American Journal of Cardiology - Articles in Press

Accuracy of Noninvasively Determined Pulmonary Artery Systolic Pressure - Corrected Proof

2010-03-08

The noninvasive estimation of pulmonary artery systolic pressure (PASP) has become a standard component of the echocardiographic examination. Our aim was to evaluate the accuracy of this modality in a large series of unselected studies obtained in clinical practice. All right heart catheterizations during a 4-year period were reviewed. Studies with echocardiographic findings available within 48 hours were evaluated for PASP agreement. In an effort to mirror clinical practice, the right heart catheterization findings were used as the reference standard and the PASP values were taken directly from the respective clinical reports. Overall, 792 right heart catheterization–echocardiogram pairs were identified. Echocardiographic PASP could not be estimated in 174 of these studies (22.0%). The correlation between modalities was moderate, but agreement was poor (bias 9.0%, 95% limits of agreement −53.2% to 71.2%, r = 0.52, p <0.001). Misclassification of clinical PASP categories occurred more often than not (54.4%). Multivariate analysis using multiple potential sources of error could only account for 3.2% of the total variation in the discrepancy between the study modalities (p = 0.003). In conclusion, noninvasively estimated PASP had limited agreement with the invasively determined PASP, and misclassification of PASP clinical categories occurred frequently. Given the widespread use of echocardiographically determined PASP, these data are in need of replication in a large prospective study.

Incidence of Subclinical Atherosclerosis as a Marker of Cardiovascular Risk in Retired Professional Football Players - Corrected Proof

2010-03-02

The purpose of this study was to evaluate subclinical atherosclerosis in retired professional football players. Two hundred one healthy former professional football players (mean age 50.8 years; mean body mass index 31.5 kg/m2) were screened for the prevalence of cardiovascular risk factors, metabolic syndrome, and subclinical atherosclerosis by carotid artery ultrasound and compared with a cohort of men of similar body mass index referred for the assessment of subclinical atherosclerosis by carotid ultrasound. The prevalence of carotid artery plaque in the players was not significantly different from that of the body mass index–matched patients (33.3% vs 29.3%, p = 0.45). For the 2 groups, the prevalence of carotid artery plaque was >3 times higher than that reported in general population studies of patients with the same age range, gender, and exclusions. Metabolic syndrome prevalence was higher in linemen than in nonlinemen (45.8% vs 22.5%, p = 0.001), but there was no statistical difference in plaque presence between linemen and nonlinemen (27.1% vs 35.9%, p = 0.23). In conclusion, despite their elite athletic histories, former professional football players have a similar prevalence of advanced subclinical atherosclerosis as a clinically referred population of overweight and obese men.

The 2009 International Hypertrophic Cardiomyopathy Summit - Corrected Proof

Barry J. Maron — 2010-03-02

In Minneapolis, Minnesota, on October 16 to 18, 2009, the fourth “International Summit on the Diagnosis and Management of Hypertrophic Cardiomyopathy and Prevention of Sudden Death: The Next 50 Years,” was held and sponsored by the Minneapolis Heart Institute Foundation in recognition of the fiftieth Anniversary of this disease (). During the previous half-century, hypertrophic cardiomyopathy (HC) persistently intrigued and challenged the cardiovascular community and, indeed, has periodically been the source of misunderstanding and even controversy. The 3 previous HC Summits held in Minneapolis were in 1997, 2002, and 2006 (with the meeting scheduled for September 14, 2001 canceled).

Comparison of Bivalirudin and Unfractionated Heparin Plus Protamine in Patients With Coronary Heart Disease Undergoing Percutaneous Coronary Intervention (from the Antithrombotic Regimens aNd Outcome [ARNO] Trial) - Corrected Proof

2010-02-22

Previous studies have compared bivalirudin and unfractionated heparin (UFH) plus the routine use of glycoprotein IIb/IIIa inhibitors. They have demonstrated that bivalirudin can decrease bleeding complications without a significant increase in ischemic complications, resulting in a better net clinical outcome, as defined by the efficacy (ischemic complications) or safety (bleeding complications) end point. The aim of the present study was to compare bivalirudin and UFH plus protamine in patients undergoing elective percutaneous coronary intervention and pretreated with clopidogrel and aspirin. We randomly assigned 850 patients with stable or unstable coronary artery disease to bivalirudin or UFH followed by protamine at the end of the percutaneous coronary intervention. The primary end point was in-hospital major bleeding. The main secondary end points were the 1-month composite of death, myocardial infarction, unplanned target vessel revascularization; and the 1-month net clinical outcome. The rate of major bleeding (primary end point) was 0.5% in patients randomized to bivalirudin and 2.1% in patients randomized to UFH (p = 0.033). At 30 days, the rate of major bleeding was 0.9% in the bivalirudin arm and 2.8% in the UFH arm (p = 0.043). The composite of death, myocardial infarction, and target vessel revascularization rate and the net clinical outcome rate was 2.8% and 6.4% (p = 0.014) and 3.3% and 7.8% (p = 0.004), respectively, in the bivalirudin and UFH arms. In conclusion, in percutaneous coronary intervention patients pretreated with clopidogrel and aspirin, bivalirudin was associated with less major bleeding and fewer ischemic complications and a better net clinical outcome than UFH.

Comparison of the Usefulness of N-Terminal Pro-Brain Natriuretic Peptide to Other Serum Biomarkers as an Early Predictor of ST-Segment Recovery After Primary Percutaneous Coronary Intervention - Corrected Proof

2010-02-22

Data on the ability of serum biomarkers to predict microvascular obstruction by ST-segment recovery after primary percutaneous coronary intervention (PCI) is largely absent. Therefore, we determined the association between 5 serum biomarkers, obtained before emergency coronary angiography, and immediate ST-segment recovery in patients who had undergone primary PCI for ST-segment elevation myocardial infarction. We measured N-terminal pro-brain natriuretic peptide (NT-pro-BNP), cardiac troponin T, creatinine kinase-MB fraction, high-sensitivity C-reactive protein, and serum creatinine from blood samples obtained through the arterial sheath at the start of primary PCI. Serial 12-lead electrocardiograms were recorded in the catheterization laboratory before arterial puncture and at the end of the PCI. ST-segment recovery was defined as incomplete if <50%. Of 662 included patients with ST-segment elevation myocardial infarction, 338 (51%) had incomplete ST-segment recovery. An elevated NT-pro-BNP level (≥608 ng/L) was the strongest predictor of incomplete ST-segment recovery (adjusted odds ratio 2.6, 95% confidence interval 1.6 to 4.1; p <0.001) compared to other serum biomarkers and clinical predictors. An elevated NT-pro-BNP level was more strongly predictive in patients without a history of coronary artery disease or hypertension (adjusted odds ratio 4.7, 95% confidence interval 2.4 to 9.2; p <0.001). NT-pro-BNP was the best contributor to both net reclassification (0.43; p <0.001) and integrated discrimination improvement (0.04; p <0.001) when added to a multivariate model with clinical predictors of incomplete ST-segment recovery. In conclusion, NT-pro-BNP was the strongest independent predictor of ST-segment recovery at the end of primary PCI for ST-segment elevation myocardial infarction compared to the other serum biomarkers reflecting myocardial cell damage, renal function, and inflammation.

Comparison of Usefulness of N-Terminal Pro-Brain Natriuretic Peptide as an Independent Predictor of Cardiac Function Among Admission Cardiac Serum Biomarkers in Patients With Anterior Wall Versus Nonanterior Wall ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention - Corrected Proof

2010-02-22

The purpose of the present study was to determine the prognostic value of N-terminal pro-brain natriuretic peptide (NT-pro-BNP), among other serum biomarkers, on cardiac magnetic resonance (CMR) imaging parameters of cardiac function and infarct size in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. We measured NT-pro-BNP, cardiac troponin T, creatinine kinase-MB fraction, high-sensitivity C-reactive protein, and creatinine on the patients' arrival at the catheterization laboratory in 206 patients with ST-segment elevation myocardial infarction. The NT-pro-BNP levels were divided into quartiles and correlated with left ventricular function and infarct size measured by CMR imaging at 4 to 6 months. Compared to the lower quartiles, patients with nonanterior wall myocardial infarction in the highest quartile of NT-pro-BNP (≥260 pg/ml) more often had a greater left ventricular end-systolic volume (68 vs 39 ml/m2, p <0.001), a lower left ventricular ejection fraction (42% vs 54%, p <0.001), a larger infarct size (9 vs 4 g/m2, p = 0.002), and a larger number of transmural segments (11% of segments vs 3% of segments, p <0.001). Multivariate analysis revealed that a NT-pro-BNP level of ≥260 pg/ml was the strongest independent predictor of left ventricular ejection fraction in patients with nonanterior wall myocardial infarction compared to the other serum biomarkers (β = −5.8; p = 0.019). In conclusion, in patients with nonanterior wall myocardial infarction undergoing primary percutaneous coronary intervention, an admission NT-pro-BNP level of ≥260 pg/ml was a strong, independent predictor of left ventricular function assessed by CMR imaging at follow-up. Our findings suggest that NT-pro-BNP, a widely available biomarker, might be helpful in the early risk stratification of patients with nonanterior wall myocardial infarction.

Contemporary Incidence and Predictors of Major Adverse Cardiac Events After Saphenous Vein Graft Intervention With Embolic Protection (an AMEthyst Trial Substudy) - Corrected Proof

2010-02-22

The incidence and predictors of major adverse cardiac events after percutaneous coronary intervention of saphenous vein grafts have not been evaluated in the era of routine embolic protection device (EPD) use and the current standards of antiplatelet therapy. The Assessment of the Medtronic AVE Interceptor Saphenous Vein Graft Filter System (AMEthyst) is the largest randomized trial of vein graft intervention comparing the Interceptor EPD and either the GuardWire or FilterWire EPD as the control. The baseline demographic, procedural, and clinical characteristics and the 30-day major adverse cardiac events ([MACE] death, myocardial infarction, and repeat revascularization [either surgery or percutaneous coronary intervention] of the target vessel) were recorded for 748 patients who had undergone vein graft intervention with distal embolic protection. At 30 days, MACE had occurred in 58 patients (7.8%). The univariate predictors of MACE at 30 days included plaque volume (odds ratio 1.005/mm3, p <0.0001), target lesion length (odds ratio 1.046/mm, p <0.001), vein graft degeneration score (odds ratio 1.631, p = 0.001), coronary narrowing classification (odds ratio 1.697, p = 0.004), reference vessel diameter (odds ratio 1.689, p = 0.004), and male gender (odds ratio 2.406, p = 0.046) and was independent of device type (p = 0.74). The plaque volume was the most important and only multivariate predictor of MACE. The highest quartile of plaque volume defined a subset at particular risk, despite EPD use (MACE 15.8% vs 5.0%, p <0.001). In conclusion, in a patient population in which EPD and preprocedure thienopyridine therapy were uniformly implemented, MACE occurred with an incidence of 7.8% at 30 days. An increasing plaque volume was the most important determinant of MACE and defined a population at particular risk.

Disparities in Management Patterns and Outcomes of Patients With Non–ST-Elevation Acute Coronary Syndrome With and Without a History of Cerebrovascular Disease - Corrected Proof

2010-02-22

Cerebrovascular (CVD) disease is commonly associated with coronary artery disease and adversely affects outcome. The goal of the present study was to examine the temporal management patterns and outcomes in relation to previous CVD in a contemporary “real-world” spectrum of patients with acute coronary syndrome (ACS). From 1999 to 2008, 14,070 patients with non–ST-segment elevation ACS were recruited into the Canadian Acute Coronary Syndrome I (ACS I), ACS II, Global Registry of Acute Coronary Events (GRACE/GRACE), and Canadian Registry of Acute Coronary Events (CANRACE) prospective multicenter registries. We stratified the study patients according to a history of CVD and compared their treatment and outcomes. Patients with a history of CVD were older, more likely to have pre-existing coronary artery disease, elevated creatinine, higher Killip class, and ST-segment deviation on admission. Despite presenting with greater GRACE risk scores (137 vs 117, p <0.001), patients with previous CVD were less likely to receive evidence-based antiplatelet and antithrombin therapies during the initial 24 hours of hospital admission. They were also less likely to undergo in-hospital coronary angiography and revascularization. These disparities in medical and invasive management were preserved temporally across all 4 registries. Patients with concomitant CVD had worse in-hospital outcomes. Previous CVD remained an independent predictor of in-hospital mortality (adjusted odds ratio 1.43, 95% confidence interval 1.06 to 1.92, p = 0.019) after adjusting for other powerful prognosticators in the GRACE risk score. However, it was independently associated with a lower use of in-hospital coronary angiography (adjusted odds ratio 0.70, 95% confidence interval 0.60 to 0.83, p <0.001). Underestimation of patient risk was the most common reason for not pursuing an invasive strategy. Revascularization was independently associated with lower 1-year mortality (adjusted odds ratio 0.48, 95% confidence interval 0.33 to 0.71, p <0.001), irrespective of a history of CVD. In conclusion, for patients presenting with non–ST-segment elevation-ACS, a history of CVD was independently associated with worse outcomes, which might have been, in part, because of the underuse of evidence-based medical and invasive therapies.

Comparison by Meta-Analysis of Drug-Eluting Stents and Bare Metal Stents for Saphenous Vein Graft Intervention - Corrected Proof

2010-02-22

This meta-analysis was undertaken to assess the efficacy and safety of drug-eluting stents (DESs) compared to bare metal stents (BMSs) in saphenous vein graft (SVG) interventions. DESs decrease the risk of target vessel revascularization in native coronary arteries compared to BMSs. The ideal treatment strategy in patients with SVG disease is unknown. A search of the published reports was conducted to identify studies that compared DESs and BMSs in SVG intervention with a minimum follow-up of 6 months. A total of 19 studies (2 randomized trials and 17 registries), including 3,420 patients who had undergone SVG intervention (DESs, n = 1,489 and BMS, n = 1,931), met the selection criteria. The mean length of follow-up was 20 ± 12 months. Using the fixed effect model, target vessel revascularization was less frequently performed in patients who had undergone SVG intervention with a DES than with a BMS (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.49 to 0.72). The incidence of myocardial infarction was lower in patients with a DES than in those with a BMS (OR 0.69, 95% CI 0.49 to 0.99). No differences were found in the risk of death (OR 0.78, 95% CI 0.59 to 1.02) or stent thrombosis (OR 0.41, 95% CI 0.15 to 1.11) between the 2 groups. In conclusion, these findings support the use of DESs in SVG lesions.

Meta-Analysis of Clinical Studies Comparing Coronary Artery Bypass Grafting With Percutaneous Coronary Intervention and Drug-Eluting Stents in Patients With Unprotected Left Main Coronary Artery Narrowings - Corrected Proof

Michael S. Lee, Tae Yang, Jashdeep Dhoot, Hsini Liao — 2010-02-22

The aim of this study was to compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. The current American College of Cardiology and American Heart Association guidelines recommend CABG for the treatment of patients with ULMCA disease on the basis of clinical trials demonstrating a survival benefit with CABG compared to medical therapy. DES reduce the rate of target vessel revascularization compared with bare-metal stents in ULMCA PCI and may be a safe alternative to CABG. A meta-analysis was conducted of clinical studies comparing CABG and PCI with DES for ULMCA disease with respect to death; the composite of death, myocardial infarction, or stroke; and target vessel revascularization at 1 year follow-up. The analysis included 2,905 patients from 8 clinical studies (2 randomized trials and 6 nonrandomized studies). At 1-year follow-up, there was no significant difference between the CABG and DES groups in the risk for death (odds ratio [OR] 1.12, 95% confidence interval [CI] 0.80 to 1.56) or the composite end point of death, myocardial infarction, or stroke (OR 1.25, 95% CI 0.86 to 1.82). The risk for target vessel revascularization was significantly lower in the CABG group compared to the PCI group (OR 0.44, 95% CI 0.32 to 0.59). In conclusion, PCI with DES is safe and could represent a good alternative to CABG for selected cases in patients with ULMCA disease.

Use of Non-Steroidal Antiinflammatory Drugs and Type-Specific Risk of Acute Coronary Syndrome - Corrected Proof

2010-02-22

The exact mechanism by which nonsteroidal anti-inflammatory drugs (NSAIDs) may increase coronary risk is not completely understood. The aim of this study was to quantify the risk for each type of acute coronary syndrome (ACS) associated using NSAIDs and the role played by dose, duration, and patient characteristics. A prospective case-control study was performed, interviewing 2,954 patients hospitalized for ACS at 32 Spanish hospitals and a similar number of age-matched controls using a structured questionnaire collecting information on the use of NSAIDs, risk factors, and cardiovascular history. Odds ratios (ORs) for any type and each ACS type were calculated adjusted for gender, body mass index, other risk factors, and concomitant medications by conditional logistic regression. The adjusted OR of ACS associated with the current use of NSAIDs was 1.16 (95% confidence interval [CI] 0.95 to 1.42). The risk was increased in patients consuming high doses (OR 1.64, 95% CI 1.06 to 2.53) and those with previous ischemic heart disease (OR 1.84, 95% CI 1.13 to 3.00). The hazard was driven mostly by the increase in the risk for non-ST-segment elevation ACS (OR 1.20, 95% CI 0.99 to 1.47), whereas NSAIDs did not increase the risk for ST-segment elevation myocardial infarction (OR 1.00, 95% CI 0.80 to 1.26). In conclusion, the use of NSAIDs was associated with a small, nonsignificant overall coronary risk that was more apparent for non-ST-segment elevation ACS. This risk was stronger when NSAIDs were used at high doses or in patients with previous ischemic heart disease.

Evaluation of Methods to Predict Early Long-Term Neurobehavioral Outcome After Coronary Artery Bypass Grafting - Corrected Proof

2010-02-22

Postoperative cognitive decrease (POCD) represents the most frequent complication in modern cardiac surgery. The application of easily assessable surrogate parameters that predict long-term POCD at early time points is tempting. The aim of the present study was to analyze the predictive value of cerebral biomarkers, diffusion-weighted magnetic resonance imaging (DWI), and cognitive bedside testing after coronary artery bypass grafting (CABG). From 106 patients who underwent elective CABG, blood samples were drawn for the measurement of protein S100B and neuron-specific enolase release at baseline, at the end of surgery, and 48 hours afterward. Cerebral DWI was carried out before and 2 to 4 days after surgery. Cognitive functioning was assessed before, 2 to 4 days (bedside testing) after, and 3 months after CABG. On DWI, lesions were detected in 15.1% of patients. Biomarker levels and the presence of acute ischemic lesions on DWI were not associated with long-term POCD. Early POCD was correlated with 3-month POCD (r = 0.46, p <0.001). Ninety-one percent of patients who had shown moderate to severe POCD (<−1.5 z scores) in the early phase still had decreased memory functioning at 3 months compared to baseline (likelihood ratio 5.23). Early POCD was asserted as the only predictor for long-term POCD in a stepwise multiple linear regression model (R2 = 0.20, p <0.001), excluding age, length of surgery, aortic clamping and cardiopulmonary bypass duration, the number of anastomoses, and postoperative neuron-specific enolase and S100B levels. In conclusion, the results show that in contrast to biomarkers, DWI, age, or intraoperative variables, early neuropsychological bedside testing predicts long-term POCD after CABG with acceptable accuracy.

Importance of Measuring Glycosylated Hemoglobin in Patients With Myocardial Infarction and Known Diabetes Mellitus - Corrected Proof

2010-02-22

Although medical co-morbidities commonly affect clinical outcomes after acute myocardial infarction (AMI), current performance measures of AMI quality focus exclusively on the management of the AMI itself. However, patients with AMIs frequently present with other co-morbidities, such as diabetes mellitus (DM), that also warrant assessment and management. To date, the quality of DM evaluation in patients presenting with AMIs has not been described. From January 2003 to June 2004, the Prospective Registry Evaluating Myocardial Infarction Patients: Events and Recovery–Quality Improvement (PREMIER-QI) enrolled 3,953 patients with AMIs at 19 centers in the United States. The frequency of glycosylated hemoglobin (HbA1c) assessment, either during the hospitalization or documented in the chart from the preceding 3 months, was prospectively evaluated. Among 1,168 patients with AMIs with preexisting DM, only 47% had recent HbA1c levels available, with marked variability in HbA1c assessment among hospitals (range 7% to 81%). Among those with available HbA1c levels, 39% had good control (HbA1c <7%), 36% had suboptimal control (HbA1c 7% to 9%), and 25% had poor control (HbA1c >9%). Patients with suboptimal and poor control were more likely to have their DM treatment intensified than those without HbA1c assessment (for HbA1c 7% to 9%, rate ratio 1.38, 95% confidence interval 1.03 to 1.85; for HbA1c >9%, rate ratio 2.20, 95% confidence interval 1.68 to 2.88). Similarly, patients with DM who had HbA1c measured were more likely to receive instructions on DM disease management before discharge. In conclusion, the assessment of chronic glycemic control is highly variable among patients with AMIs and DM. Because much of this variability occurs at the hospital level, the evaluation of DM control could represent an additional quality indicator and an opportunity to advance patient-centered AMI care.

Differential Effects of Statins (Pravastatin or Simvastatin) on Ventricular Ectopic Complexes: Gαi2, a Possible Molecular Marker for Ventricular Irritability - Corrected Proof

2010-02-22

Retrospective studies suggest that statins might exert an antiarrhythmic effect on the heart. The mechanism of this effect is unclear. Parasympathetic stimulation of the heart has been shown to protect against ventricular arrhythmias. The goal of this study was to determine the effect of statins on ventricular arrhythmias and its correlation with changes in parasympathetic responsiveness and Gαi2 expression. Patients were randomized to pravastatin and simvastatin in a double-blind crossover design. Ventricular arrhythmias were determined by analysis of 24-hour Holter recordings. Spectral RR interval analysis of Holter studies determined peak high-frequency power fraction, which reflects parasympathetic modulation of heart rate. Expression of Gαi2, a molecular component of the parasympathetic response pathway, was determined by Western blots of patients' lymphocytes. Pravastatin treatment decreased the incidence of ventricular premature complexes by 22.5 ± 3.4% (n = 20, p <0.05), couplets, and runs of 3 to 6 beats of nonsustained ventricular tachycardia from 9.8 ± 2.67 to 3.9 ± 1.25 events/patient/24 hours (n = 12, p <0.05). Pravastatin increased peak high-frequency fraction by 29.8 ± 4.3% (n = 33, p <0.001), while Gαi2 expression increased by 51.3 ± 22.5% (n = 21, p <0.05). Effects of simvastatin on ventricular premature complexes and nonsustained ventricular tachycardia were not significant. Relative changes in couplets and nonsustained ventricular tachycardia in pravastatin-treated patients correlated negatively with changes in Gαi2 and high-frequency fraction (ρ = −0.588 and ρ = −0.763, respectively, n = 12, p <0.05). In conclusion, these data suggest that pravastatin might decrease cardiac irritability via an increase in parasympathetic responsiveness and that changes in Gαi2 expression might serve as a molecular marker for this effect, which might play a role in the molecular mechanism of the antiarrhythmic effect of statins.

The First Provocative Test for Coronary Artery Spasm at the Cleveland Clinic - Corrected Proof

Wayne Siegel — 2010-02-22

This article provides narration of the events during the development of ergonovine maleate infusions for detecting coronary artery spasm at the Cleveland Clinic in 1973. This was the first safe, reproduceable and reliable test for angiographic visualization of the pathophysiology associated with the Prinzmetal Syndrome termed “angina inversa”.

Practice Patterns Among United States Cardiologists for Managing Adults With Atrial Fibrillation (from the AFFECTS Registry) - Corrected Proof

2010-02-22

The Atrial Fibrillation: Focus on Effective Clinical Treatment Strategies (AFFECTS) Registry was designed to examine atrial fibrillation (AF) treatment by United States cardiologists in the context of the American College of Cardiology, American Heart Association, and European Society of Cardiology guidelines after recent landmark clinical trials. Most patients in AFFECTS had AF without clinically significant structural heart disease or only uncomplicated hypertension. Among the all-enrolled population (n = 1,461), initial treatment strategies assigned were rhythm control in 64% and rate control in 36%. Among patients with either paroxysmal (n = 1,165) or persistent (n = 273) AF, 67% and 55%, respectively, were assigned rhythm control. The trend to assign rhythm control as the initial treatment goal decreased with age. In the rhythm-control group, most patients (74%) also received a rate-control agent during the registry, while 25% of those assigned to rate control received antiarrhythmic drugs. Most first prescriptions of antiarrhythmic drugs were for first-line therapy compliant with 2001 (76%) and 2006 (86%) guidelines. Most second prescriptions were for first-line therapies as well. Rates of serious adverse events were low. In conclusion, data from this study provide insight into community treatment patterns in patients with AF, most without clinically significant structural heart disease or with only uncomplicated hypertension.

Long-Term Outcomes for Cryoablation of Pediatric Patients With Atrioventricular Nodal Reentrant Tachycardia - Corrected Proof

Martin J. LaPage, J. Philip Saul, John H. Reed — 2010-02-22

The long-term efficacy and complications of cryoablation for pediatric atrioventricular nodal reentrant tachycardia (AVNRT) have not been completely defined. We performed a retrospective review of pediatric patients diagnosed with AVNRT and treated with cryoablation therapy. A total of 73 patients underwent cryoablation for AVNRT from 2003 to 2008. Of the 73 patients, 61 were included in the present study. The mean interval from initial successful ablation was 3 ± 1 years. Of the 61 patients, 4 had documented recurrence of AVNRT after the initially successful ablation, 3 with late recurrence 1 to 2 years after ablation. Procedural complications consisting of transient atrioventricular block developed in 10 patients, and 2 patients were diagnosed with new arrhythmias after AVNRT ablation (1 with junctional ectopic tachycardia and 1 with left ventricular outflow tract tachycardia originating near the region of the atrioventricular node 3 months after ablation). In conclusion, cryoablation is a safe and effective therapy for AVNRT. Recurrences can develop late, up to 2 years after initially successful ablation.

Warfarin and Aspirin Use in Atrial Fibrillation Among Practicing Cardiologist (from the AFFECTS Registry) - Corrected Proof

2010-02-22

Among patients with atrial fibrillation (AF), the risk of thromboembolism is a significant concern. However, the reported use of warfarin among patients with AF at elevated risk of stroke remains low. In the present study, we have provided information on anticoagulation use reported during the recent Atrial Fibrillation: Focus on Effective Clinical Treatment Strategies (AFFECTS) Registry. Among patients identified by their physician at baseline to be at an increased risk of stroke, as determined from an assessment of the medical history, 74% received warfarin and 29% received aspirin. Post hoc analysis of warfarin use stratified by Congestive heart failure, Hypertension, Age, Diabetes, Stroke, (CHADS2) doubled score revealed that at the end of the study, warfarin use was 73% (155 of 213) and 66% (185 of 280) in the rate- and rhythm-control patients with a score of ≥2, respectively, compared to 60% (183 of 306) and 49% (322 of 662) in the rate- and rhythm-control patients with a score of <2, respectively. The practicing cardiologists who participated in this registry initiated anticoagulation therapy in most of their patients with AF. However, warfarin use is not yet in line with the guidelines and evidence-based recommendations. Patients considered at no risk of stroke appear to have been overprescribed anticoagulant agents, and a considerable portion of high-risk patients did not receive warfarin. In conclusion, these results suggest that continued physician education of appropriate anticoagulation use in patients with AF is needed.

Determinants of Adiponectin Levels in Patients With Chronic Systolic Heart Failure - Corrected Proof

2010-02-22

Adiponectin, an adipocytokine, is secreted by adipocytes and mediates antihypertrophic and anti-inflammatory effects in the heart. Plasma concentrations of adiponectin are decreased in the presence of obesity, insulin resistance, and obesity-associated conditions such as hypertension and coronary heart disease. However, a paradoxical increase in adiponectin levels is observed in human systolic heart failure (HF). We sought to investigate the determinants of adiponectin levels in patients with chronic systolic HF. Total adiponectin levels were measured in 99 patients with stable HF and a left ventricular (LV) ejection fraction of <40%. The determinants of adiponectin levels on univariate analysis were included in a multivariate linear regression model. At baseline, 62% of the patients were black, 63% were men, the mean age was 60 ± 13 years, the LV ejection fraction was 21 ± 9%, and the body mass index was 30.6 ± 6.7 kg/m2. The mean adiponectin level was 15.8 ± 15 μg/ml. Beta-Blocker use, body mass index, and blood urea nitrogen were significant determinants of adiponectin level on multivariate analysis. The LV mass, structure, and LV ejection fraction were not related to adiponectin levels on multivariate analysis. The effect of β-blocker therapy was most marked in nonobese patients with a body mass index <30 kg/m2. In conclusion, in patients with chronic systolic HF, β-blocker therapy correlated with lower adiponectin levels, especially in nonobese patients. This relation should be taken into account when studying the complex role of adiponectin in patients with chronic systolic HF.

Influence of Renal Function on the Use of Guideline-Recommended Therapies for Patients With Heart Failure - Corrected Proof

2010-02-22

Guidelines have been established for the treatment of patients with heart failure (HF) and left ventricular dysfunction, but renal dysfunction might limit adherence to these guidelines. Few data have characterized the use of guideline-recommended therapy for patients with HF, left ventricular dysfunction, and renal dysfunction who are treated in outpatient settings. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) was a prospective study of patients receiving treatment as outpatients in cardiology practices in the United States. The rates of adherence to 7 guideline-recommended therapies were evaluated for patients with a left ventricular ejection fraction of ≤35%. The estimated glomerular filtration rate was estimated using the Modification of Diet in Renal Disease formula for 13,164 patients who were categorized as having stage 1 through stage 4/5 chronic kidney disease (CKD). More than 1/2 (52.2%) of the patients had stage 3 or 4/5 CKD. Older patients and women were at increased risk of higher stage CKD, and the rates of co-morbid health conditions were significantly greater among patients with more severe CKD. The patients with more severe CKD were significantly less likely to receive all interventions except cardiac resynchronization therapy. However, multivariate analysis controlling for patient characteristics revealed that the severity of CKD was an independent predictor of adherence to angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy but not to any of the 6 other guideline-recommended measures. In conclusion, these results confirm that CKD is common in patients with HF and left ventricular dysfunction but is not independently associated with adherence to guideline-recommended therapy in outpatient cardiology practices, with the exception of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy.

Characteristics and Predictors of Obstructive Sleep Apnea in Patients With Systemic Hypertension - Corrected Proof

2010-02-22

Obstructive sleep apnea (OSA) is a secondary cause of hypertension and independently associated with target-organ damage in hypertensive patients. However, OSA remains largely underdiagnosed and undertreated. The aim of the present study was to evaluate the characteristics and clinical predictors of OSA in a consecutive series of patients followed up in a hypertension unit. A total of 99 patients (age 46 ± 11 years, body mass index 28.8 kg/m2, range 25.1 to 32.9) underwent polysomnography. The clinical parameters included age, gender, obesity, daytime sleepiness, snoring, Berlin Questionnaire, resistant hypertension, and metabolic syndrome. Of the 99 patients, 55 (56%) had OSA (apnea-hypopnea index >5 events/hour). Patients with OSA were older and more obese, had greater levels of blood pressure, and presented with more diabetes, dyslipidemia, resistant hypertension, and metabolic syndrome than the patients without OSA. Of the patients with OSA, 51% had no excessive daytime sleepiness. The Berlin Questionnaire and patient age revealed a high sensitivity (0.93 and 0.91, respectively) but low specificity (0.59 and 0.48, respectively), and obesity and resistant hypertension revealed a low sensitivity (0.58 and 0.44, respectively) but high specificity (0.75 and 0.91, respectively) for OSA. Metabolic syndrome was associated with high sensitivity and specificity for OSA (0.86 and 0.85, respectively). Multiple regression analysis showed that age of 40 to 70 years (odds ratio 1.09, 95% confidence interval 1.03 to 1.16), a high risk of OSA on the Berlin Questionnaire (odds ratio 8.36, 95% confidence interval 1.67 to 41.85), and metabolic syndrome (odds ratio 19.04, 95% confidence interval 5.25 to 69.03) were independent variables associated with OSA. In conclusion, more important than the typical clinical features that characterize OSA, including snoring and excessive daytime sleepiness, the presence of the metabolic syndrome is as an important marker of OSA among patients with hypertension.

Value of Tissue Doppler Echocardiography in Predicting Response to Cardiac Resynchronization Therapy in Patients With Heart Failure - Corrected Proof

2010-02-22

Several studies have demonstrated a relation between left ventricular (LV) dyssynchrony and response to cardiac resynchronization therapy (CRT). Many methods of determining LV dyssynchrony have been proposed, including a value of 65 ms as assessed by tissue Doppler imaging. The aim of the present validation study was to prospectively test the predictive accuracy of the 65-ms cutoff for LV dyssynchrony in a large cohort of patients with heart failure undergoing CRT. The study included 361 patients who had undergone CRT. The clinical and echocardiographic parameters were assessed at baseline and at 6 months of follow-up. The clinical response was defined as an improvement of ≥1 New York Heart Association class, and the echocardiographic response was defined as a reduction in LV end-systolic volume of ≥15%. At 6 months of follow-up, 259 patients (72%) had a clinical response and 187 patients (52%) had an echocardiographic response. The patients with a response had more LV dyssynchrony than did those without a response (91 ± 49 ms vs 50 ± 44 ms for the clinical response and 101 ± 46 ms vs 55 ± 45 ms for the echocardiographic response). On multivariate analysis, LV dyssynchrony remained predictive of the response, independent of other characteristics. In conclusion, LV dyssynchrony of ≥65 ms was an independent predictor of both the clinical and the echocardiographic response in patients with heart failure who underwent CRT in this validation study.

Cardiac Risk in Patients Aged >75 Years With Asymptomatic, Severe Aortic Stenosis Undergoing Noncardiac Surgery - Corrected Proof

2010-02-22

Severe aortic stenosis (AS) is a known predictor of cardiac risk during noncardiac surgery. However, for patients with asymptomatic AS, it is unclear whether aortic valve surgery should precede noncardiac surgery. We studied 30 patients with asymptomatic, severe AS with a mean age of 78 ± 9 years, an aortic valve area of 0.77 ± 0.16 cm2, a mean gradient of 50.1 ± 9.5 mm Hg, and a peak gradient of 84 ± 22 mm Hg. They were compared to 60 age-matched (within 2 years) and gender-matched (ratio of 1:2) patients with mild-to-moderate AS (controls). The primary end point of the study was a composite of death, myocardial infarction, heart failure, ventricular arrhythmias before dismissal, and intraoperative hypotension requiring vasopressor administration. Most patients (>75%) and controls underwent intermediate-risk surgical procedures that were similar with respect to the nature of the surgery, type of anesthesia used, and preoperative risk assessment. Combined postoperative events were more common for the patients (n = 10; 33%) than for the controls (n = 14; 23%), but the difference was not statistically significant (p = 0.06). Intraoperative hypotension requiring vasopressor use was more likely for the patients (n = 9; 30%) than for the controls (n = 10; 17%; odds ratio 2.5; p = 0.11). The perioperative myocardial infarction rates were similar for both groups (3%; p = 0.74). No deaths, heart failure events, or ventricular arrhythmias occurred in the patients and 1 death and 1 ventricular arrhythmia episode occurred in the controls. In conclusion, intermediate-to-low–risk noncardiac surgery for patients with severe, asymptomatic AS can be performed relatively safely. Intraoperative hypotension was frequent and required prompt and aggressive treatment.

Relation of Systemic Venous Return, Pulmonary Vascular Resistance, and Diastolic Dysfunction to Exercise Capacity in Patients With Single Ventricle Receiving Fontan Palliation - Corrected Proof

Bryan H. Goldstein, Chad E. Connor, Lindsay Gooding, Albert P. Rocchini — 2010-02-22

Fontan patients have a reduced exercise capacity, primarily owing to limitations in the ability to augment pulmonary blood flow and stroke volume. To date, the mechanism of peak exercise pulmonary blood flow restriction has not been elucidated. We performed a single-center, prospective, crossover trial of supine and upright exercise in Fontan patients and healthy controls to determine the mechanisms of exercise limitation in the Fontan-palliated patient. A total of 29 Fontan patients and 16 control subjects completed the protocol. The duration of exercise, percentage of predicted peak oxygen consumption (VO2) and peak work were reduced in the Fontan group, regardless of posture (p ≤0.03). The percentage of predicted oxygen pulse, a surrogate for pulmonary stroke volume, was not increased with supine posture in the Fontan cohort (upright, 82.3 ± 18.8% vs supine, 82.4 ± 19.7%; p = 0.6). In both groups, the percentage of predicted peak VO2 was lower with supine exercise than with upright exercise (p ≤0.002). Diastolic dysfunction was present in 57% of the Fontan patients and was associated with a reduced percentage of predicted peak VO2 (p = 0.04) and supine peak work (p = 0.008). Six Fontan patients who underwent supine exercise with indwelling catheters failed to demonstrate the expected decrease in pulmonary vascular resistance characteristically seen with peak exercise (at rest, 2.8 ± 0.7 mm Hg/L/min/m2 vs at peak, 2.8 ± 0.9 mm Hg/L/min/m2; p = 0.9). In conclusion, supine exercise in Fontan patients does not result in an increased VO2 or oxygen pulse, suggesting that inadequate venous return might not be the primary limitation of exercise capacity in this population. Diastolic dysfunction and relatively excessive peak exercise pulmonary vascular resistance might be more important factors in Fontan exercise limitation.

Relation of High Heart Rate Variability to Healthy Longevity - Corrected Proof

Usman Zulfiqar, Donald A. Jurivich, Weihua Gao, Donald H. Singer — 2010-02-22

The population's aging underscores the need to understand the process and define the physiologic markers predictive of healthy longevity. The findings that aging is associated with a progressive decrease in heart rate variability (HRV), an index of autonomic function, suggests that longevity might depend on preservation of autonomic function. However, little is known about late life changes. We assessed the relation between autonomic function and longevity by a cross-sectional study of HRV of 344 healthy subjects, 10 to 99 years old. The HRV was determined from 24-hour Holter records, using 4 time domain measures of HRV (the root mean square of the successive normal sinus RR interval difference [rMSSD], percentage of successive normal sinus RR intervals >50 ms [pNN50], standard deviation of all normal sinus RR intervals during a 24-hour period [SDNN], and standard deviation of the averaged normal sinus RR intervals for all 5-minute segments [SDANN]). Autonomic modulation of the 4 measures differs, permitting distinctions between changes in HRV–parasympathetic function, using rMSSD and pNN50, and HRV–sympathetic function using SDNN and SDANN. Decade values were compared using analysis of variance and t-multiple comparison testing. The HRV of all measures decreases rapidly from the second to fifth decades. It then slows. The HRV–sympathetic function continues to decrease throughout life. In contrast, the decrease in HRV–parasympathetic function reaches its nadir in the eighth decade, followed by reversal and a progressive increase to higher levels (p <0.05), more characteristic of a younger population. In conclusion, healthy longevity depends on preservation of autonomic function, in particular, HRV–parasympathetic function, despite the early age-related decrease. The eighth decade reversal of the decrease in HRV–parasympathetic function and its subsequent increase are key determinants of longevity. Persistently high HRV in the elderly represents a marker predictive of longevity.

Relation of Elevated Levels of Plasma Myeloperoxidase to Impaired Myocardial Microcirculation After Reperfusion in Patients With Acute Myocardial Infarction - Corrected Proof

2010-02-16

Previous studies have shown that oxidative stress and endothelial dysfunction are related to impaired myocardial microcirculation after reperfusion. Moreover, elevated myeloperoxidase (MPO) levels are associated with endothelial dysfunction. Plasma MPO levels were measured in patients with ST-segment elevation acute myocardial infarction (n = 160) who had undergone percutaneous coronary stenting within 12 hours of symptom onset. We investigated whether the plasma MPO level at admission was associated with impaired myocardial microcirculation, as indicated by ST-segment resolution and myocardial blush grade after reperfusion, and left ventricular ejection fraction and remodeling at 6 months. The patients were divided into 2 groups according to the median MPO value for the entire cohort (low-MPO group ≤50 ng/ml, n = 80; high-MPO group >50 ng/ml, n = 80). ST-segment resolution and the myocardial blush grade were significantly lower in the high-MPO than in the low-MPO group (48 ± 27% vs 61 ± 24%, p <0.005; and 2.1 ± 0.8 vs 2.4 ± 0.7, p <0.01; respectively). Moreover, the percentage of increase in the left ventricular end-diastolic volume index was significantly greater and the left ventricular ejection fraction at 6 months was significantly lower in the high-MPO group than in the low-MPO group (8.2 ± 24.7% vs −1.9 ± 23.5%, p <0.05; and 46 ± 9% vs 54 ± 9%, p <0.0001, respectively). Multiple regression analysis showed that the plasma MPO level was an independent predictor of incomplete ST-segment resolution (odds ratio 6.94, 95% confidence interval 2.10 to 22.9, p = 0.0015). In conclusion, elevated plasma MPO levels at admission were associated with impaired myocardial microcirculation after reperfusion in patients with acute myocardial infarction.

Effect of Multivessel Coronary Disease With or Without Concurrent Chronic Total Occlusion on One-Year Mortality in Patients Treated With Primary Percutaneous Coronary Intervention for Cardiogenic Shock - Corrected Proof

2010-02-16

Despite early revascularization, mortality remains high in patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. It has been shown that the effect of multivessel disease (MVD) on mortality in patients with STEMI treated with primary percutaneous coronary intervention is mainly caused by the presence of chronic total occlusion (CTO) in a noninfarct-related coronary artery. Whether this association also exists in patients with STEMI with cardiogenic shock is unknown. In our institution, 292 consecutive patients with STEMI complicated by cardiogenic shock were admitted from 1997 to 2005 and treated with primary percutaneous coronary intervention. Patients were classified as having single vessel disease, MVD without CTO, and CTO. Cox regression analysis was used for multivariate analysis. The 1-year mortality rate of patients with single-vessel disease, MVD, and CTO was 31%, 47%, and 63%, respectively. After adjustment for possible confounders, MVD alone was not an independent predictor of 1-year mortality (hazard ratio 1.5, 95% confidence interval 0.98 to 2.3, p = 0.07). In contrast, CTO in a noninfarct-related artery was an independent predictor of 1-year mortality (hazard ratio 2.1, 95% confidence interval 1.5 to 3.1, p <0.01). In conclusion, the presence of CTO in a non–infarct-related artery was an independent predictor of 1-year mortality. In contrast, MVD alone lost its predictive significance after multivariate analysis.

Socioeconomic Position, Ethnicity, and Outcomes in Heart Transplant Recipients - Corrected Proof

2010-02-16

The purpose of the present study was to assess whether a low socioeconomic (SE) position is associated with outcomes in heart transplant recipients. We used the US Census 2000 database to derive a summary SE score for 520 patients who had undergone underwent a first heart transplant at 1 of 4 Boston hospitals during 1996 to 2005 and compared the outcomes in the lowest quartile SE group (n = 129) to those for the remaining patients (n = 391). The low SE group and controls were similar with respect to cardiac diagnosis, hemodynamic support, listing status, year of transplant, and initial immune suppression. Low SE patients were more likely to be nonwhite. Graft loss occurred in 142 patients (135 deaths and 7 repeat transplants). Hospital mortality after transplantation was not associated with race/ethnicity or low SE position. In patients who survived the transplant hospitalization, nonwhite ethnicity (hazard ratio 1.8, 95% confidence interval 1.1 to 2.9) and low SE group (hazard ratio 1.7, 95% confidence interval 1.1 to 2.5) were associated with a greater risk of subsequent graft loss. In the adjusted analysis, the risk of graft loss remained greater for both nonwhite race/ethnicity (hazard ratio 1.7, 95% confidence interval 1.0 to 2.9) and low SE position (hazard ratio 1.5, 95% confidence interval 1.0 to 2.4). Rejection episodes were more frequent in nonwhite transplant recipients and in those in the low SE group. In conclusion, among heart transplant recipients who survive the transplant hospitalization, nonwhite recipients and those in a low SE position are at greater risk of rejection and graft loss.

Significance of Postprandial Symptom Exacerbation in Hypertrophic Cardiomyopathy - Corrected Proof

2010-02-16

Patients with hypertrophic cardiomyopathy (HC) can experience exacerbation of exertional symptoms after a meal. The present study was designed to determine the prevalence and clinical correlates of postprandial symptom exacerbation (PPSE) in patients with HC. The records of 558 patients with HC and PPSE data who had undergone echocardiography at our institution from 2002 to 2006 were reviewed. Continuous-wave Doppler velocities were used to determine the left ventricular outflow tract gradient. Left ventricular filling was assessed using transmitral velocity curves. The Minnesota Living With Heart Failure questionnaire was administered to measure symptom limitations. A multivariate regression model was developed to determine the independent correlates with PPSE. Of the 558 patients whose records were reviewed, 189 (33.8%) had PPSE. The patients with PPSE were more likely to experience New York Heart Association class III/IV dyspnea or presyncope. PPSE was associated with greater resting outflow gradients and lower perceived quality of life. In conclusion, patients presenting with severe postprandial symptoms and reduced quality of life should be carefully evaluated for the presence of dynamic left ventricular outflow tract obstruction.

Relation of Left Ventricular Ejection Fraction and Functional Capacity With Metabolism and Inflammation in Chronic Heart Failure With Reduced Ejection Fraction (from the MIMICA Study) - Corrected Proof

2010-02-16

Catabolism and inflammation play a role in the physiopathology of heart failure with reduced ejection fraction and are more pronounced in the advanced stages of the disease. Our aim was to demonstrate that in patients with stable heart failure with reduced ejection fraction adequately treated, a direct relation exists between functional impairment, as evaluated by left ventricular ejection fraction (LVEF) and the 6-minute walking distance (6MWD), and catabolic and inflammatory markers. In 151 outpatients with heart failure and a LVEF of ≤40% (median age 64 years, LVEF 29%, and 6MWD 290 m) we measured the laboratory and body composition parameters that indicate directly or indirectly inflammatory activation, anabolic-catabolic balance, and nutritional status. We performed an analysis stratified by quartiles of LVEF and 6MWD and linear regression analysis to explore our hypothesis. In the linear regression analysis, after adjusting for age, gender, and etiology, LVEF was not related to the metabolic, inflammatory, or nutritional parameters. The 6MWD was directly related to albumin (p = 0.002) and log transformation of dehydroepiandrosterone (p = 0.013) and inversely to adiponectin (p = 0.001) and the log-transformation of high-sensitivity C-reactive protein (p = 0.037). In conclusion, in a population with stable heart failure with reduced ejection fraction, the 6MWD was related to the degree of inflammatory activity and catabolism, but LVEF was not. Even a slightly diminished functional capacity implies underlying inflammation and catabolic activation.

Different Vascular Healing Patterns With Various Drug-Eluting Stents in Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction: Optical Coherence Tomographic Findings - Corrected Proof

2010-02-16

The introduction of optical coherence tomography has provided a new method for evaluating the vascular response to drug-eluting stents (DESs). We used optical coherence tomography to compare neointimal coverage and stent malapposition among DESs in patients with ST-segment elevation myocardial infarction. Optical coherence tomography was performed at 9 months after implantation of 3 types of DESs at the culprit lesions in 46 patients with ST-segment elevation myocardial infarction (16 sirolimus-eluting stents [SESs, Cypher Select], 11 paclitaxel-eluting stents [PESs, Taxus Liberte], and 19 zotarolimus-eluting stents [ZESs, Endeavor Sprint]). The neointimal thickness and apposition at each strut at each 1-mm interval and the presence of thrombi in each stent were evaluated. A total of 11,512 stent struts were analyzed. SESs had the thinnest neointimal thickness (SES 62 ± 43 μm vs PES 244 ± 142 μm vs ZES 271 ± 128 μm, p <0.001). The incidence of uncovered struts and malapposed struts were significantly greater in SESs and PESs than in ZESs (SES vs PES vs ZES, 16.2 ± 17.8% vs 4.7 ± 7.4% vs 0.6 ± 1.5%, respectively, p = 0.001; and 4.0 ± 8.2% vs 2.1 ± 4.5% vs 0 ± 0%, respectively, p = 0.001). Thrombus was also detected more often in SESs and PESs than in ZESs (SES, 6 [38%] vs PES, 3 [27%] vs ZES, 1 [5%], p = 0.02). In conclusion, the rate of stent strut coverage and malapposition were significantly different among the DES types in ST-segment elevation myocardial infarction. In particular, most stent struts in ZESs were covered with neointima and well-apposed. These findings imply that the type of DES might affect the vascular response in thrombotic lesions of ST-segment elevation myocardial infarction.

Gender Differences in Cardiac Remodeling and Clinical Outcomes in Chronic Stable Angina Pectoris (from the ACTION Trial) - Corrected Proof

2010-02-16

Our objective was to determine the gender differences in the relation between the echocardiographic parameters of cardiac remodeling and clinical outcomes in patients with chronic stable angina. The baseline ejection fraction (EF), end-diastolic volume, and end-systolic volume were assessed in 7,016 patients in the study “A Coronary disease Trial Investigating Outcomes with Nifedipine gastrointestinal therapeutic system” (ACTION). All-cause and cardiac mortality and incident heart failure were determined after a median of 5.0 years. Cox proportional hazard models were fit to determine the effect of gender on the relation between the echocardiographic parameters and clinical outcomes (interaction p <0.10). The association between the EF and mortality differed significantly between men and women, with women demonstrating a marked increase in risk as the EF decreased, compared to men (interaction p = 0.03, adjusted p = 0.07). Also, a significant interaction by gender was seen for the association between the end-systolic volume and the risk of heart failure (interaction p = 0.01, adjusted p = 0.05). In conclusion, the relation between EF and mortality differed according to gender in patients with chronic coronary disease, with women having a greater risk of adverse outcomes as the EF decreased. Similar findings were observed with the end-systolic and end-diastolic volumes and the risk of heart failure. These findings may reflect inherent gender-based differences in ischemic heart disease and cardiac remodeling and might help to identify women at high risk.

Standardizing the Method of Measuring by Echocardiogram the Diameter of the Ascending Aorta in Patients With a Bicuspid Aortic Valve - Corrected Proof

Alfred J. Albano, Elizabeth Mitchell, Linda A. Pape — 2010-02-16

Serial echocardiographic follow-up of patients with a bicuspid aortic valve (BAV), in addition to providing assessment of valve dysfunction, can help identify those at risk of aortic complications. However, currently there is no standardized echocardiographic method for measuring the ascending aorta. We examined the echocardiograms of 45 patients with a BAV and 45 matched controls to understand the effects of the measurement location (1, 2, and 3 cm above the sinotubular junction) and the point in the cardiac cycle (end-diastole, mid-systole, and end-systole) at which the ascending aortic measurements are made. A greater length of aorta could be measured in end-systole than in end-diastole, presumably because of aortic recoil. Using the control data for comparison, we found that more dilated ascending aortas were detected by measuring 3 cm above the sinotubular junction in the patients with a BAV (56%) than at 1 cm (42%). The increases in size between 1 and 2 cm were greater than those between 2 and 3 cm. In conclusion, we propose that all transthoracic echocardiograms should include the proximal aorta at least 2 cm and preferably 3 cm above the sinotubular junction and suggest that for standardization and optimal visualization the measurements be done at end-systole in all patients.

Comparison of Hospital Mortality With Intra-Aortic Balloon Counterpulsation Insertion Before Versus After Primary Percutaneous Coronary Intervention for Cardiogenic Shock Complicating Acute Myocardial Infarction - Corrected Proof

2010-02-16

Primary percutaneous coronary intervention (PCI) and intra-aortic balloon pump counterpulsation (IABP) are established treatment modalities in acute myocardial infarction complicated by cardiogenic shock. We hypothesized that the insertion of the IABP before primary PCI might result in better survival of patients with cardiogenic shock compared to postponing the insertion to after primary PCI. We, therefore, retrospectively studied 48 patients who had undergone primary PCI with IABP because of cardiogenic shock complicating acute myocardial infarction (26 patients received the IABP before and 22 patients after primary PCI). No significant differences were present in the baseline clinical characteristics between the 2 groups. The mean number of diseased vessels was greater in the group of patients treated with the IABP before primary PCI (2.8 ± 0.5 vs 2.3 ± 0.7, p = 0.012), but the difference in the number of treated vessels was not significant. The peak creatine kinase and creatine kinase -MB levels were lower in patients treated with the IABP before primary PCI (median 1,077, interquartile range 438 to 2067 vs median 3,299, interquartile range 695 to 6,834, p = 0.047, and median 95, interquartile range 34 to 196 vs median 192, interquartile range 82 to 467, p = 0.048, respectively). In-hospital mortality and the overall incidence of major adverse cardiac and cerebrovascular events were significantly lower in the group of patients receiving the IABP before primary PCI (19% vs 59% and 23% vs 77%, p = 0.007 and p = 0.0004, respectively). Multivariate analysis identified renal failure (odds ratio 15.2, 95% confidence interval 3.13 to 73.66) and insertion of the IABP after PCI (odds ratio 5.2, 95% confidence interval 1.09 to 24.76) as the only independent predictors of in-hospital mortality. In conclusion, the results of the present study suggest that patients with cardiogenic shock complicating acute myocardial infarction who undergo primary PCI assisted by IABP have a more favorable in-hospital outcome and lower in-hospital mortality than patients who receive IABP after PCI.

Value of Color Doppler Three-Dimensional Transesophageal Echocardiography in the Percutaneous Closure of Mitral Prosthesis Paravalvular Leak - Corrected Proof

Simon Biner, Saibal Kar, Robert J. Siegel, Asim Rafique, Takahiro Shiota — 2010-02-16

We investigated the clinical value of three-dimensional (3D) transesophageal echocardiography (TEE) color flow Doppler (TEE-CFD) for percutaneous transcatheter closure of mitral valve prosthesis paravalvular leaks (PVLs) compared to two-dimensional (2D) TEE. The number, location, and size of the mitral valve prosthesis PVLs were determined in 8 patients using 2D and 3D TEE-CFD. We also evaluated 2D and 3D TEE-CFD for identifying the canalization of the target PVL during the intervention and assessing the change in the PVL effective orifice after the endovascular procedure. We visualized 12 PVLs using 2D TEE-CFD and 15 PVLs using 3D TEE-CFD. No substantial disagreement was found between 2D and 3D TEE-CFD for the location for each of the PVLs. No difference was found in the vena contracta short axis width obtained by 2D TEE-CFD and 3D TEE-CFD (5.7 ± 1.4 mm vs 5.5 ± 1.3 mm, respectively, p = 0.09). However, only 3D TEE-CFD demonstrated the effective circumferential orifice length of the PVL (12.2 ± 8.5 mm). A closure device was deployed in 6 cases. In 1 case, the canalization of a nontarget PVL, visualized only on 3D TEE-CFD, led to an appropriate change in the treatment strategy. The reduction in the mean PVL vena contracta width demonstrated using 2D TEE-CFD and 3D TEE-CFD was similar (2.2 ± 0.7 mm vs 2.1 ± 1.1 mm, respectively, p = 0.69). However, only 3D TEE-CFD verified the reduction of the effective orifice circumferential length of the PVL by 10.5 ± 5.6 mm. In conclusion, 3D TEE-CFD provided unique and additive information in patients with mitral valve prosthesis PVLs. This new technology has the potential to improve the procedural success of percutaneous transcatheter closure of PVLs.

Screening Stress Myocardial Perfusion Imaging and Eligibility for Liver Transplantation - Corrected Proof

Steven M. Bradley, Laurie A. Soine, James H. Caldwell, Steven L. Goldberg — 2010-02-16

Screening for coronary artery disease is common practice in the evaluation of liver transplantation candidates. However, it is unclear whether coronary screening influences transplantation eligibility. We sought to determine the association between screening stress myocardial perfusion imaging (MPI) results and the eligibility for liver transplantation. Within a retrospective cohort of liver transplantation candidates referred for screening stress MPI at a single institution from April 1998 to February 2004, we obtained the baseline characteristics, stress MPI results, transplantation eligibility, and transplantation denial criteria by chart review. Of 294 patients (39%) denied transplantation, the denial criteria were multifactorial for 91 (31%) of the candidates. Compared to candidates with low-risk stress MPI results, the odds of being denied transplantation were the same for candidates with intermediate-risk MPI results (odds ratio 0.93, 95% confidence interval 0.45 to 1.82) or high-risk MPI results (odds ratio 1.42, 95% confidence interval 0.54 to 3.73). This lack of association persisted in our analysis with additional stratification of stress MPI results into negative, positive–low-risk, positive–intermediate-risk, and positive–high-risk. In conclusion, the screening stress MPI results were not associated with liver transplantation eligibility. The large number of competing factors considered before transplantation listing and the low proportion of positive stress MPI results suggests that targeting screening to patients deemed otherwise acceptable for transplantation might increase the influence of stress MPI findings on transplantation eligibility.

Effect of Baseline Glycemic Level on Long-Term Cardiovascular Outcomes After Coronary Revascularization Therapy in Patients With Type 2 Diabetes Mellitus Treated With Hypoglycemic Agents - Corrected Proof

2010-02-16

The present study evaluated the association between preoperative hemoglobin A1c (HbA1c) levels and cardiovascular outcomes in patients with type 2 diabetes mellitus (DM) treated with hypoglycemic agents and undergoing coronary revascularization. We conducted a multicenter registry of Japanese patients undergoing first elective coronary revascularization. The present study included 3,571 patients whose HbA1c value at the index hospitalization was available. Of the 3,571 patients, 2,067 did not have DM and 1,504 had type 2 DM. Of the patients with type 2 DM, 202 had a HbA1c level of <6% (very low HbA1c group [VLG]), 426 had a HbA1c level of ≥6% but <7% (low HbA1c group), 405 had a HbA1c level of '7% but <8% (intermediate HbA1c group), and 471 had a HbA1c level of ≥8% (high HbA1c group). The patients with type 2 DM treated with diet only were not included in the present study. The VLG had the lowest rate of freedom from major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, and stroke. On multivariate analyses, the low HbA1c group had the lowest hazard ratio for MACE relative to those without DM (hazard ratio 1.13, 95% confidence interval 0.80 to 1.55). The VLG, intermediate HbA1c group, and high HbA1c group were significantly associated with an increased risk of MACE. On multivariate analyses of patients with DM using the low HbA1c group as a reference, a high HbA1c group level was significantly associated with an increased risk of MACE. The VLG and intermediate HbA1c group tended to be associated with an increased risk of MACE (VLG, hazard ratio 1.54, 95% confidence interval 0.98 to 2.40; intermediate HbA1c group, hazard ratio 1.44, 95% confidence interval 0.98 to 2.13). In conclusion, patients with type 2 DM treated with hypoglycemic agents and undergoing first elective coronary revascularization had significantly worse cardiovascular outcomes than patients without DM, except for patients with DM and a HbA1c of 6% to 7%. In the patients with DM, those with a HbA1c of 6% to 7% tended to have the lowest risk of MACE.

Risk Factors Predictive of Right Ventricular Failure After Left Ventricular Assist Device Implantation - Corrected Proof

2010-02-16

Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation appears to be associated with increased mortality. However, the determination of which patients are at greater risk of developing postoperative RVF remains controversial and relatively unknown. We sought to determine the preoperative risk factors for the development of RVF after LVAD implantation. The data were obtained for 175 consecutive patients who had received an LVAD. RVF was defined by the need for inhaled nitric oxide for ≥48 hours or intravenous inotropes for >14 days and/or right ventricular assist device implantation. An RVF risk score was developed from the β coefficients of the independent variables from a multivariate logistic regression model predicting RVF. Destination therapy (DT) was identified as the indication for LVAD implantation in 42% of our patients. RVF after LVAD occurred in 44% of patients (n = 77). The mortality rates for patients with RVF were significantly greater at 30, 180, and 365 days after implantation compared to patients with no RVF. By multivariate logistic regression analysis, 3 preoperative factors were significantly associated with RVF after LVAD implantation: (1) a preoperative need for intra-aortic balloon counterpulsation, (2) increased pulmonary vascular resistance, and (3) DT. The developed RVF risk score effectively stratified the risk of RV failure and death after LVAD implantation. In conclusion, given the progressively growing need for DT, the developed RVF risk score, derived from a population with a large percentage of DT patients, might lead to improved patient selection and help stratify patients who could potentially benefit from early right ventricular assist device implantation.

Effect of Narcotic Treatment on Outcomes of Acute Coronary Syndromes - Corrected Proof

2010-02-16

Current guidelines have recommended intravenous narcotics (IVNs) for patients with ST-segment elevation acute coronary syndromes (STEACS) and patients with non-STEACS (NSTEACS), although the safety of IVNs has been challenged. We performed a retrospective analysis of the 30-day outcomes stratified by IVN use among patients enrolled in a national survey, using logistic regression and propensity score analysis. Of the 765 patients with STEACS and 993 patients with NSTEACS, 261 (34.1%) and 97 (9.8%) had received IVNs, respectively. The patients with STEACS who received IVNs were more likely to undergo reperfusion (79.7% vs 55.2%, p <0.0001), received it more rapidly (median 59 minutes vs 70 minutes, p = 0.02), and were more likely to undergo coronary angiography and revascularization. No difference was found in hemodynamic status. The patients with NSTEACS who received IVNs were more likely to present with Killip class II-IV (39.2% vs 10.0%, p <0.001) and to have left ventricular systolic dysfunction (39.0% vs 17.0%, p <0.001). No difference was found in the use of invasive procedures. Using propensity score analysis, of 249 matched STEACS pairs, the rate of 30-day death was lower in the group that had received IVNs (2.4% vs 6.2%, p = 0.04), and this trend persisted after logistic regression analysis (odds ratio 0.40, 95% confidence interval 0.14 to 1.14, p = 0.09). Using propensity score analysis, of 95 matched NSTEACS pairs, no difference was found in the 30-day death rate (2.2% for patients receiving IVNs vs 6.3%, p = 0.16), even after logistic regression analysis (odds ratio 0.56, 95% confidence interval 0.14 to 2.33, p = 0.43). In conclusion, IVNs were commonly used in different scenarios—patients with STEACS were more likely to receive IVNs in the context of prompt reperfusion, and patients with NSTEACS were more likely to receive IVNs in the context of heart failure. In both scenarios, IVN use did not adversely affect the outcomes.

Coronary Artery Spatial Distribution, Morphology, and Composition of Nonculprit Coronary Plaques by 64-Slice Computed Tomographic Angiography in Patients With Acute Myocardial Infarction - Corrected Proof

2010-02-16

Noninvasive identification of nonculprit lesions could improve preventive strategies for acute myocardial infarction (AMI). We assessed the morphology, composition, and spatial distribution of nonculprit coronary plaques in patients with AMI using computed tomographic angiography (CTA). A total of 64 patients with AMI underwent 64-slice CTA within 2 weeks after admission, and 162 symptomatic patients with stable angina pectoris (SAP) underwent CTA and stress myocardial perfusion imaging (MPI). Of these 226 patients, 16 were excluded from the analysis because of image artifacts. The mean number of nonculprit plaques per patient was 5.0 ± 2.6 in the AMI group (n = 60), 4.2 ± 2.6 in the SAP group with abnormal MPI findings (n = 67), and 1.1 ± 1.3 in the SAP group with normal MPI findings (n = 83; p <0.01). Positive remodeling and low-attenuation plaques (<30 Hounsfield units) were more frequently observed in the AMI group (1.9 ± 1.8) than in the SAP groups (0.6 ± 0.9 with abnormal MPI findings and 0.2 ± 0.4 with normal MPI findings; p <0.01). Within the AMI group, positive remodeling and low-attenuation plaques were present significantly more frequently in patients with metabolic syndrome than in those without (2.6 ± 2.2 vs 1.4 ± 1.4; p = 0.03) and was significantly more frequently distributed in the proximal segments of the left anterior descending artery (p <0.01). In conclusion, 64-slice CTA could provide promising information for preventive strategies by identifying nonculprit plaque morphology and zones at high risk of future events.

Is Accurate Intravascular Ultrasound Evaluation of the Left Circumflex Ostium from a Left Anterior Descending to Left Main Pullback Possible? - Corrected Proof

2010-02-16

Treatment of left main coronary artery bifurcation lesions might depend on the ostial left circumflex (LC) or ostial left anterior descending (LAD) disease severity. We sought to evaluate whether intravascular ultrasound assessment of the side branch ostium requires direct imaging or is accurate from the main vessel. Our retrospective analysis included 126 patients with left main coronary artery bifurcation disease (plaque burden ≥40% by intravascular ultrasound scanning). We analyzed pullbacks from the LAD and the LC. First, during the main vessel pullback (ie, from the LAD), we evaluated the side branch ostium (ie, of the LC). Second, we compared this oblique view with the direct ostial measurements during LC pullback. Finally, we repeated this process, imaging the ostial LAD from the LC. From the LAD, the oblique LC ostial lumen diameter was 3.0 ± 0.8 mm compared to the directly measured lumen diameter of 2.9 ± 0.6 mm. From the LC, the oblique LAD ostial lumen diameter was 2.9 ± 1.1 mm compared to the directly measured lumen diameter of 2.8 ± 0.5 mm. However, Bland-Altman plots showed significant variation in the oblique versus direct comparisons. The 95% limits of agreement ranged from −1.84 to 1.14 mm (mean difference −0.35, SD 0.75) for the LAD and −1.69 to 1.22 mm (mean difference −0.23, SD 0.73) for the LC. The “oblique view” detection of any plaque in the side branch predicted 40% or 70% plaque burden with good sensitivity but poor specificity. In conclusion, intravascular ultrasound evaluation of a side branch ostium from the main vessel is only moderately reliable, especially for distal left main coronary artery lesions. For an accurate assessment of the side branch ostium, direct imaging is necessary.

Further Experience With Catheter Closure of Patent Ductus Arteriosus Using the New Amplatzer Duct Occluder in Children - Corrected Proof

2010-02-16

The aim of the present study was to report our additional experience with transcatheter closure of the patent ductus arteriosus in 65 consecutive patients using the new Amplatzer duct occluder. The median patient age was 3.6 years (range 0.2to 12), and the median weight was 10.5 kg (range 4 to 38). The device was a modified Amplatzer duct occluder made of fabric-free fine Nitinol wire net in to 2 very low profile disks with an articulated connecting waist. It is delivered through a 4Fr to 5Fr delivery sheath. The device was permanently implanted in 62 of 65 patients. The mean patent ductus arteriosus diameter (at the pulmonary end) was 3.6 ± 1.3 mm (range 0.5 to 5.5). The mean device diameter (waist diameter) was 4.2 ± 1.5 mm (range 3 to 6). Complete echocardiographic closure of the PDA at 1 month follow-up was observed in 61 (98%) of 62 patients. Immediately after the procedure, mild left pulmonary stenosis (peak pressure gradient of 8, 10, and 12 mm Hg) in 3 of 63 patients. Device embolization in 1 patient was the main complication of the procedure. No other complications were observed. In conclusion, catheter closure using the Amplatzer duct occluder II is an effective and safe therapy for most patients with patent ductus arteriosus. Additional studies are required to document its efficacy, safety, and long-term results in a larger patient population.

Racial Disparities in Prescriptions for Cardioprotective Drugs and Cardiac Outcomes in Veterans Affairs Hospitals - Corrected Proof

2010-02-16

Previous reports have suggested that blacks receive life-saving cardioprotective therapies less often than whites, probably because of a lower socioeconomic status, which leads to poor access to physicians. We questioned whether racial disparity existed in the Veterans Affairs Healthcare System. We examined the Veterans' Integrated Service Network (VISN 16) database with regard to the prescription rates for 4 cardiovascular agents—aspirin, β blockers, statins, and angiotensin-converting enzyme inhibitors. The database, encompassing 474,565 patients (117,071 blacks and 357,494 whites), was analyzed. Cardioprotective drugs were prescribed significantly less often to black patients than compared to white patients (β blockers 19.7% vs 24.8%, odds ratio [OR] 0.74, 95% confidence interval [CI] 0.72 to 0.75; statins 20.5% vs 30.2%, OR 0.54, 95% CI 0.52 to 0.55; and angiotensin-converting enzyme inhibitors 27.7% vs 30.0%, OR 0.94, 95% CI 0.92 to 0.96; all p <0.0001, after adjustment for all covariates used in the analysis). Nonetheless, the prescription rates for aspirin were greater among the black patients than among the white patients (OR 1.31, 95% CI 1.27 to 1.35, p <0.001) after adjustment. The black patients received coronary artery bypass grafting less often than did the white patients (0.4% vs 1.21%, OR 0.40% to 0.48%, 95% CI 1.34 to 1.42, p <0.001). After adjustment for the use of cardioprotective drugs and coronary artery bypass grafting, black patients still had greater odds of developing angina (OR 1.38, 95% CI 1.34 to 1.42, p <0.001) and acute myocardial infarction (OR 1.11, 95% CI 1.03 to 1.19, p <0.006) than did white patients in the Department of Veterans Affairs Veterans' Integrated Service Network 16 hospitals. In conclusion, the lower prescription rates of cardioprotective drugs and lower rates of coronary artery bypass grafting might be a partial basis for the high rates of cardiac morbidity among black patients.

Accuracy of Knowledge-Based Reconstruction for Measurement of Right Ventricular Volume and Function in Patients With Tetralogy of Fallot - Corrected Proof

2010-02-16

We tested the accuracy and reproducibility of knowledge-based reconstruction (KBR) for measuring right ventricular (RV) volume and function. KBR enables rapid assessment of the right ventricle from sparse user input by referencing a database. KBR generates a 3-dimensional surface to fit points that the user enters at anatomic landmarks. We measured the RV volume using KBR from magnetic resonance images in 20 patients with repaired tetralogy of Fallot at end-diastole and end-systole. We entered points in the long- and short-axis and/or oblique views. The true volume was computed by manually tracing the RV borders for 3-dimensional reconstruction using the piecewise smooth subdivision surface method. The reference database included 54 patients with tetralogy of Fallot patients. The KBR values agreed closely with the true values for the end-diastolic volume (r = 0.993), end-systolic volume (r = 0.992), and ejection fraction (EF; r = 0.930). KBR slightly overestimated the end-diastolic volume (4 ± 10 ml, p = NS), end-systolic volume (1 ± 9 ml, p = NS), and EF (4 ± 3%, p = NS). No bias in the error was found by Bland-Altman analysis (p = NS for end-diastolic and end-systolic volume and EF). The KBR volumes had approached the true volumes (235 ± 93 vs 243 ± 93, p = 0.012, r = 0.978 for end-diastolic and end-systolic volumes combined) already after the first run and the entry of 19 ± 3 points. In conclusion, KBR provided accurate measurement of the RV volume and EF with minimal user input. KBR is a clinically feasible alternative to full manual tracing of the heart borders from imaging data.