A clinical and echocardiographic score for assigning risk of major events after dobutamine echocardiograms

Death and Myocardial Infarction Following Initial Revascularization Versus Optimal Medical Therapy in Chronic Coronary Syndromes With Myocardial Ischemia: A Systematic Review and Meta-Analysis of Contemporary Randomized Controlled Trials

Background

In chronic coronary syndromes, myocardial ischemia is associated with a greater risk of death and nonfatal myocardial infarction (MI). We sought to compare the effect of initial revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) plus optimal medical therapy (OMT) with OMT alone in patients with chronic coronary syndrome and myocardial ischemia on long‐term death and nonfatal MI.

Methods and Results

Ovid Medline, Embase, Scopus, and Cochrane Library databases were searched for randomized controlled trials of PCI or CABG plus OMT versus OMT alone for patients with chronic coronary syndromes. Studies were screened and data were extracted independently by 2 authors. Random‐effects models were used to generate pooled treatment effects. The search yielded 7 randomized controlled trials that randomized 10 797 patients. Median follow‐up was 5 years. Death occurred in 640 of the 5413 patients (11.8%) randomized to revascularization and in 647 of the 5384 patients (12%) randomized to OMT (odds ratio [OR], 0.97; 95% CI, 0.86–1.09; P=0.60). Nonfatal MI was reported in 554 of 5413 patients (10.2%) in the revascularization arms compared with 627 of 5384 patients (11.6%) in the OMT arms (OR, 0.75; 95% CI, 0.57–0.99; P=0.04). In subgroup analysis, nonfatal MI was significantly reduced by CABG (OR, 0.35; 95% CI, 0.21–0.59; P<0.001) but was not reduced by PCI (OR, 0.92; 95% CI, 0.75–1.13; P=0.43) (P‐interaction <0.001).

Conclusions

In patients with chronic coronary syndromes and myocardial ischemia, initial revascularization with PCI or CABG plus OMT did not reduce long‐term mortality compared with OMT alone. CABG plus OMT reduced nonfatal MI compared with OMT alone, whereas PCI did not.

Unsupervised clustering for phenotypic stratification of clinical, demographic, and stress attributes of cardiac risk in patients with nonischemic exercise stress echocardiography

INTRODUCTION AND AIM

Patients undergoing exercise echocardiography with no evidence of myocardial ischemia are considered a low-risk group; however, this group is likely heterogeneous in terms of short-term adverse events and subsequent cardiac testing. We hypothesized that unsupervised cluster modeling using clinical and stress characteristics can detect heterogeneity in cardiovascular risk and need for subsequent cardiac testing among these patients.

METHODS

We retrospectively studied 445 patients who had exercise echocardiography results negative for myocardial ischemia. All patients were followed for adverse cardiovascular events, subsequent cardiac testing, and nonacute coronary syndrome (ACS) revascularization. The heterogeneity of the study subjects was tested using computational clustering, an exploratory statistical method designed to uncover invisible natural groups within data. Clinical and stress predictors of adverse events were extracted and used to construct 3 unsupervised cluster models: clinical, stress, and combined. The study population was split into training (357 patients) and testing sets (88 patients).

RESULTS

In the training set, the clinical, stress, and combined cluster models yielded 5, 4, and 3 clusters, respectively. Each model had 1 high-risk and 1 low-risk cluster while other clusters were intermediate. The combined model showed a better predictive ability compared to the clinical or stress models alone. The need for future testing mirrored the pattern of adverse cardiovascular events. A risk score derived from the combined cluster model predicted end points with acceptable accuracy. The patterns of risk and the calculated risk scores were preserved in the testing set.

CONCLUSIONS

Patients with no evidence of ischemia on exercise stress echocardiography represent a heterogeneous group. Cluster-based modeling using combined clinical and stress characteristics can expose this heterogeneity. The findings can help better risk-stratify this group of patients and aid cost-effective healthcare utilization toward better diagnostics and therapeutics.

Simple six-item clinical score improves risk prediction capability of stress echocardiography

Objectives

To assess the value of a simple score integrating non-ischaemia-related variables in expanding the wall motion abnormalities risk power during stress echocardiography (SE).

Methods

Study includes 14 279 patients who underwent SE for evaluation of coronary artery disease. All-cause death was the end point. Patients were randomly divided into the modelling and validation group of equal size. In the modelling group, multivariate analysis was conducted using clinical, rest and SE data, and a score was obtained from the number of non-ischaemia-related independent prognostic predictors. The score prognostic capability was compared in both groups.

Results

During a median follow-up of 31 months, 1230 patients died: 622 (9%) in the modelling and 608 (9%) in the validation group (p=0.68). Independent predictors of mortality were ischaemia at SE (HR 1.77, 95% CI 1.49 to 2.12; p<0.0001) and six other parameters: age>65 years, wall motion at rest, diabetes, left bundle branch block, anti-ischaemic therapy and male sex. Risk score resulted prognostically effective in the modelling and validation groups, both with and without inducible ischaemia subset. When risk score was included in the multivariate analysis, besides ischaemia at SE it was the only independent predictor of mortality in the modelling (HR 1.70, 95% CI 1.60 to 1.82; p<0.0001), in the validation (HR 1.77, 95% CI 1.65 to 1.90; p<0.0001) and in the overall group (HR 1.73, 95% CI 1.66 to 1.82; p<0.0001).

Conclusions

Simple clinical variables may be able to optimise SE risk stratification.

Feasibility of exercise stress echocardiography for cardiac risk assessment in chronic kidney disease patients prior to renal transplantation

BACKGROUND

Pharmacologic stress testing is utilized in preference to exercise stress echocardiography (ESE) for cardiac risk evaluation in potential renal transplant recipients due to the perceived lower feasibility of ESE for achieving adequate workload and target heart rate (THR) in this population.

METHODS

Consecutive patients referred for cardiac risk evaluation prior to potential kidney transplantation were evaluated. All patients attempted ESE before pharmacologic testing was considered. Treadmill ESE utilized BRUCE protocol to maximum capacity. THR was defined as >85% of the maximum predicted heart rate (220-age). Functional capacity was assessed by metabolic equivalents (METs) and the rate pressure product (RPP).

RESULTS

Of 535 patients (349 male, age 56±11), 372(70%) reached THR. Mean METs were 10±3 with 531(99%) achieving ≥4 METs and 87% ≥7 METs. Mean RPP was 25 821±5820 bpm×mm Hg (83% achieving >20 000 bpm×mm Hg). On multivariate analysis, independent predictors of failure to reach THR were rate-control medication and diabetes; failure to reach 7 METs: females, diabetics, age≥65, and previous cardiac disease; failure to reach RPP>20 000: rate-control medication. There were 97% of ESE completed to physiologic endpoints.

CONCLUSION

In unselected potential renal transplant candidates, cardiac assessment by ESE is well tolerated, with 9-in-10 exercising to satisfactory functional capacity. ESE should be considered a feasible alternative to pharmacologic testing in this population.

Diagnostic and prognostic value of non-invasive imaging in known or suspected coronary artery disease

The role of non-invasive imaging techniques in the evaluation of patients with suspected or known coronary artery disease (CAD) has increased exponentially over the past decade. The traditionally available imaging modalities, including nuclear imaging, stress echocardiography and magnetic resonance imaging (MRI), have relied on detection of CAD by visualisation of its functional consequences (i.e. ischaemia). However, extensive research is being invested in the development of non-invasive anatomical imaging using computed tomography or MRI to allow detection of (significant) atherosclerosis, eventually at a preclinical stage. In addition to establishing the presence of or excluding CAD, identification of patients at high risk for cardiac events is of paramount importance to determine post-test management, and the majority of non-invasive imaging tests can also be used for this purpose. The aim of this review is to provide an overview of the available non-invasive imaging modalities and their merits for the diagnostic and prognostic work-up in patients with suspected or known CAD.

Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies

Despite a dramatic decline in mortality over the past three decades, coronary heart disease is the leading cause of death and disability in the U.S. Importantly, recent advances in the field of cardiovascular medicine have not led to significant declines in case fatality rates for women when compared to the dramatic declines realized for men. The current review highlights gender-specific issues in ischemic heart disease presentation, evaluation, and outcomes with a special focus on the results published from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. We will present recent evidence on traditional and novel risk markers (e.g., high sensitivity C-reactive protein) as well as gender-specific differences in symptoms and diagnostic approaches. An overview of currently available diagnostic test evidence (including exercise electrocardiography and stress echocardiography and single-photon emission computed tomographic imaging) in symptomatic women will be presented as well as data using innovative imaging techniques such as magnetic resonance subendocardial perfusion, and spectroscopic imaging will also be discussed.

Prognostic value of a multiparametric risk score in patients undergoing dipyridamole stress echocardiography

To set up a prognostic score including clinical data and stress echocardiographic findings, the data of 3,969 patients who underwent dipyridamole stress were analyzed. Age (hazard ratio [HR] 3.21), peak wall motion score index (HR 2.62), diabetes mellitus (HR 2.36), and male gender (HR 1.69) were independent predictors of mortality and were incorporated into a prognostic score allowing us to estimate 1-, 3-, and 5-year survival in the patient cohort. The multiparametric risk score, immediately available at the bedside, can be used to predict the survival of patients undergoing dipyridamole stress echocardiography.