Long-term outcomes of optimized medical management of outpatients with stable coronary artery disease

CHA2DS2-VASc score as predictor of stroke and all-cause death in stable ischaemic heart disease patients without atrial fibrillation

BACKGROUND

Cerebrovascular and coronary artery disease share risk factors. The aim was to study CHA₂DS₂-VASc score as predictor of stroke incidence and death in a sample of patients with sinus rhythm and stable ischemic heart disease (sIHD) during long-term follow-up.

METHODS

1184 patients with sIHD and without atrial fibrillation were included in this single-centre prospective cohort study between February 2000 and January 2004. Stroke and death prediction abilities of CHA₂DS₂-VASc score in this population were investigated.

RESULTS

The median age was 66 (interquartile range (IQR), 60-73 years). The mean follow-up was 11.2 ± 10 years (maximum 17 years). Along this period, 137 patients (11.6% of the sample) suffered a stroke. The mean value of CHA₂DS₂-VASc score was 3.04 ± 1.36, with CHA₂DS₂-VASc score ≤ 4 in 85.5% of the sample. Higher CHA₂DS₂-VASc score at baseline was associated with higher risk of suffering stroke (Hazard Ratio = 1.36, 95% CI 1.20-1.54, p < 0,001) and all-cause death during follow-up (Hazard Ratio = 1.49, 95% CI 1.40-1.58, p < 0,001).

CONCLUSIONS

Higher CHA₂DS₂-VASc score values were associated with higher risk of stroke and all-cause mortality during long-term follow-up in this real-world sample of patients with sIHD in sinus rhythm.

Long-term Survival in a Spanish Population With Stable Ischemic Heart Disease. The CICCOR Registry

INTRODUCTION AND OBJECTIVES

Data are lacking on the long-term prognosis of stable ischemic heart disease (SIHD). Our aim was to analyze long-term survival in patients with SIHD and to identify predictors of mortality.

METHODS

A total of 1268 outpatients with SIHD were recruited in this single-center prospective cohort study from January 2000 to February 2004. Cardiovascular and all-cause death during follow-up were registered. All-cause and cardiovascular mortality rates were compared with those in the Spanish population adjusted by age, sex, and year. Predictors of these events were investigated.

RESULTS

The mean age was 68±10 years and 73% of the patients were male. After a follow-up lasting up to 17 years (median 11 years), 629 (50%) patients died. Independent predictors of all-cause mortality were age (HR, 1.08; 95%CI, 1.07-1.11; P <.001), diabetes (HR, 1.36; 95%CI, 1.14-1.63; P <.001), resting heart rate (HR, 1.01; 95%CI, 1.00-1.02; P <.001), atrial fibrillation (HR, 1.61; 95%CI, 1.22-2.14; P=.001), electrocardiographic changes (HR, 1.23; 95%CI, 1.02-1.49; P=.02) and active smoking (HR, 1.85; 95%CI, 1.31-2.80; P=.001). All-cause mortality and cardiovascular mortality rates were significantly higher in the sample than in the general Spanish population (47.81/1000 patients/y vs 36.29/1000 patients/y (standardized mortality rate, 1.31; 95%CI, 1.21-1.41) and 15.25/1000 patients/y vs 6.94/1000 patients/y (standardized mortality rate, 2.19; 95%CI, 1.88-2.50, respectively).

CONCLUSIONS

The mortality rate was higher in this sample of patients with SIHD than in the general population. Several clinical variables can identify patients at higher risk of death during follow-up.

Impact of subclinical hypothyroidism on clinical outcomes following percutaneous coronary intervention

BACKGROUND

Similar to overt hypothyroidism, subclinical hypothyroidism (SCH) has been reported to increase the risk of cardiovascular disease. However, the influence of SCH on clinical outcomes following percutaneous coronary intervention (PCI) remains unclear.

METHODS

We performed a prospective cohort study. SCH was defined as a thyroid-stimulating hormone (TSH) level ≥4.5mIU/l and a normal level of free thyroxine (FT4). A composite event was defined as the combination of cardiac death, non-fatal myocardial infarction (MI) and repeat revascularization.

RESULTS

Of 936 patients, who were observed for 3.1years, 100 patients (10.7%) were diagnosed with SCH. Repeat revascularization, cardiac death and a composite event occurred more frequently in the SCH group than in the euthyroidism group, while the incidence of non-fatal MI was similar between the two groups. Multiple Cox regression analysis showed that SCH was associated with the risk of a composite event (hazard ratio, 1.52; 95% confidence interval, 1.04-2.22) after adjustment for age, sex, current smoking, ST-segment elevation MI, prior PCI, diabetes, hypertension, renal function, left ventricular ejection fraction, B-type natriuretic peptide, stent numbers, total stent length, stent types, obesity and lipid profiles. Serum TSH levels were also significantly associated with the risk of a composite event. SCH was not associated with repeat PCIs for de novo stenotic lesions but was associated with repeated PCIs for in-stent restenotic lesions.

CONCLUSIONS

SCH negatively impacted clinical outcomes following PCIs. Therefore, patients with SCH should be carefully observed after undergoing a PCI.

Cardiosphere-Derived Cells and Ischemic Heart Failure

After a myocardial infarction, heart tissue becomes irreversibly damaged, leading to scar formation and inevitably ischemic heart failure. Of the many available interventions after a myocardial infarction, such as percutaneous intervention or pharmacological optimization, none can reverse the ischemic insult on the heart and restore cardiac function. Thus, the only available cure for patients with scarred myocardium is allogeneic heart transplantation, which comes with extensive costs, risks, and complications. However, multiple studies have shown that the heart is, in fact, not an end-stage organ and that there are endogenous mechanisms in place that have the potential to spark regeneration. Stem cell therapy has emerged as a potential tool to tap into and activate this endogenous framework. Particularly promising are stem cells derived from cardiac tissue itself, referred to as cardiosphere-derived cells (CDCs). CDCs can be extracted and isolated from the patient's myocardium and then administered by intramyocardial injection or intracoronary infusion. After early success in the animal model, multiple clinical trials have demonstrated the safety and efficacy of autologous CDC therapy in humans. Clinical trials with allogeneic CDCs showed early promising results and pose a potential "off-the-shelf" therapy for patients in the acute setting after a myocardial infarction. The mechanism responsible for CDC-induced cardiac regeneration seems to be a combination of triggering native cardiomyocyte proliferation and recruitment of endogenous progenitor cells, which most prominently occurs via paracrine effects. A further understanding of the mediators involved in paracrine signaling can help with the development of a stem cell-free therapy, with all the benefits and none of the associated complications.

Understanding the nature of health: New perspectives for medicine and public health. Improved wellbeing at lower costs

BACKGROUND

Current dilemmas of health care systems call for a new look at the nature of health. This is offered by the Meikirch model. We explore its hypothetical benefit for the future of medicine and public health. Meikirch model: It states: "Health is a dynamic state of wellbeing emergent from conducive interactions between individuals' potentials, life's demands, and social and environmental determinants." "Throughout the life course health results when an individuals' biologically given potential (BGP) and his or her personally acquired potential (PAP), interacting with social and environmental determinants, satisfactorily respond to the demands of life."

METHODS

We explored the Meikirch model's possible applications for personal and public health care.

RESULTS

The PAP of each individual is the most modifiable component of the model. It responds to constructive social interactions and to personal growth. If an individual's PAP is nurtured to develop further, it likely will contribute much more to health than without fostering. It may also compensate for losses of the BGP. An ensuing new culture of health may markedly improve health in the society. The rising costs of health care presumably are due in part to the tragedy of the commons and to moral hazard. Health as a complex adaptive system offers new possibilities for patient care, particularly for general practitioners.

DISCUSSION

Analysis of health systems by the Meikirch model reveals that in many areas more can be done to improve people's health and to reduce health care costs than is done today. The Meikirch model appears promising for individual and public health in low and high income countries. Emphasizing health instead of disease the Meikirch model reinforces article 12 of the International Covenant on Economic, Social and Cultural Rights of the United Nations - that abandons the WHO definition - and thereby may contribute to its reinterpretation.

Recent advances in the secondary prevention of coronary heart disease

Current practice guidelines provide recommendations for the secondary prevention of coronary heart disease. Following the publication of clinical trials in recent years, this review will highlight some controversial issues: the role of angiotensin and aldosterone antagonists after acute myocardial infarction; the effects of angiotensin-converting enzyme inhibitors in patients with stable coronary heart disease and preserved left ventricular ejection fraction; high-intensity lowering of low-density lipoprotein cholesterol; use of 3-hydroxy-3-methyl-glutaryl coenzyme A reductase inhibitors in the elderly; and the targeting of high-density lipoprotein cholesterol with niacin.

Determinants of cardiovascular mortality in a cohort of primary care patients with chronic ischemic heart disease. BARBANZA Ischemic Heart Disease (BARIHD) study

BACKGROUND

Prognosis of chronic patients with established ischemic heart disease (IHD) is not fully understood. The objective was to determine which factors are related to cardiovascular death and hospitalizations in patients with IHD within a primary care network.

MATERIALS AND METHODS

A cohort study was carried out by 69 primary care providers in Spain in 2007. Participants were followed up for a mean of 2.2 ± 0.3 years. 1095 patients were recruited if they had established (at least 1 year of known disease) IHD (myocardial infarction or and stable or unstable angina). Several hypothesized determinants of cardiovascular mortality were studied, using Cox proportional hazard regression models. Subgroup analysis was also performed for participants without cardiovascular admissions within the last year.

RESULTS

Mean time since first IHD diagnosis was 7.6 ± 6.0 years. Annual all-cause mortality rate was 3.25%, with 44 cardiovascular deaths and 119 cardiovascular admissions. The main prognostic factor for cardiovascular death was previous heart failure (hazard ratio [HR] 4.32, 95% confidence interval [CI] 2.30 to 8.11, p<0.001). Recent cardiovascular admission doubled the risk for death (HR 2.01, CI 1.06 to 3.81, p=0.031). Results showed that use of beta blockers and increased physical activity were the main protective factors. Patients without a recent cardiovascular admission showed previous heart failure as the main significant factor for cardiovascular death.

CONCLUSIONS

Patients with chronic IHD in a primary care setting may need a closer follow-up in the presence of previous conditions such as heart failure. Physical activity and treatment with beta blockers were the factors giving these patients the greatest protection.

Comparison of Clinical characteristics and long-term outcomes of patients with ischemic cardiomyopathy with versus without angina pectoris (from the Duke Databank for Cardiovascular Disease)

Myocardial ischemic origin is a significant independent predictor of mortality in patients with heart failure (HF). The implications of angina pectoris (AP) in HF are less well characterized. The aim of this study was to compare the clinical characteristics and outcomes of patients with and without AP in a cohort of patients with reduced ejection fractions and ischemic cardiomyopathy (iCM). Patients who underwent coronary angiography at Duke University Medical Center from January 2000 to September 2009 with ejection fractions <40% and diagnoses of iCM with AP in the previous 6 weeks were compared to similar patients without AP. Time to event was examined using Kaplan-Meier methods for 5 end points: death; death or nonfatal myocardial infarction (MI); death, MI, or revascularization; death or hospitalization; and cardiovascular (CV) death or CV hospitalization. Of 2,376 patients with iCM, 1,412 (59%) had AP. They had more co-morbidities and more previous revascularization than patients without AP. After multivariate adjustment, those with and without AP had similar risks for death (p = 0.32), death or MI (p = 0.15), and death or hospitalization (p = 0.37) (5-year event rates 41% vs 41%, 46% vs 47%, and 87% vs 85%, respectively), but those with AP had lower rates of death, MI, or revascularization (p = 0.01) and higher rates of CV death or CV hospitalization (p = 0.03) (5-year event rates 85% vs 87% and 77% vs 73%, respectively). In conclusion, AP is common in patients with iCM despite medical therapy and previous revascularization and is associated with increased CV death or CV rehospitalization.

Long-Term Cardiovascular and Noncardiovascular Mortality of 1023 Patients With Confirmed Acute Pulmonary Embolism

Background—

There are currently no guidelines advising long-term surveillance of patients following an acute pulmonary embolism (PE), because long-term outcome studies are rare. We investigated the long-term cardiovascular and all-cause mortality of a large patient cohort with confirmed PE in relation to baseline cardiovascular disease (CVD).

Methods and Results—

Clinical details of all patients presenting with acute PE to a tertiary hospital were retrieved from medical records, and their survival tracked from a statewide death registry. There were 1023 (45% males) patients admitted with confirmed PE from 2000 to 2007. During a mean follow-up of 3.8±2.6 years, 363 patients died (35.5%), of whom only 31 (3.0%) died in-hospital during the index PE admission. The 3-month, 6-month, 1-year, 3-year, and 5-year cumulative mortality rates were 8.3%, 11.1%, 16.3%, 26.7%, and 31.6% respectively. Annual mortality did not improve over the 7-year period. The postdischarge mortality of 8.5%/patient-year was 2.5-fold that of an age- and sex-matched general population, being 12.6-fold in the youngest quintile (<55 years) and 1.9-fold in the oldest quintile (≥83 years). Patients with known CVD at baseline had 2.2-fold greater all-cause mortality than those without CVD, and this effect, although at a lower level of risk, remained significant after multivariate analysis. Of the 332 deaths occurring postdischarge, 40% were attributed to cardiovascular causes.

Conclusions—

In a contemporary adult population, PE is associated with a substantially increased long-term mortality, of which nearly half is cardiovascular. Our study highlights the urgent need to develop long-term surveillance strategies in this population.

Perioperative management of the patient with cardiac disease

The overall incidence of perioperative death is relatively low. However, patients with coronary artery disease are at higher than average risk of perioperative cardiac complications. Thus, preoperative testing for cardiac disease should be done in certain patients in an effort to reduce postoperative mortality and morbidity. Patients who require emergent orthopaedic surgery are at greater risk of perioperative cardiac events than are those who undergo elective procedures. Certain modalities, such as beta blockers, statins, and alpha-2 agonists, may be started or continued in the postoperative period to further enhance cardiac function. We review the current recommendations for preoperative cardiac testing in orthopaedic patients and for perioperative management of orthopaedic patients with known cardiac disease.

Reduction in downstream test utilization following introduction of coronary computed tomography in a cardiology practice

To compare utilization of non-invasive ischemic testing, invasive coronary angiography (ICA), and percutaneous coronary intervention (PCI) procedures before and after introduction of 64-slice multi-detector row coronary computed tomographic angiography (CCTA) in a large urban primary and consultative cardiology practice. We utilized a review of electronic medical records (NotesMD) and the electronic practice management system (Megawest) encompassing a 4-year period from 2004 to 2007 to determine the number of exercise treadmill (TME), supine bicycle exercise echocardiography (SBE), single photon emission computed tomography (SPECT) myocardial perfusion stress imaging (MPI), coronary calcium score (CCS), CCTA, ICA, and PCI procedures performed annually. Test utilization in the 2 years prior to and 2 years following availability of CCTA were compared. Over the 4-year period reviewed, the annual utilization of ICA decreased 45% (2,083 procedures in 2004 vs. 1,150 procedures in 2007, P < 0.01) and the percentage of ICA cases requiring PCI increased (19% in 2004 vs. 28% in 2007, P < 0.001). SPECT MPI decreased 19% (3,223 in 2004 vs. 2,614 in 2007 P < 0.02) and exercise stress treadmill testing decreased 49% (471 in 2004 vs. 241 in 2007 P < 0.02). Over the same period, there were no significant changes in measures of practice volume (office and hospital) or the annual incidence of PCI (405 cases in 2004 vs. 326 cases in 2007) but a higher percentage of patients with significant disease undergoing PCI 19% in 2004 vs. 29% in 2007 P < 0.01. Implementation of CCTA resulted in a significant decrease in ICA and a corresponding significant increase in the percentage of ICA cases requiring PCI, indicating that CCTA resulted in more accurate referral for ICA. The reduction in unnecessary ICA is associated with avoidance of potential morbidity and mortality associated with invasive diagnostic testing, reduction of downstream SPECT MPI and TME as well as substantial savings in health care dollars.

Anxiety Worsens Prognosis in Patients With Coronary Artery Disease

OBJECTIVES

This study examined the effect of anxiety on mortality and nonfatal myocardial infarction (MI) in patients with coronary artery disease (CAD).

BACKGROUND

Inconsistent data exist regarding the impact of anxiety on the prognosis of patients with CAD.

METHODS

The authors conducted a prospective cohort study at an outpatient cardiology clinic of 516 patients with CAD (mean age 68 years at entry, 82% male) by administering the Kellner Symptom Questionnaire annually. The primary outcome was the composite of nonfatal MI or all-cause mortality.

RESULTS

During an average follow-up of 3.4 years, we documented 44 nonfatal MIs and 19 deaths. A high cumulative anxiety score was associated with an increased risk of nonfatal MI or death. Comparing the highest to lowest tertile of anxiety score, the age-adjusted hazard ratio was 1.97 (95% confidence interval 1.03 to 3.78, p = 0.04). In a multivariate Cox model after adjusting for age, gender, education, marital status, smoking, hypertension, diabetes mellitus, previous MI, body mass index, and total cholesterol, each unit increase in the cumulative mean anxiety score was associated with increased risk of nonfatal MI or total mortality; the hazard ratio was 1.06 (95% confidence interval 1.01 to 1.12, p = 0.02).

CONCLUSIONS

A high level of anxiety maintained after CAD diagnosis constitutes a strong risk of MI or death among patients with CAD.

Letalidade hospitalar nas angioplastias coronárias no Estado do Rio de Janeiro, Brasil, 1999-2003

O estudo analisa a letalidade hospitalar nas angioplastias coronárias, pagas pelo Sistema Único de Saúde (SUS), realizadas nos hospitais do Estado do Rio de Janeiro, Brasil, de 1999 até 2003. As informações sobre as angioplastias coronárias provieram do banco de Autorizações de Internações Hospitalares da Secretaria de Estado de Saúde do Estado do Rio de Janeiro. As taxas de letalidade foram estimadas segundo faixas etárias, sexo, diagnósticos e hospitais. A letalidade geral foi de 1,9% em 8.735 angioplastias coronárias. A taxa mais baixa ocorreu nas anginas (0,8%), as mais elevadas nos infartos agudos do miocárdio (6%) e em outros diagnósticos (7%). A letalidade foi menor nas mulheres na faixa etária entre 50 e 69 anos, e a partir dos setenta anos foi quase três vezes maior que a dos mais jovens (de 1,4 a 4%), em ambos os sexos. Ocorreu grande variabilidade entre as taxas de letalidade nas angioplastias coronárias nos diferentes hospitais (entre 0 e 6,5%). Portanto, é necessário acompanhar de modo contínuo a adequação da utilização da angioplastia coronária. Em conclusão, a performance deste procedimento no âmbito da modalidade de atenção pelo SUS nos hospitais, dentro do período estudado, não foi satisfatória.

Comparison of the long-term survival benefits associated with revascularization or medical therapy in patients with known coronary artery disease undergoing transesophageal atrial pacing stress echocardiography

Although the utility of stress echocardiography for the diagnosis and prognostic evaluation of patients with suspected coronary artery disease (CAD) has been widely reported, few studies have evaluated the role of revascularization in relation to the presence of inducible ischemia during stress in patients with known CAD. The study population consisted of 295 consecutive patients who underwent transesophageal atrial pacing stress echocardiography (TAPSE) in the echocardiographic laboratory of our division between January 1988 and September 1997, in whom coronary angiography was performed within 10 days of the test. Patients were then assigned to revascularization or medical treatment according to the treatment given within 60 days of TAPSE. Cardiac-related deaths were higher in medically treated (19 of 135) than in revascularized (8 of 160) patients (p = 0.03). Parameters measured with TAPSE, i.e., positivity of the test, change in wall motion score index (DeltaWMSI and peak WMSI) were significantly related to mortality in medically treated patients but not in revascularized patients. At multivariate analysis, DeltaWMSI remained the most powerful predictor of cardiac death in medically treated patients (p = 0.005). Mortality progressively increased with increments in extent of inducible ischemia among medically treated patients (5 of 71 patients in DeltaWMSI 0, 3 of 27 in DeltaWMSI 0 to 25, 11 of 37 patients in DeltaWMSI >25) but not among revascularized patients (3 of 58 patients in DeltaWMSI 0, 2 of 51 in DeltaWMSI 0 to 25, 3 of 51 patients in DeltaWMSI >25). The survival curve in medically treated patients with ischemia in a remote zone (24 patients, 8 deaths) was worse than in other groups of medically treated patients (41 patients, 6 deaths). In conclusion, in patients with known CAD, the presence and extent of ischemia as evaluated with TAPSE worsens survival, if revascularization is not performed. In patients without ischemia at TAPSE, revascularization or medical therapy are equally effective.

Controversies in stable coronary artery disease

Coronary heart disease is still highly prevalent worldwide, and stable angina pectoris is one of its more common presentations. Three major controversies are risk factor management, drug therapy, and intervention. As well as the major risk factors stated by the Framingham study and European guidelines, other factors include abdominal obesity, metabolic syndrome, and psychological stress. How should these additional factors be rated? With respect to drug therapy, apart from aspirin, all patients with stable angina should be assessed for statin treatment. Although statins will reduce coronary events by about one third in patients with vascular disease, the absolute benefit depends on the absolute risk. Non-controversially, all patients should be considered for angiotensin-converting-enzyme inhibitors. The concept that beta blockers are protective from future coronary events can be disputed. Percutaneous coronary intervention can relieve symptoms without extending lifespan beyond medical therapy. However, strong mortality data favour coronary-artery bypass grafting in individuals with triple-vessel or even double-vessel disease. Thus, effort angina needs comprehensive assessment, lifestyle changes, and treatment tailored to the individual patient.

Favourable long term prognosis in stable angina pectoris: an extended follow up of the angina prognosis study in Stockholm (APSIS)

OBJECTIVE

To evaluate the long term prognosis of patients with stable angina pectoris.

DESIGN

Registry based follow up (median 9.1 years) of patients participating in the APSIS (angina prognosis study in Stockholm), which was a double blind, single centre trial of antianginal drug treatment.

PATIENTS

809 patients (31% women) with stable angina pectoris < 70 (mean (SD) 59 (7) years at inclusion) and an age and sex matched reference population from the same catchment area.

INTERVENTIONS

Double blind treatment with metoprolol or verapamil during 3.4 years (median), followed by referral for usual care with open treatment.

MAIN OUTCOME MEASURES

Cardiovascular (CV) death and non-fatal myocardial infarction (MI) in the APSIS cohort and total mortality in comparison with reference subjects.

RESULTS

123 patients died (41 MI, 36 other CV causes) and 72 had non-fatal MI. Mortality (19% v 6%, p < 0.001) and fatal MI (6.6% v 1.6%, p < 0.001) were increased among male compared with female patients. Diabetes, previous MI, hypertension, and male sex independently predicted CV mortality (p < 0.001). Diabetes greatly increased the risk in a small subgroup of female patients. Male patients had higher mortality than men in the reference population during the first three years (cumulative absolute difference 3.8%) but apparently not thereafter. Female patients had similar mortality to women in the reference population throughout the 9.1 years of observation.

CONCLUSIONS

Female patients with stable angina had similar mortality to matched female reference subjects but male patients had an increased risk. Diabetes, previous MI, hypertension, and male sex were strong risk factors for CV death or MI.