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Juraschek SP, Daya N, Appel LJ, Miller ER, McEvoy JW, Matsushita K, Ballantyne CM, Selvin E. Orthostatic Hypotension and Risk of Clinical and Subclinical Cardiovascular Disease in Middle-Aged Adults. J Am Heart Assoc 2018; 7:JAHA.118.008884. [PMID: 29735525 PMCID: PMC6015335 DOI: 10.1161/jaha.118.008884] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Although orthostatic hypotension (OH) is a well‐recognized manifestation of neuropathy and hypovolemia, its contribution to cardiovascular disease (CVD) risk is controversial. Methods and Results Participants with OH, defined as a decrease in blood pressure (systolic ≥20 mm Hg or diastolic ≥10 mm Hg) from the supine to standing position, were identified during the first visit of the ARIC (Atherosclerosis Risk in Communities) Study (1987–1989) within 2 minutes of standing. All participants were followed up for the development of myocardial infarction, heart failure, stroke, fatal coronary heart disease (CHD), any CHD (combination of silent, nonfatal, and fatal CHD or cardiac procedures), and all‐cause mortality. Participants were assessed for carotid intimal thickness and plaque during the first visit. Detectable high‐sensitivity troponin T (≥5 ng/L) and elevated NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide; ≥100 pg/mL) were determined in blood collected during the second visit (1990–1992). All associations were adjusted for known CVD risk factors. In 9139 participants (57% women; 23% black; mean age, 54±5.7 years), 3% had OH. During follow‐up (median, 26 years), OH was associated with myocardial infarction (hazard ratio [HR], 1.88; 95% confidence interval [CI], 1.44–2.46), congestive heart failure (HR, 1.65; 95% CI, 1.34–2.04), stroke (HR, 1.83; 95% CI, 1.35–2.48), fatal CHD (HR, 2.77; 95% CI, 1.93–3.98), any CHD (HR, 2.00; 95% CI, 1.64–2.44), and all‐cause mortality (HR, 1.68; 95% CI, 1.45–1.95). OH was also associated with carotid intimal thickness (β, 0.05 mm; 95% CI, 0.04–0.07 mm), carotid plaque (odds ratio, 1.51; 95% CI, 1.18–1.93), detectable high‐sensitivity troponin T (odds ratio, 1.49; 95% CI, 1.16–1.93), and elevated NT‐proBNP (odds ratio, 1.92; 95% CI, 1.48–2.49). Conclusions OH identified in community‐dwelling middle‐aged adults was associated with future CVD events and subclinical CVD. Further research is necessary to establish a causal role for OH in the pathogenesis of CVD.
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Affiliation(s)
- Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA .,Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,The Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD.,Johns Hopkins Medical Institutions, Baltimore, MD
| | - Natalie Daya
- Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Johns Hopkins Medical Institutions, Baltimore, MD
| | - Lawrence J Appel
- Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Johns Hopkins Medical Institutions, Baltimore, MD
| | - Edgar R Miller
- Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Johns Hopkins Medical Institutions, Baltimore, MD
| | - John William McEvoy
- Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Johns Hopkins Medical Institutions, Baltimore, MD
| | - Kunihiro Matsushita
- Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Johns Hopkins Medical Institutions, Baltimore, MD
| | - Christie M Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX.,Houston Methodist DeBakey Heart and Vascular Center, Houston, TX
| | - Elizabeth Selvin
- Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Johns Hopkins Medical Institutions, Baltimore, MD
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Mazzotta G, Pace L, Bonow RO. Risk stratification of patients with coronary artery disease and left ventricular dysfunction by exercise radionuclide angiography and exercise electrocardiography. J Nucl Cardiol 1994; 1:529-36. [PMID: 9420747 DOI: 10.1007/bf02939976] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The results of multicenter trials indicate that patients with left ventricular dysfunction and either three-vessel or left main coronary artery disease have improved prognosis when treated surgically. OBJECTIVE As part of a larger evaluation and follow-up study of coronary artery disease, the objective of this investigation was to determine whether exercise radionuclide angiography can be used, in patients with mild symptoms of coronary artery disease and left ventricular dysfunction at rest, to identify patients with three-vessel or left main coronary artery disease. METHODS AND RESULTS Eighty-four consecutive patients were studied with angiographically defined coronary artery disease in whom left ventricular ejection fraction at rest ranged from 20% to 40%. Patients underwent exercise electrocardiography, rest and exercise radionuclide angiography, and 24-hour electrocardiographic monitoring. There were 22 patients with one-vessel, 31 with two-vessel, 27 with three-vessel, and four with left main coronary artery disease. All but four patients had a documented history of myocardial infarction. By univariate analysis, the following parameters were related to the anatomic severity of coronary artery disease: magnitude of ST segment depression with exercise (p < 0.001), magnitude of change in ejection fraction with exercise (p < 0.005), and occurrence of angina during exercise (p < 0.005). However, because of the extensive overlap among anatomic subgroups, no single factor had both a satisfactory sensitivity and a satisfactory specificity in identifying patients with three-vessel and left main coronary artery disease. Multivariate stepwise regression analysis also failed to predict three-vessel or left main coronary artery disease satisfactorily (sensitivity 73% and specificity 73%; positive predictive accuracy 59% and negative predictive accuracy 83%). Nonetheless, this multivariate analysis provided important prognostic information. During medical therapy (mean follow-up 56 months), the patients with a high likelihood of three-vessel or left main coronary artery disease had a greater risk of death or reinfarction than had patients with a low likelihood (p < 0.05). These functional data were better than coronary anatomy alone in providing risk stratification. Four of six patients with two-vessel disease who died were classified incorrectly by the multivariate analysis in the high-likelihood group for three-vessel or left main coronary artery disease, but classified correctly as being at high risk; whereas none of the patients with three-vessel disease who were misclassified in the low-likelihood group died during medical therapy. CONCLUSION Although exercise radionuclide angiography in patients with minimal symptoms of coronary artery disease and left ventricular dysfunction is not precise in predicting three-vessel or left main coronary artery disease, it provides important functional information regarding subsequent prognosis during medical therapy.
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Affiliation(s)
- G Mazzotta
- Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md., USA
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Mazzotta G, Camerini A, Scopinarô G, Villavecchiâ G, Lionetto R, Vecchio C. Predicting severe ischemic events after uncomplicated myocardial infarction by exercise testing and rest and exercise radionuclide ventriculography. J Nucl Cardiol 1994; 1:246-53. [PMID: 9420707 DOI: 10.1007/bf02940338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND In 183 patients with uncomplicated myocardial infarction, exercise-induced angina, ST segment depression, decrease in ejection fraction, or inadequate increase in systolic blood pressure and low exercise tolerance were significantly associated with 4-year incidence of hard ischemic events. METHODS AND RESULTS Only the onset of both ST segment depression and a decrease in left ventricular ejection fraction with exercise was an independent predictor. ST segment depression and decrease in left ventricular ejection fraction had low sensitivity (61% and 70%) and specificity (56% and 51%) for hard ischemic events, but specificity increased to 78% when both were present. During medical therapy, 22 of 53 patients with both ST segment depression and a decrease in left ventricular ejection fraction with exercise had an ischemic event (i.e., 48.1% 4-year probability on Kaplan-Meier analysis vs 19.2% in the remaining 130 patients [p < 0.0005]). CONCLUSIONS Even if no single variable, derived from exercise testing, is a highly sensitive and specific predictor, specificity increases to a clinically relevant level by combining ST segment depression and a decrease in left ventricular ejection fraction with exercise, and in this way patients with recent infarction may be selected for coronary arteriography.
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Affiliation(s)
- G Mazzotta
- Divisione di Cardiologia, E.O. Ospedali Galliera, Epidemiologia Clinica e Sperimentazioni Controllate, Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy
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Davis MH, Rezaie B, Weiland FL. Assessment of left ventricular ejection fraction from technetium-99m-methoxy isobutyl isonitrile multiple-gated radionuclide angiocardiography. IEEE TRANSACTIONS ON MEDICAL IMAGING 1993; 12:189-199. [PMID: 18218407 DOI: 10.1109/42.232248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Abnormal left ventricular function is a diagnostic indication of cardiac disease. Left ventricular function is commonly quantified by ejection fraction measurements. A novel approach for the determination of left ventricular ejection fraction from technetium-99m-methoxy isobutyl isonitrile multiple-gated radionuclide angiocardiography is presented. Data from 23 patients, symptomatic of cardiac disease, indicate that ejection fractions determined using the radionuclide technique correlate well with contrast X-ray single-plane cineangiography (r=0.83, p<10(-6)). Data from 14 of the patients indicate favorable correlation with technetium-99m-pertechnetate gated blood pool radionuclide angiocardiography (r=0.87, p<10(-4)).
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Affiliation(s)
- M H Davis
- Dept. of Electr. Eng., St. Mary's Univ., San Antonio, TX
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