a trend for dobutamine stress echocardiography to perform better than the other tests, but this only reached significance against myocardial perfusion scintigraphy (relative diagnostic odds ratio 5.5, 95% CI 2.0 to 14.9). CONCLUSIONS: On meta-analysis of six non-invasive tests, dobutamine stress echocardiography showed a positive trend towards better diagnostic performance than the other tests, but this was only significant in the comparison with myocardial perfusion scintigraphy. However, dobutamine stress echocardiography may be the favoured test in situations where there is valvar or left ventricular dysfunction.

Quantification of regional left ventricular function in Q wave and non-Q wave dysfunctional regions by tissue Doppler imaging in patients with ischaemic cardiomyopathy (Article)

2003-01-01T00:00:00Z

OBJECTIVE: To quantify regional left ventricular (LV) function and contractile reserve in Q wave and non-Q wave regions in patients with previous myocardial infarction. DESIGN: An observational study. SETTING: Tertiary care centre. PATIENTS: 81 patients with previous myocardial infarction and depressed LV function. INTERVENTIONS: All patients underwent surface ECG at rest and pulsed wave tissue Doppler imaging at rest and during low dose dobutamine infusion. The left ventricle was divided into four major regions (anterior, inferoposterior, septal, and lateral). Severely hypokinetic, akinetic, and dyskinetic regions on two dimensional echocardiography at rest were considered dysfunctional. MAIN OUTCOME MEASURES: Regional myocardial systolic velocity (Vs) at rest and the change in Vs during low dose dobutamine infusion (DeltaVs) in dysfunctional regions with and without Q waves on surface ECG. RESULTS: 220 (69%) regions were dysfunctional; 60 of these regions corresponded to Q waves and 160 were not related to Q waves. Vs and DeltaVs were lower in dysfunctional than in non-dysfunctional regions (mean (SD) Vs 6.2 (1.9) cm/s v 7.1 (1.7) cm/s (p < 0.001), and DeltaVs 1.9 (1.9) cm/s v 2.6 (2.5) cm/s (p = 0.009), respectively). There were no significant differences in Vs and DeltaVs among dysfunctional regions with and without Q waves (Q wave regions: Vs 6.2 (1.8) cm/s, DeltaVs 1.6 (2.2) cm/s; non-Q wave regions: Vs 6.3 (1.9) cm/s, DeltaVs 2.0 (2.0) cm/s). CONCLUSIONS: Quantitative pulsed wave tissue Doppler demonstrated that, among dysfunctional regions, Q waves on the ECG do not indicate more severe dysfunction, and myocardial contractile reserve is comparable in Q wave and non-Q wave dysfunctional myocardium.

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.

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.

Prevalence of myocardial viability assessed by single photon emission computed tomography in patients with chronic ischaemic left ventricular dysfunction (Article)

2002-01-01T00:00:00Z

OBJECTIVE: To assess the prevalence of myocardial viability by technetium-99m (Tc-99m)-tetrofosmin/fluorine-18-fluorodeoxyglucose (FDG) single photon emission computed tomography (SPECT) in patients with ischaemic cardiomyopathy. DESIGN: A retrospective observational study. SETTING: Thoraxcenter Rotterdam (a tertiary referral centre). PATIENTS: 104 patients with chronic coronary artery disease and severely depressed left ventricular function presenting with heart failure symptoms. MAIN OUTCOME MEASURES: Prevalence of myocardial viability as evaluated by Tc-99m-tetrofosmin/FDG SPECT imaging. Two strategies for assessing viability in dysfunctional myocardium were used: perfusion imaging alone, and the combination of perfusion and metabolic imaging. RESULTS: On perfusion imaging alone, 56 patients (54%) had a significant amount of viable myocardium, whereas 48 patients (46%) did not. Among the 48 patients with no significant viability by perfusion imaging alone, seven additional patients (15%) had significantly viable myocardium on combined perfusion and metabolic imaging. Thus with a combination of perfusion and metabolic imaging, 63 patients (61%) had viable myocardium and 41 (39%) did not. CONCLUSIONS: On the basis of the presence of viable dysfunctional myocardium, 61% of patients with chronic coronary artery disease and depressed left ventricular ejection fraction presenting with heart failure symptoms may be considered for coronary revascularisation. The combination of perfusion and metabolic imaging identified more patients with significant viability than myocardial perfusion imaging alone.

Deterioration of left ventricular function following atrio-ventricular node ablation and right ventricular apical pacing in patients with permanent atrial fibrillation (Article)

2002-01-01T00:00:00Z

AIMS: Transcatheter radiofrequency ablation of the atrio-ventricular (AV) node followed by ventricular pacing has been shown to improve symptoms and quality of life of patients with atrial fibrillation (AF). It is assumed that function improves, but this has been less well demonstrated. The aim of this study was to assess the long-term effect of AV node ablation and ventricular pacing on left ventricular ejection fraction (LVEF) in patients with permanent AF. METHODS AND RESULTS: All 12 patients studied had permanent AF for at least 12 months (mean age 70 years, range 41 to 78). LVEF was determined 6 days and 3 months after AV node ablation by radionuclide ventriculography, at a paced rate of 80 beats . min (-1). Cardiac dimensions were measured by means of transthoracic echocardiography. No major changes in pharmacological therapy were made during 3 months follow-up period. LVEF showed a significant deterioration after 3 months follow-up period for the group (47.5 +/- 14.4%; 6 days after ablation vs 43.2 +/- 13.7%; 3 months after ablation, P < 0.05). There were no significant differences in left ventricular cavity dimensions directly after AV node ablation and 3 months later (LVEDD 51.2 +/- 10.7 mm vs 52.6 +/- 8.6 mm, P = NS: LVESD: 36.1 +/- 14.2 mm vs 36.6 +/- 9.7 mm, P = NS). Left atrial size did not show reduction 3 months after AV node ablation (50.8 +/- 13.6 mm vs 51.0 +/- 14.1 mm, P = NS). CONCLUSION: The restoration of a regular ventricular rhythm following AV node ablation for patients in permanent AF does not result in improvement in left ventricular function.

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.

Left ventricular hypertrophy screening using a hand-held ultrasound device (Article)

2002-01-01T00:00:00Z

AIMS: To test the diagnostic potential of a hand-held ultrasound device for screening for left ventricular hypertrophy in a hypertensive population using a standard echocardiographic system as a reference. METHODS: One hundred consecutive hypertensive patients were enrolled. An experienced investigator performed measurements of the thickness of the anterior septum and posterior wall using the parasternal 2D-long axis view and the end-diastolic dimension of the left ventricle with both imaging devices. Left ventricular hypertrophy was defined as an increase in left ventricular mass > or = 134 g x m(-2) for men and > or = 110 g x m(-2) for women, when indexed for body surface area and > or = 143 g x m(-1) for men and > or = 102 g x m(-1) for women, when indexed for height. RESULTS: Sixty-five men and 35 women were studied (age 60 +/- 11 years); mean duration of hypertension: 13 +/- 11 years; mean blood pressures: systolic 150 +/- 20 mmHg and diastolic 89 +/- 11 mmHg. The anterior septum and posterior wall were visualized in all patients with both imaging devices. The standard echocardiographic system identified left ventricular hypertrophy by body surface area in 18 (18%) patients and by height in 26 (26%) patients. The agreement between the standard echocardiographic system and the hand-held device for the assessment of left ventricular hypertrophy was 93%, kappa: 0.77 (left ventricular mass/body surface area) and 90%, kappa: 0.76 (left ventricular mass/height). CONCLUSIONS: We conclude that hand-held devices can be effectively applied for screening for left ventricular hypertrophy in hypertensive patients.

Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery. (Article)

2001-08-22T00:00:00Z

AIM: To assess the long-term cardioprotective effect of bisoprolol in a randomized high-risk population after successful major vascular surgery. High-risk patients were defined by the presence of one or more cardiac risk factor(s) and a dobutamine echocardiography test positive for ischaemia. METHODS: 1351 patients were screened prior to surgery, 846 patients had one or more risk factor(s), and 173 of these patients also had ischaemia during dobutamine echocardiography. One hundred and twelve patients could be randomized for additional bisoprolol therapy or standard care. Eleven patients died in the peri-operative period (up to 1 month after surgery). Randomized patients continued bisoprolol or standard care after surgery. During follow-up of 101 survivors (median 22 months, range 11-30) cardiac death or myocardial infarction was noted. No patient was lost during follow-up.Results The incidence of cardiac events during follow-up in the bisoprolol group was 12% vs 32% in the standard care group (P=0.025). Cardiac death occurred in 15 patients, nine patients in the standard care and in six in the bisoprolol group; myocardial infarction occurred in six patients, five in the standard care and one in the bisoprolol group. The odds ratio for cardiac death or myocardial infarction after surgery in high-risk patients with additional bisoprolol therapy was 0.30 (0.11-0.83). CONCLUSIONS: Bisoprolol significantly reduced long-term cardiac death and myocardial infarction in high-risk patients after successful major cardiac vascular surgery.

Improved identification of viable myocardium using second harmonic imaging during dobutamine stress echocardiography (Article)

2001-01-01T00:00:00Z

OBJECTIVE: To determine whether, compared with fundamental imaging, second harmonic imaging can improve the accuracy of dobutamine stress echocardiography for identifying viable myocardium, using nuclear imaging as a reference. PATIENTS: 30 patients with chronic left ventricular dysfunction (mean (SD) age, 60 (8) years; 22 men). METHODS: Dobutamine stress echocardiography was carried out in all patients using both fundamental and second harmonic imaging. All patients underwent dual isotope simultaneous acquisition single photon emission computed tomography (DISA-SPECT) with (99m)technetium-tetrofosmin/(18)F-fluorodeoxyglucose on a separate day. Myocardial viability was considered present by dobutamine stress echocardiography when segments with severe dysfunction showed a biphasic sustained improvement or an ischaemic response. Viability criteria on DISA-SPECT were normal or mildly reduced perfusion and metabolism, or perfusion/metabolism mismatch. RESULTS: Using fundamental imaging, 330 segments showed severe dysfunction at baseline; 144 (44%) were considered viable. The agreement between dobutamine stress echocardiography by fundamental imaging and DISA-SPECT was 78%, kappa = 0.56. Using second harmonic imaging, 288 segments showed severe dysfunction; 138 (48%) were viable. The agreement between dobutamine stress echocardiography and DISA-SPECT was significantly better when second harmonic imaging was used (89%, kappa = 0.77, p = 0.001 v fundamental imaging). CONCLUSIONS: Second harmonic imaging applied during dobutamine stress echocardiography increases the agreement with DISA-SPECT for detecting myocardial viability.

Long-term prognostic value of dobutamine stress echocardiography in patients with atrial fibrillation (Article)

2001-01-01T00:00:00Z

STUDY OBJECTIVE: To assess the long-term prognostic value of dobutamine stress echocardiography (DSE) for cardiac events (cardiac death, myocardial infarction, and late revascularization) in patients with atrial fibrillation (AF). METHODS: Baseline ECGs were studied in patients undergoing DSE between 1989 and 1998. Sixty-nine patients had AF before DSE. Prognostic value of DSE in these patients was compared with a control group who had sinus rhythm (n = 1,664). The presence of stress-induced ischemia was noted for every patient. The mean follow-up period was 35 months (range, 6 to 84 months). Data are presented as hazards ratio (HR) with 95% confidence interval (CI). RESULTS: Heart rate at rest was higher in patients with AF (77 +/- 15 beats/min vs 73 +/- 14 beats/min; p = 0.04); however, double product at peak stress was not different between patients with AF and sinus rhythm (17,602 vs 17,169, respectively; p = 0.46). In patients with AF, target heart rate was achieved at a lower dobutamine dose (33 +/- 8 microg/kg/min vs 35 +/- 9 microg/kg/min; p = 0.01). Cardiac arrhythmias occurred more frequently (12% vs 5%; p = 0.001) in patients with AF during DSE. During a follow-up period of 7 years, cardiac death occurred in 5 patients, myocardial infarction in 2 patients, and late revascularization in 10 patients. Prognostic value of DSE for all late cardiac events was similar in patients with AF (HR, 3.0; 95% CI, 0.9 to 9.5) and sinus rhythm (HR, 3.4; 95% CI, 2.7 to 4.3; p = 0.85). CONCLUSION: The prognostic value of DSE for late cardiac events is maintained in patients with AF.

Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy (Article)

2001-01-01T00:00:00Z

CONTEXT: Patients who undergo major vascular surgery are at increased risk of perioperative cardiac complications. High-risk patients can be identified by clinical factors and noninvasive cardiac testing, such as dobutamine stress echocardiography (DSE); however, such noninvasive imaging techniques carry significant disadvantages. A recent study found that perioperative beta-blocker therapy reduces complication rates in high-risk individuals. OBJECTIVE: To examine the relationship of clinical characteristics, DSE results, beta-blocker therapy, and cardiac events in patients undergoing major vascular surgery. DESIGN AND SETTING: Cohort study conducted in 1996-1999 in the following 8 centers: Erasmus Medical Centre and Sint Clara Ziekenhuis, Rotterdam, Twee Steden Ziekenhuis, Tilburg, Academisch Ziekenhuis Utrecht, Utrecht, and Medisch Centrum Alkmaar, Alkmaar, the Netherlands; Ziekenhuis Middelheim, Antwerp, Belgium; and San Gerardo Hospital, Monza, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy. PATIENTS: A total of 1351 consecutive patients scheduled for major vascular surgery; DSE was performed in 1097 patients (81%), and 360 (27%) received beta-blocker therapy. MAIN OUTCOME MEASURE: Cardiac death or nonfatal myocardial infarction within 30 days after surgery, compared by clinical characteristics, DSE results, and beta-blocker use. RESULTS: Forty-five patients (3.3%) had perioperative cardiac death or nonfatal myocardial infarction. In multivariable analysis, important clinical determinants of adverse outcome were age 70 years or older; current or prior angina pectoris; and prior myocardial infarction, heart failure, or cerebrovascular accident. Eighty-three percent of patients had less than 3 clinical risk factors. Among this subgroup, patients receiving beta-blockers had a lower risk of cardiac complications (0.8% [2/263]) than those not receiving beta-blockers (2.3% [20/855]), and DSE had minimal additional prognostic value. In patients with 3 or more risk factors (17%), DSE provided additional prognostic information, for patients without stress-induced ischemia had much lower risk of events than those with stress-induced ischemia (among those receiving beta-blockers, 2.0% [1/50] vs 10.6% [5/47]). Moreover, patients with limited stress-induced ischemia (1-4 segments) experienced fewer cardiac events (2.8% [1/36]) than those with more extensive ischemia (>/=5 segments, 36% [4/11]). CONCLUSION: The additional predictive value of DSE is limited in clinically low-risk patients receiving beta-blockers. In clinical practice, DSE may be avoided in a large number of patients who can proceed safely for surgery without delay. In clinically intermediate- and high-risk patients receiving beta-blockers, DSE may help identify those in whom surgery can still be performed and those in whom cardiac revascularization should be considered.

Doppler tissue velocity sampling improves diagnostic accuracy during dobutamine stress echocardiography for the assessment of viable myocardium in patients with severe left ventricular dysfunction. (Article)

2000-07-01T00:00:00Z

BACKGROUND: Both nuclear imaging with F18-fluorodeoxyglucose and dobutamine stress echocardiography have been used to identify viable myocardium, although dobutamine-stress echocardiography has been demonstrated to be the less sensitive of the two. AIM: To compare the accuracy of pulsed-wave Doppler tissue sampling with dobutamine-stress echocardiography for the detection of viable myocardium, using F18-fluorodeoxyglucose imaging as a reference. Methods Forty patients with chronic coronary artery disease and left ventricular dysfunction (mean ejection fraction 33+/-11%), underwent F18-fluorodeoxyglucose imaging, dobutamine-stress echocardiography and pulsed-wave Doppler tissue sampling. Evaluation was performed using a six-segment model. RESULTS: Visual assessment by resting echo was feasible in 230 out of 240 segments (96%); 177 (77%) segments showed severe dyssynergy at rest. F18-fluorodeoxyglucose imaging showed viability in 95 (54%) segments while 82 (46%) were non-viable. Ejection phase velocity at rest was not significantly different; ejection velocities during low-dose and peak-dose dobutamine, however, were significantly higher in viable myocardium (8.6+/-2.9 vs 6.0+/-1.8 and 9.3+/-3.1 vs 6.2+/-2.1 cm x s(-1)). Using receiver operating characteristic curves the optimal cut-off value for viability assessment was an increase in the ejection phase velocity low-dose of 1+/-0.5 cm x s(-1), while 0+/-0.5 cm x s(-1)predicted non-viability. The sensitivity and specificity (95%CI) of pulsed-wave Doppler tissue sampling and dobutamine-stress echocardiography for the prediction of viability was respectively 87% (82-92) vs 75% (67-81) (P<0.05) and 52% (44-59) vs 51% (45-59) (P=ns). CONCLUSIONS: The sensitivity of pulsed-wave Doppler tissue sampling is superior to dobutamine-stress echocardiography for the assessment of myocardial viability.

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.

Long-Term Prognostic Value of Dobutamine-Atropine Stress Echocardiography in 1737 Patients With Known or Suspected Coronary Artery Disease (Article)

1999-01-01T00:00:00Z

Background—The purpose of this study was to assess the long-term value of dobutamine-atropine stress echocardiography (DSE) for prediction of late cardiac events in patients with proven or suspected coronary artery disease. Methods and Results—Clinical data and DSE results were analyzed in 1734 consecutive patients undergoing DSE between 1989 and 1997. Seventy-four patients who underwent revascularization within 3 months of DSE and 1 patient lost to follow-up were excluded; the remaining 1659 (median age, 62 years; range, 14 to 99 years) were followed up for 36 months (range, 6 to 96 months). Wall motion abnormalities at rest and the presence and extent of stress-induced wall motion abnormalities (ischemia) were scored for each patient. Cardiac events were related to clinical and ECG data and DSE results. Four hundred twenty-eight cardiac events occurred in 366, documented cardiac death in 108 (total death, 247), nonfatal infarction in 128, and late revascularization in 192 patients. In a multivariable Cox proportional-hazards model, the ratio of documented cardiac death or (re)infarction was increased in the presence of stress-induced ischemia (hazard ratio, 3.3; 95% CI, 2.4 to 4.4) and extensive rest wall motion abnormalities (hazard ratio, 1.9; 95% CI, 1.3 to 2.6). The number of ischemic segments was predictive for late cardiac events. A normal DSE carried a relatively good prognosis, with an annual event rate of cardiac death or infarction of 1.3% over a 5-year period. Conclusions—In a large group of patients, DSE has an added value for predicting late cardiac events during long-term follow-up, improving the separation between high- risk and very-low-risk patients.

Long-term prognostic value of dobutamine-atropine stress echocardiography in 1737 patients with known or suspected coronary artery disease: A single-center experience (Article)

1999-01-01T00:00:00Z

BACKGROUND--The purpose of this study was to assess the long-term value of dobutamine-atropine stress echocardiography (DSE) for prediction of late cardiac events in patients with proven or suspected coronary artery disease. METHODS AND RESULTS--Clinical data and DSE results were analyzed in 1734 consecutive patients undergoing DSE between 1989 and 1997. Seventy-four patients who underwent revascularization within 3 months of DSE and 1 patient lost to follow-up were excluded; the remaining 1659 (median age, 62 years; range, 14 to 99 years) were followed up for 36 months (range, 6 to 96 months). Wall motion abnormalities at rest and the presence and extent of stress-induced wall motion abnormalities (ischemia) were scored for each patient. Cardiac events were related to clinical and ECG data and DSE results. Four hundred twenty-eight cardiac events occurred in 366, documented cardiac death in 108 (total death, 247), nonfatal infarction in 128, and late revascularization in 192 patients. In a multivariable Cox proportional-hazards model, the ratio of documented cardiac death or (re)infarction was increased in the presence of stress-induced ischemia (hazard ratio, 3.3; 95% CI, 2.4 to 4.4) and extensive rest wall motion abnormalities (hazard ratio, 1.9; 95% CI, 1.3 to 2.6). The number of ischemic segments was predictive for late cardiac events. A normal DSE carried a relatively good prognosis, with an annual event rate of cardiac death or infarction of 1.3% over a 5-year period. CONCLUSIONS--In a large group of patients, DSE has an added value for predicting late cardiac events during long-term follow-up, improving the separation between high- risk and very-low-risk patients.

The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group (Article)

1999-01-01T00:00:00Z

BACKGROUND: Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery. METHODS: We performed a randomized, multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events. High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography. Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol. RESULTS: A total of 1351 patients were screened, and 846 were found to have one or more cardiac risk factors. Of these 846 patients, 173 had positive results on dobutamine echocardiography. Fifty-nine patients were randomly assigned to receive bisoprolol, and 53 to receive standard care. Fifty-three patients were excluded from randomization because they were already taking a beta-blocker, and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing. Two patients in the bisoprolol group died of cardiac causes (3.4 percent), as compared with nine patients in the standard-care group (17 percent, P=0.02). Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (P<0.001). Thus, the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (3.4 percent) and 18 patients in the standard-care group (34 percent, P<0.001). CONCLUSIONS: Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery.

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.

Dobutamine-atropine stress echocardiography : a method for preoperative cardiac risk stratification in patients undergoing major vascular surgery (Doctoral Thesis)

1994-02-02T00:00:00Z

Atherosclerosis is a systemic disease that may affect several blood vessels in different organs simultaneously. The spectrum of disease ranges from stroke to myocardial infarction, aortic aneurysms and peripheral vascular insufficiency. Patients suffering from one aspect of atherosclerotic disease will often have asymptomatic lesions elsewhere. Most patients seen with vascular disease by the internist or surgeon have a high prevalence of coronary artery disease, for example, 40-70% of patients undergoing major vascular surgery without clinically evident coronary artery disease will indeed have angiographically demonstrable coronary artery stenosisl . The coronary artery disease may be dormant due to lack of exercise but will undoubtedly have an impact on the management of patients. In patients undergoing vascular surgery coronary artery disease contributes to both perioperative and late death. The number of patients with vascular disease and concomitant coronary artery disease is increasing as the prevalence of cardiovascular diseases increases with age, and the population of Europe is aging rapidly. The number of people over 60 years of age in Europe will probably increase with more than 92 million to 224 million in the year 20252 • Conventional testing in patients with vascular disease for coronary artery disease by exercise stress tests is often impossible due to noncardiac disease. Most patients are suffering from claudication or neurological disease.