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Quality of life as predictor for the development of cardiac ischemia in high-risk asymptomatic diabetic patients. J Nucl Cardiol 2017; 24:772-782. [PMID: 28091969 DOI: 10.1007/s12350-016-0759-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 07/01/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ischemia induced by psychological stress and depression is a common phenomenon in stable coronary artery disease (CAD). We evaluated the quality of life (QoL) of diabetic patients screened for CAD and assessed the prognostic value of mental and physical QoL scores to predict the development of new cardiac ischemia. METHODS Prospective multicentre outcome study. The study comprised 400 asymptomatic diabetic patients without history or symptoms of CAD. They underwent myocardial perfusion single-photon emission computed tomography (MPS) and assessment of QoL by two questionnaires: Hospital Depression and Anxiety Scale (HADS-D and HADS-A) and Medical Outcomes Study Short Form 36 (SF-36) at baseline and after 2 years. Patients with normal MPS received usual care; those with abnormal MPS received medical or combined invasive and medical management. RESULTS Only mental QoL scores but not physical QoL scores or traditional cardiovascular risk factors were predictive of new ischemia (n = 11/306) during follow-up. The prognostic value for new ischemia as quantified by the area under the receiver operating characteristics curve (AUC) amounted to 0.784 (95% confidence interval (CI) 0.654-0.914, P = 0.002) for HADS-D and to 0.737 (95% CI 0.580-0.893, P = 0.011) for HADS-A. This finding was confirmed by SF-36 mental sum score (AUC 0.688, 95% CI 0.539-0.836, P = 0.036), but not SF-36 physical sum score. QoL scores did not change after 2 years in patients with ischemia at baseline. CONCLUSIONS QoL scores assessing mental health, particularly depression and anxiety, predicted the development of new cardiac ischemia in asymptomatic diabetic patients. The study is limited by a small number of events (new ischemia) and so the results should be considered hypothesis generating rather than conclusive.
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N-Terminal Pro-B-Type Natriuretic Peptide-Guided Therapy in Chronic Heart Failure Reduces Repeated Hospitalizations-Results From TIME-CHF. J Card Fail 2017; 23:382-389. [PMID: 28232046 DOI: 10.1016/j.cardfail.2017.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 11/29/2016] [Accepted: 02/08/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although heart failure (HF) patients are known to experience repeated hospitalizations, most studies evaluated only time to first event. N-Terminal B-type natriuretic peptide (NT-proBNP)-guided therapy has not convincingly been shown to improve HF-specific outcomes, and effects on recurrent all-cause hospitalization are uncertain. Therefore, we investigated the effect of NT-proBNP-guided therapy on recurrent events in HF with the use of a time-between-events approach in a hypothesis-generating analysis. METHODS AND RESULTS The Trial of Intensified Versus Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) randomized 499 HF patients, aged ≥60 years, left ventricular ejection fraction ≤45%, New York Heart Association functional class ≥I,I to NT-proBNP-guided versus symptom-guided therapy for 18 months, with further follow-up for 5.5 years. The effect of NT-proBNP-guided therapy on recurrent HF-related and all-cause hospitalizations and/or all-cause death was explored. One hundred four patients (49 NT-proBNP-guided, 55 symptom-guided) experienced 1 and 275 patients (133 NT-proBNP-guided, 142 symptom-guided) experienced ≥2 all-cause hospitalization events. Regarding HF hospitalization, 132 patients (57 NT-proBNP-guided, 75 symptom-guided) experienced 1 and 122 patients (57 NT-proBNP-guided, 65 symptom-guided) experienced ≥2 events. NT-proBNP-guided therapy was significant in preventing 2nd all-cause hospitalizations (hazard ratio [HR] 0.83; P = .01), in contrast to nonsignificant results in preventing 1st all-cause hospitalization events (HR 0.91; P = .35). This was not the case regarding HF hospitalization events (HR 0.85 [P = .14] vs HR 0.73 [P = .01]) The beneficial effect of NT-proBNP-guided therapy was seen only in patients aged <75 years, and not in those aged ≥75 years (interaction terms with P = .01 and P = .03 for all-cause hospitalization and HF hospitalization events, respectively). CONCLUSION NT-proBNP-guided therapy reduces the risk of recurrent events in patients <75 years of age. This included all-cause hospitalization by mainly reducing later events, adding knowledge to the neutral effect on this end point when shown using time-to-first-event analysis only. CLINICAL TRIAL REGISTRATION isrctn.org, identifier: ISRCTN43596477.
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Predicting hospitalization and mortality in patients with heart failure: The BARDICHE-index. Int J Cardiol 2016; 227:901-907. [PMID: 27915084 DOI: 10.1016/j.ijcard.2016.11.122] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 11/04/2016] [Accepted: 11/06/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prediction of events in chronic heart failure (CHF) patients is still difficult and available scores are often complex to calculate. Therefore, we developed and validated a simple-to-use, multidimensional prognostic index for such patients. METHODS A theoretical model was developed based on known prognostic factors of CHF that are easily obtainable: Body mass index (B), Age (A), Resting systolic blood pressure (R), Dyspnea (D), N-termInal pro brain natriuretic peptide (NT-proBNP) (I), Cockroft-Gault equation to estimate glomerular filtration rate (C), resting Heart rate (H), and Exercise performance using the 6-min walk test (E) (the BARDICHE-index). Scores were given for all components and added, the sum ranging from 1 (lowest value) to 25 points (maximal value), with estimated risk being highest in patients with highest scores. Scores were categorized into three groups: a low (≤8 points); medium (9-16 points), or high (>16 points) BARDICHE-score. The model was validated in a data set of 1811 patients from two prospective CHF-cohorts (median follow-up 887days). The primary outcome was 5-year all-cause survival. Secondary outcomes were 5-year survival without all-cause hospitalization and 5-year survival without CHF-related hospitalization. RESULTS There were significant differences between BARDICHE-risk groups for mortality (hazard ratio=3.63 per BARDICHE-group, 95%-CI 3.10-4.25), mortality or all-cause hospitalization (HR=2.00 per BARDICHE-group, 95%-CI 1.83-2.19), and mortality or CHF-related hospitalization (HR=3.43 per BARDICHE-group, 95%-CI 3.01-3.92; all P<10-50). Outcome was predicted independently of left ventricular ejection fraction (LVEF) and gender. CONCLUSIONS The BARDICHE-index is a simple multidimensional prognostic tool for patients with CHF, independently of LVEF.
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Prognostic Value of the Change in Heart Rate From the Supine to the Upright Position in Patients With Chronic Heart Failure. J Am Heart Assoc 2016; 5:JAHA.116.003524. [PMID: 27503849 PMCID: PMC5015278 DOI: 10.1161/jaha.116.003524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background The prognostic value of the change in heart rate from the supine to upright position (∆HR) in patients with chronic heart failure (HF) is unknown. Methods and Results ∆HR was measured in patients enrolled in the Trial of Intensified Medical Therapy in Elderly Patients with Congestive Heart Failure (TIME‐CHF) who were in sinus rhythm and had no pacemaker throughout the trial (n=321). The impact of ∆HR on 18‐month outcome (HF hospitalization‐free survival) was assessed. In addition, the prognostic effect of changes in ∆HR between baseline and month 6 on outcomes in the following 12 months was determined. A lower ∆HR was associated with a higher risk of death or HF hospitalization (hazard ratio 1.79 [95% confidence interval {95% CI} 1.19‐2.75] if ∆HR ≤3 beats/min [bpm], P=0.004). In the multivariate analysis, lower ∆HR remained an independent predictor of death or HF hospitalization (hazard ratio 1.75 [95% CI, 1.18‐2.61] if ∆HR ≤3 bpm, P=0.004) along with ischemic HF etiology, lower estimated glomerular filtration rate, presence and extent of rales, and no baseline β‐blocker use. In patients without event during the first 6 months, the change in ∆HR from baseline to month 6 predicted death or HF hospitalization during the following 12 months (hazard ratio=2.13 [95% CI 1.12–5.00] if rise in ∆HR <2 bpm; P=0.027). Conclusions ∆HR as a simple bedside test is an independent prognostic predictor in patients with chronic HF. ∆HR is modifiable, and changes in ∆HR also provide prognostic information, which raises the possibility that ∆HR may help to guide treatment. Clinical Trial Registration Information URL: www.isrctn.org. Unique identifier: ISRCTN43596477.
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Circulating biomarkers of distinct pathophysiological pathways in heart failure with preserved vs. reduced left ventricular ejection fraction. Eur J Heart Fail 2015; 17:1006-14. [PMID: 26472682 DOI: 10.1002/ejhf.414] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 07/15/2015] [Accepted: 08/02/2015] [Indexed: 01/16/2023] Open
Abstract
AIMS The aim of this study was to evaluate whether biomarkers reflecting pathophysiological pathways are different between heart failure with preserved (HFpEF) and reduced ejection fraction (HFrEF) and whether the prognostic value of biomarkers is different in HFpEF vs. HFrEF. METHODS AND RESULTS A total of 458 HFrEF (LVEF ≤40%) and 112 HFpEF (LVEF ≥50%) patients aged ≥60 years with NYHA class ≥II from TIME-CHF were included. Endpoints are 18-month overall and HF hospitalization-free survival. After correction for baseline characteristics that differed between the HF types, i.e. age, gender, body mass index, systolic blood pressure, cause of HF, and AF, HFpEF patients exhibited higher soluble interleukin 1 receptor-like 1 [ST2; 37.6 (28.5-54.7) vs. 35.7 (25.6-52.2), P = 0.02], high sensitivity C-reactive protein (hsCRP; 8.54 (3.39-25.86) vs. 6.66 (2.42-15.39), P = 0.01), and cystatin-C [1.94 (1.57-2.37) vs. 1.75 (1.39-2.12), P = 0.01]. In contrast, HFrEF patients exhibited higher NT-proBNP [2142 (1473-4294) vs. 4202 (2239-7411), P < 0.001], high sensitivity troponin T [hsTnT; 27.7 (16.8-48.0) vs. 32.4 (19.2-59.0), P = 0.03], and haemoglobin [124 (110-135) vs. 134 (122-145), P < 0.001]. In addition to these clinical characteristics, NT-proBNP, haemoglobin, cystatin-C, hsTnT, and ST2 improved the area under the curve from 0.86 (0.82-0.89) to 0.91 (0.87-0.94; P < 0.001) for discriminating HFpEF from HFrEF. There were no significant interactions between HFpEF and HFrEF when considering the prognostic value of the investigated biomarkers (P > 0.10 for both endpoints), except for cystatin-C which had less prognostic impact in HFpEF (P < 0.01). CONCLUSION Biomarker levels suggest a different amount of activation of several pathophysiological pathways between HFpEF and HFrEF. No important differences in the prognostic value of biomarkers in HFpEF vs. HFrEF were found except for cystatin-C, and for NT-proBNP in the NT-proBNP-guided study arm only, both of which had less prognostic value in HFpEF. TRIAL REGISTRATION ISRCTN43596477.
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Which heart failure patients profit from natriuretic peptide guided therapy? A meta-analysis from individual patient data of randomized trials. Eur J Heart Fail 2015; 17:1252-61. [PMID: 26419999 DOI: 10.1002/ejhf.401] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 06/26/2015] [Accepted: 06/10/2015] [Indexed: 12/17/2022] Open
Abstract
AIMS Previous analyses suggest that heart failure (HF) therapy guided by (N-terminal pro-)brain natriuretic peptide (NT-proBNP) might be dependent on left ventricular ejection fraction, age and co-morbidities, but the reasons remain unclear. METHODS AND RESULTS To determine interactions between (NT-pro)BNP-guided therapy and HF with reduced [ejection fraction (EF) ≤45%; HF with reduced EF (HFrEF), n = 1731] vs. preserved EF [EF > 45%; HF with preserved EF (HFpEF), n = 301] and co-morbidities (hypertension, renal failure, chronic obstructive pulmonary disease, diabetes, cerebrovascular insult, peripheral vascular disease) on outcome, individual patient data (n = 2137) from eight NT-proBNP guidance trials were analysed using Cox-regression with multiplicative interaction terms. Endpoints were mortality and admission because of HF. Whereas in HFrEF patients (NT-pro)BNP-guided compared with symptom-guided therapy resulted in lower mortality [hazard ratio (HR) = 0.78, 95% confidence interval (CI) 0.62-0.97, P = 0.03] and fewer HF admissions (HR = 0.80, 95% CI 0.67-0.97, P = 0.02), no such effect was seen in HFpEF (mortality: HR = 1.22, 95% CI 0.76-1.96, P = 0.41; HF admissions HR = 1.01, 95% CI 0.67-1.53, P = 0.97; interactions P < 0.02). Age (74 ± 11 years) interacted with treatment strategy allocation independently of EF regarding mortality (P = 0.02), but not HF admission (P = 0.54). The interaction of age and mortality was explained by the interaction of treatment strategy allocation with co-morbidities. In HFpEF, renal failure provided strongest interaction (P < 0.01; increased risk of (NT-pro)BNP-guided therapy if renal failure present), whereas in HFrEF patients, the presence of at least two of the following co-morbidities provided strongest interaction (P < 0.01; (NT-pro)BNP-guided therapy beneficial only if none or one of chronic obstructive pulmonary disease, diabetes, cardiovascular insult, or peripheral vascular disease present). (NT-pro)BNP-guided therapy was harmful in HFpEF patients without hypertension (P = 0.02). CONCLUSION The benefits of therapy guided by (NT-pro)BNP were present in HFrEF only. Co-morbidities seem to influence the response to (NT-pro)BNP-guided therapy and may explain the lower efficacy of this approach in elderly patients.
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Impact of worsening renal function related to medication in heart failure. Eur J Heart Fail 2014; 17:159-68. [PMID: 25808849 DOI: 10.1002/ejhf.210] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 10/29/2014] [Accepted: 11/05/2014] [Indexed: 12/22/2022] Open
Abstract
AIMS Renal failure is a major challenge in treating heart failure (HF) patients. HF medication may deteriorate renal function, but the impact thereof on outcome is unknown. We investigated the effects of HF medication on worsening renal function (WRF) and the relationship to outcome. METHODS AND RESULTS This post-hoc analysis of TIME-CHF (NT-proBNP-guided vs. symptom-guided management in chronic HF) included patients with LVEF ≤45% and ≥1 follow-up visit (n = 462). WRF III was defined as a rise in serum creatinine ≥0.5 mg/dL (i.e. 44.2 µmol/L) at any time during the first 6 months. Four classes of medication were considered: loop diuretics, beta-blockers, renin-angiotensin system (RAS)-blockers, and spironolactone. Functional principal component analysis of daily doses was used to comprehend medication over time. All-cause mortality after 18 months was the primary outcome. Interactions between WRF, medication, and outcome were tested. Patients with WRF III received on average higher loop diuretic doses (P = 0.0002) and more spironolactone (P = 0.02), whereas beta-blockers (P = 0.69) did not differ and lower doses of RAS-blockers were given (P = 0.09). There were significant interactions between WRF III, medicationn and outcome. Thus, WRF III was associated with poor prognosis if high loop diuretic doses were given (P = 0.001), but not with low doses (P = 0.29). The opposite was found for spironolactone (poor prognosis in the case of WRF III with no spironolactone, P <0.0001; but not with spironolactone, P = 0.31). Beta-blockers were protective in all patients (P <0.001), but most in those with WRF III (P <0.05 for interaction). RAS-blockade was associated with improved outcome (P = 0.006), irrespective of WRF III. CONCLUSION Based on this analysis, it may be hypothesized that high doses of loop diuretics might have detrimental effects, particularly in combination with significant WRF, whereas spironolactone and beta-blockers might be protective in patients with WRF.
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A new memetic pattern based algorithm to diagnose/exclude coronary artery disease. Int J Cardiol 2014; 174:184-6. [PMID: 24750720 DOI: 10.1016/j.ijcard.2014.03.184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 03/29/2014] [Indexed: 10/25/2022]
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Biomarkers in outpatient heart failure management; Are they correlated to and do they influence clinical judgment? Neth Heart J 2014; 22:115-21. [PMID: 24338787 PMCID: PMC3931853 DOI: 10.1007/s12471-013-0503-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
AIMS Heart failure (HF) management is complicated by difficulties in clinical assessment. Biomarkers may help guide HF management, but the correspondence between clinical evaluation and biomarker serum levels has hardly been studied. We investigated the correlation between biomarkers and clinical signs and symptoms, the influence of patient characteristics and comorbidities on New York Heart Association (NYHA) classification and the effect of using biomarkers on clinical evaluation. METHODS AND RESULTS This post-hoc analysis comprised 622 patients (77 ± 8 years, 76 % NYHA class ≥3, 80 % LVEF ≤45 %) participating in TIME-CHF, randomising patients to either NT-proBNP-guided or symptom-guided therapy. Biomarker measurements and clinical evaluation were performed at baseline and after 1, 3, 6, 12 and 18 months. NT-proBNP, GDF-15, hs-TnT and to a lesser extent hs-CRP and cystatin-C were weakly correlated to NYHA, oedema, jugular vein distension and orthopnoea (ρ-range: 0.12-0.33; p < 0.01). NT-proBNP correlated more strongly to NYHA class in the NT-proBNP-guided group compared with the symptom-guided group. NYHA class was significantly influenced by age, body mass index, anaemia, and the presence of two or more comorbidities. CONCLUSION In HF, biomarkers correlate only weakly with clinical signs and symptoms. NYHA classification is influenced by several comorbidities and patient characteristics. Clinical judgement seems to be influenced by a clinician's awareness of NT-proBNP concentrations.
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Cognitive impairment in heart failure: results from the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF) randomized trial. Eur J Heart Fail 2014; 15:699-707. [DOI: 10.1093/eurjhf/hft020] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Interaction between pulmonary hypertension and diastolic dysfunction in an elderly heart failure population. J Card Fail 2013; 20:98-104. [PMID: 24361805 DOI: 10.1016/j.cardfail.2013.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 11/06/2013] [Accepted: 12/11/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Pulmonary hypertension due to left heart disease is very common. Our aim was to investigate the relationship of the severity of left ventricular diastolic dysfunction with precapillary and postcapillary pulmonary hypertension (PH) in an elderly heart failure (HF) population. METHODS AND RESULTS A post hoc analysis of the Trial of Intensified Medical Therapy in Elderly Patients With Congestive Heart Failure data was done. Baseline transthoracic echocardiography was used to categorize diastolic function, estimate pulmonary artery pressure and pulmonary capillary wedge pressure, and calculate the transpulmonary pressure gradient (TPG). Among 392 HF patients, PH was present in 31% of patients with grade 1, in 37% of patients with grade 2, and in 65% of patients with grade 3 diastolic dysfunction; 54% of all HF patients with PH had a TPG >12 mm Hg, suggesting not only a postcapillary but also an additional precapillary component of PH. Survival was not related to the severity of diastolic dysfunction, but was worse in patients with PH (hazard ratio 1.63, 95% confidence interval 1.07-2.51; P = .024). CONCLUSIONS Our data indicate that HF patients with even mild diastolic dysfunction often have PH. Echocardiographic assessment suggest that the presence of PH might not simply be due to increased PCWP, but in part due to a precapillary component.
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Safety and tolerability of intensified, N-terminal pro brain natriuretic peptide-guided compared with standard medical therapy in elderly patients with congestive heart failure: results from TIME-CHF. Eur J Heart Fail 2013; 15:910-8. [PMID: 23666681 DOI: 10.1093/eurjhf/hft079] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS NT-proBNP-guided therapy results in intensification of medical heart failure (HF) therapy and is suggested to improve outcome. However, it is feared that an intensified, NT-proBNP-guided therapy carries a risk of adverse effects. Therefore, the safety and tolerability of NT-proBNP-guided therapy in the Trial of Intensified vs standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF) was assessed. METHODS AND RESULTS A total of 495 chronic HF patients, aged ≥60, with an LVEF ≤45%, NYHA class ≥II, randomized to NT-proBNP-guided or symptom-guided therapy and ≥1 month follow-up were included in the present safety analysis. All adverse events (AEs) were recorded during the 18-month trial period. A total of 5212 AEs were noted, 433 of them serious. NT-proBNP-guided therapy led to a higher up-titration of HF medication and was well tolerated, with a dropout rate (12% vs. 11%, P = 1.0) and AE profile [number of AEs/patient-year 4.7 (2.8-9.4) vs. 5.4 (2.7-11.4), P = 0.69; number of severe AEs/patient-year 0.7 (0-2.7) vs. 1.3 (0-3.9), P = 0.21] similar to that of symptom-guided therapy, although most subjects in both treatment groups (96% vs. 95%, P = 0.55) experienced at least one AE. Age and number of co-morbidities were associated with AEs and interacted with the safety profile of NT-proBNP-guided therapy: positive effects were more frequent in younger and less co-morbid patients whereas potential negative effects-although small and related to non-severe AEs only-were only seen in the older and more co-morbid patients. CONCLUSIONS NT-proBNP-guided therapy is safe in elderly and highly co-morbid HF patients. Trial registration ISRCTN43596477.
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Stent Thrombosis after Coronary Stent Implantation: A Protective Effect of High-Dose Statin Therapy? Cardiology 2013; 126:115-21. [DOI: 10.1159/000350822] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 03/05/2013] [Indexed: 11/19/2022]
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Prognostic Value of Self-Reported Versus Objectively Measured Functional Capacity in Patients With Heart Failure. J Am Coll Cardiol 2012; 60:2125-6. [DOI: 10.1016/j.jacc.2012.08.968] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 08/01/2012] [Indexed: 11/24/2022]
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How reliable are left ventricular ejection fraction cut offs assessed by echocardiography for clinical decision making in patients with heart failure? Int J Cardiovasc Imaging 2012; 29:581-8. [PMID: 22965859 DOI: 10.1007/s10554-012-0122-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 08/29/2012] [Indexed: 01/07/2023]
Abstract
We aimed to study the potential influence of the variability in the assessment of echocardiographically measured left ventricular ejection fraction (LVEF) on indications for the implantation of internal cardioverter defibrillator and/or cardiac resynchronization devices in heart failure patients. TIME-CHF was a multicenter trial comparing NT-BNP versus symptom-guided therapy in patients aged ≥60 years. Patients had their LVEF assessed at the recruiting centre using visual assessment, the area-length or biplane Simpson's method. Echocardiographic data were transferred to the study core-lab for re-assessment. Re-assessment in the core-lab was done with biplane Simpson's method, and included an appraisal of image quality. 413 patients had the LVEF analyzed at the recruiting centre and at the core lab. Image quality was optimal in 191 and suboptimal in 222. Overall, the correlation between LVEF at the recruiting centres and at the core-lab was good, independent of image quality (R² = 0.62). However, when a LVEF ≤30 % or ≥30 % was used as a cut-off, about 20 % of all patients would have been re-assigned to having either a LVEF above or below the cut-off, this proportion was not significantly influenced by image quality. We conclude that correlation between LVEF assessed by different centres based on the same ultrasound data is good, regardless of image quality. However, one fifth of patients would have been re-assigned to a different category when using the clinically important cut-off of 30 %.
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Reply to letter to the editor entitled “Proposed strategy for optimizing aldosterone blockade in heart failure” by Dr Jolobe. Am Heart J 2012; 164:e3. [DOI: 10.1016/j.ahj.2012.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Combined clopidogrel and proton pump inhibitor therapy is associated with higher cardiovascular event rates after percutaneous coronary intervention: a report from the BASKET trial. J Intern Med 2012; 271:257-63. [PMID: 21726302 DOI: 10.1111/j.1365-2796.2011.02423.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To investigate whether there is an increased risk of cardiac events with a combined therapy of clopidogrel and proton pump inhibitors (PPIs) after percutaneous coronary intervention (PCI). DESIGN In the BAsel Stent Kosten Effektivitäts Trial (BASKET), all patients undergoing PCI received 6 months of clopidogrel and were analysed for the use of PPI therapy. Endpoints were major adverse cardiac events (MACE), myocardial infarction (MI), death and target vessel revascularization (TVR) after 36 months. RESULTS Of 801 patients with available discharge medication data, 109 (14%) received PPIs. Patients who received PPIs were older (66.5 ± 10.5 vs. 63.3 ± 11.3 years, P = 0.006), more likely to be woman (80% vs. 69%, P = 0.009) and have a history of diabetes (29.6% vs. 17.3%, P = 0.002) or gastrointestinal ulcer disease (8.3% vs. 3.3%, P = 0.015) and more often received nonsteroidal anti-inflammatory drugs (7.3% vs. 2.2%, P = 0.003) and corticosteroids (11% vs. 3.6%, P = 0.001) but not aspirin (91.7% vs. 97%, P = 0.008) compared with those who did not receive PPIs. Patients who received PPI therapy had higher rates of MACE (30.3% vs. 20.8%, P = 0.027) and MI (14.7% vs. 7.4%, P = 0.01) but similar rates of death (9.2% vs. 7.4%, P = 0.51) and TVR (20.2% vs. 15.3%, P = 0.2) compared with those who did not. By multivariate analysis, diabetes (hazard ratio 1.83, 95% confidence interval 1.07-3.15) and PPI use (hazard ratio 1.88, 95% confidence interval 1.05-3.37) were the only independent risk factors for MI. CONCLUSION In a real-world PCI population, the combination of PPIs and clopidogrel was associated with a doubling of MI rates after 3 years. Even after correction for confounding factors, concomitant PPI use remained an independent predictor of outcome emphasizing the clinical importance of this drug-drug interaction.
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Limited usefulness of the modified Academic Research Consortium stent thrombosis definition for clinical trials. JACC Cardiovasc Interv 2011; 4:1151; author reply 1151-2. [PMID: 22017945 DOI: 10.1016/j.jcin.2011.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 08/04/2011] [Indexed: 11/28/2022]
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Primary PCI in STEMI--dilemmas and controversies: multivessel disease in STEMI patients. Complete versus Culprit Vessel revascularization in acute ST--elevation myocardial infarction. Minerva Cardioangiol 2011; 59:225-233. [PMID: 21516071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The best strategy regarding percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in multivessel disease is an unresolved issue. Although current guidelines recommend that PCI in non-culprit arteries should not be attempted unless the patient is hemodynamically unstable, it is unclear whether PCI of the infarct-related artery only or a strategy of complete revascularization, either in a simultaneous or staged multivessel PCI approach, will improve outcome. Based on available data, PCI of the culprit lesion has the advantages of shorter procedure duration, a smaller amount of dye used, and a lower rate of periprocedural myocardial infarctions, while complete revascularization has lower rates of recurrent angina and a better left ventricular ejection fraction. Although data available give controversial results for the right strategy to choose, the only adequately powered randomized controlled trial shows that a strategy of multivessel PCI should be pursued notwithstanding the timing of complete revascularization. However, to avoid the potential risks of simultaneous multivessel PCI, a strategy of staged complete revascularization appears to be the best choice. It should be considered whether current guidelines should be changed to account for these considerations, and other adequately powered randomized controlled trials should be performed to endorse current knowledge.
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Early revascularization is beneficial across all ages and a wide spectrum of cardiogenic shock severity: A pooled analysis of trials. ACTA ACUST UNITED AC 2011; 13:14-20. [PMID: 21244231 DOI: 10.3109/17482941.2010.538696] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND A pooled analysis in cardiogenic shock due to acute coronary syndromes is desirable to assess the effect of early revascularization (ERV) across all ages and a wide spectrum of disease severity. METHODS Only two randomized controlled trials (RCT), i.e. SMASH and SHOCK, met the inclusion criteria and were combined for a pooled analysis using individual patient data (n = 348). RESULTS SMASH patients (n = 54, 16%) had more severe disease than SHOCK patients (n = 294, 84%). After adjustment for age, anoxic brain damage, non-inferior myocardial infarction, prior coronary artery bypass graft surgery, renal failure, systolic blood pressure, and selection for coronary angiography, one-year mortality was similar (relative risk SHOCK versus SMASH 0.87, 95% CI: 0.61-1.25). Relative risk of one-year death for ERV versus initial medical stabilization was 0.82 (95% CI: 0.70-0.96). There was no significant difference in the treatment effect by age (≤75 years relative risk at one year 0.79, 95% CI: 0.63-0.99; > 75 years relative risk at one year 0.93, 95% CI: 0.56-1.53; interaction P = 0.10). CONCLUSIONS Only two RCT have been published emphasizing the difficulty of enrolling critically ill patients. Despite large differences in shock severity, ERV benefit is similar across all ages and not significantly different for the elderly.
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Abstract
Results of two randomised controlled trials for the management of mild-to-moderate chronic stable coronary artery disease (Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation [COURAGE] and Bypass Angioplasty Revascularization Investigation type-2 Diabetes [BARI-2D]) have stimulated a vigorous debate about whether an initial strategy of revascularisation or a conservative approach with drugs is most effective. The conclusions of these two trials were clear: for some patients randomly assigned after angiography to revascularisation or pharmacological therapy, rates of death and myocardial infarction did not differ between the two strategies. What remains unresolved is how to generalise these data to patients without angiography, the role of stress testing, and the preferred approach to patients with relevant ischaemia on stress testing. This Review draws attention to the controversial issues in both management approaches, analyses the strengths and limitations of recent trials, and proposes a treatment algorithm that is applicable to daily clinical practice. Findings suggest that the severity of anginal symptoms and the extent of ischaemia in stress testing could help to identify patients who are at increased risk and who might benefit from an early invasive strategy. On the basis of the data and considerations presented, a strategy of initial optimum pharmacological therapy or direct invasive management can be tailored to an individual's circumstances and preferences.
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Comparison of six-month outcomes for primary percutaneous revascularization for acute myocardial infarction with drug-eluting versus bare metal stents (from the APEX-AMI study). Am J Cardiol 2009; 103:181-6. [PMID: 19121433 DOI: 10.1016/j.amjcard.2008.08.066] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Revised: 08/31/2008] [Accepted: 08/31/2008] [Indexed: 11/19/2022]
Abstract
We evaluated the use and outcomes of drug-eluting stents (DESs) and bare metal stents (BMSs) in a large primary percutaneous coronary intervention (PCI) acute ST-elevation myocardial infarction (MI) trial. Recently concerns have been raised with "off-label" use of DESs for short- and long-term clinical outcomes. Limited randomized data exist evaluating DESs versus BMSs in ST-elevation MI. Patients (n=5,745) in the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial were categorized by stent type used. Baseline variables and clinical outcomes were collected at 90 days and 6 months. Outcomes by stent type were adjusted for using conventional multivariable predictors of 90-day mortality (age, anterior location, total ST-segment deviation, and Killip class), time to PCI, and Thrombolysis In Myocardial Infarction grade flow. Stents were deployed (at the investigator's discretion) in 5,124 patients (89.2%) with acute MI, with DES use in 2,221 (43.3%) and BMS use in 2,903 (56.7%). Patients receiving DESs were younger (median 59 vs 63 years of age, p<0.001), had left anterior descending coronary artery PCI (57.9% vs 48.1%, p<0.001), and often were treated in the United States (58.2%). DES-treated patients had a lower adjusted mortality at 90 days (hazard ratio 0.73, 95% confidence interval [CI] 0.54 to 0.99, p=0.046) and trended toward lower mortality (hazard ratio 0.77, 95% CI 0.58 to 1.03, p=0.084) and recurrent MI (hazard ratio 0.81, 95% CI 0.59 to 1.11, p=0.186) at 6 months compared with BMSs. In conclusion, in this observational analysis of stent use from a large primary percutaneous intervention for acute MI trial, DESs appear as safe as BMSs with similar 6-month clinical outcomes with regard to death and recurrent MI.
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Drug-Eluting Stents Compared with Bare Metal Stents Improve Late Outcome after Saphenous Vein Graft but Not after Large Native Vessel Interventions. Cardiology 2009; 112:49-55. [DOI: 10.1159/000137699] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 01/25/2008] [Indexed: 11/19/2022]
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Abstract
BACKGROUND Few studies describe recent changes in the incidence, treatment, and outcomes of cardiogenic shock. OBJECTIVE To examine temporal trends in the incidence, therapeutic management, and mortality rates of patients with the acute coronary syndrome (ACS) and cardiogenic shock, and to assess associations of therapeutic management with death and cardiogenic shock developing during hospitalization. DESIGN Analysis of registry data collected among patients admitted to hospitals between 1997 and 2006. SETTING 70 of the 106 acute cardiac care hospitals in Switzerland. PATIENTS 23 696 adults with ACS enrolled in the AMIS (Acute Myocardial Infarction in Switzerland) Plus Registry. MEASUREMENTS Cardiogenic shock incidence; treatment, including rates of percutaneous coronary intervention; and in-hospital mortality rates. RESULTS Rates of overall cardiogenic shock (8.3% of patients with ACS) and cardiogenic shock developing during hospitalization (6.0% of patients with ACS and 71.5% of patients with cardiogenic shock) decreased during the past decade (P < 0.001 for temporal trend), whereas rates of cardiogenic shock on admission remained constant (2.3% of patients with ACS and 28.5% of patients with cardiogenic shock). Rates of percutaneous coronary intervention increased among patients with cardiogenic shock (7.6% to 65.9%; P = 0.010), whereas in-hospital mortality decreased (62.8% to 47.7%; P = 0.010). Percutaneous coronary intervention was independently associated with lower risk for both in-hospital mortality in all patients with ACS (odds ratio, 0.47 [95% CI, 0.30 to 0.73]; P = 0.001) and cardiogenic shock development during hospitalization in patients with ACS but without cardiogenic shock on admission (odds ratio, 0.59 [CI, 0.39 to 0.89]; P = 0.012). LIMITATIONS There was no central review of cardiogenic shock diagnoses, and follow-up duration was confined to the hospital stay. Unmeasured or inaccurately measured characteristics may have confounded observed associations of treatment with outcomes. CONCLUSION Over the past decade, rates of cardiogenic shock developing during hospitalization and in-hospital mortality decreased among patients with ACS. Increased percutaneous coronary intervention rates were associated with decreased mortality among patients with cardiogenic shock and with decreased development of cardiogenic shock during hospitalization.
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Late stent thrombosis after drug-eluting stent implantation for acute myocardial infarction: a new red flag is raised. Circulation 2008; 118:1117-9. [PMID: 18779453 DOI: 10.1161/circulationaha.108.803627] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
OBJECTIVE To compare the effectiveness and safety of three types of stents (sirolimus eluting, paclitaxel eluting, and bare metal) in people with and without diabetes mellitus. DESIGN Collaborative network meta-analysis. DATA SOURCES Electronic databases (Medline, Embase, the Cochrane Central Register of Controlled Trials), relevant websites, reference lists, conference abstracts, reviews, book chapters, and proceedings of advisory panels for the US Food and Drug Administration. Manufacturers and trialists provided additional data. REVIEW METHODS Network meta-analysis with a mixed treatment comparison method to combine direct within trial comparisons between stents with indirect evidence from other trials while maintaining randomisation. Overall mortality was the primary safety end point, target lesion revascularisation the effectiveness end point. RESULTS 35 trials in 3852 people with diabetes and 10,947 people without diabetes contributed to the analyses. Inconsistency of the network was substantial for overall mortality in people with diabetes and seemed to be related to the duration of dual antiplatelet therapy (P value for interaction 0.02). Restricting the analysis to trials with a duration of dual antiplatelet therapy of six months or more, inconsistency was reduced considerably and hazard ratios for overall mortality were near one for all comparisons in people with diabetes: sirolimus eluting stents compared with bare metal stents 0.88 (95% credibility interval 0.55 to 1.30), paclitaxel eluting stents compared with bare metal stents 0.91 (0.60 to 1.38), and sirolimus eluting stents compared with paclitaxel eluting stents 0.95 (0.63 to 1.43). In people without diabetes, hazard ratios were unaffected by the restriction. Both drug eluting stents were associated with a decrease in revascularisation rates compared with bare metal stents in people both with and without diabetes. CONCLUSION In trials that specified a duration of dual antiplatelet therapy of six months or more after stent implantation, drug eluting stents seemed safe and effective in people both with and without diabetes.
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Use of B-type natriuretic peptide outside of the emergency department. Int J Cardiol 2008; 127:5-16. [DOI: 10.1016/j.ijcard.2007.10.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2006] [Revised: 08/03/2007] [Accepted: 10/20/2007] [Indexed: 10/22/2022]
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Outpatient Rehabilitation in Patients With Coronary Artery and Peripheral Arterial Occlusive Disease. Arch Phys Med Rehabil 2008; 89:618-21. [DOI: 10.1016/j.apmr.2007.09.040] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Revised: 09/10/2007] [Accepted: 09/11/2007] [Indexed: 10/22/2022]
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Long-term outcomes after intracoronary Beta-irradiation for in-stent restenosis in bare-metal stents. THE JOURNAL OF INVASIVE CARDIOLOGY 2008; 20:179-184. [PMID: 18398235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE We sought to characterize the long-term outcomes of patients undergoing intracoronary brachytherapy using Beta- irradiation (Beta-BT). BACKGROUND Beta-BT is effective in reducing angiographic restenosis as well as target vessel revascularization (TVR) in patients with in-stent restenosis (ISR) after bare-metal stenting (BMS). METHODS 81 consecutive patients undergoing Beta-BT for ISR (irradiated length 32 [32-54] mm) after BMS in native vessels (n = 79) or saphenous vein grafts (n = 2) between 2001 and 2003 were followed. Major cardiac events (MACE), including cardiac death, nonfatal myocardial infarction (MI), and TVR occurring > 1 year or > 1 year were assessed 5.2 (4.4-5.6) years after the index procedure. RESULTS During the entire follow-up period, the total MACE rate was 49.4%. Within the first year and at > 1 year, MACE rates were 25.9% and 23.5%, cardiac death occurred in 2.4% and 6.2%, and nonfatal MI in 6.2% and 12.3% for annual cardiac death/MI rates of 8.7% at < 1 year and 4.1% thereafter. TVR was required in 19% at < 1 year and in 16% of patients later on. The only independent predictor of MACE occurring < 1 year was an irradiated vessel length > 32 mm (odds ratio [OR] 2.73, 95% confidence interval [CI] 1.10-6.78; p = 0.03). The best, albeit not statistically significant, predictor of MACE occurring at > 1 year was the presence of diabetes mellitus (OR 2.49, 95% CI 0.94-6.57; p = 0.07). CONCLUSIONS Patients undergoing Beta-BT for ISR after BMS carry a substantial risk of MACE also beyond the first year, with annual cardiac death and nonfatal MI rates of 1.5% and 2.9% up to 5 years postprocedure.
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Value and limitations of target-vessel ischemia in predicting late clinical events after drug-eluting stent implantation. J Nucl Med 2008; 49:550-6. [PMID: 18344439 DOI: 10.2967/jnumed.107.046771] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Drug-eluting stents reduce clinical events related to restenosis but may be complicated by late stent-thrombosis. Whereas assessment of target-vessel ischemia by myocardial perfusion scintigraphy identifies relevant restenosis noninvasively, it is unknown whether this technique may also predict late clinical events related to late stent-thrombosis and to restenosis after drug-eluting stent implantation. METHODS All 826 patients treated with stenting between May 2003 and May 2004 were included in the Basel Stent Cost Effectiveness Trial (Basel Stent Kosten-Effektivitäts Trial, or BASKET) and randomized (2:1) to drug-eluting stents or bare metal stents. Myocardial scintigraphy was performed on 476 (64%) of 747 patients without major events after 6 mo. Patients were followed for 1 y for cardiac death, nonfatal myocardial infarction, and target-vessel revascularization due to restenosis or late stent-thrombosis. RESULTS The rate of target-vessel ischemia in these patients was lower with drug-eluting stents than with bare metal stents (5.4% vs. 10.4%, P = 0.045), similar to the rates of symptom-driven target-vessel revascularization up to 6 mo (4.6% vs. 7.8%, P = 0.08). Ischemia was silent in 68%. During follow-up, patients with target-vessel ischemia had higher event rates than did patients without ischemia (32.4% vs. 6.1%, P < 0.001); however, ischemia did not predict late stent-thrombosis (0/11 cases). CONCLUSION The rate of clinical restenosis assessed scintigraphically was lower with drug-eluting stents than with bare metal stents and paralleled that of symptom-driven target-vessel revascularization. Target-vessel ischemia independently predicted late clinical events related to restenosis but not to late stent-thrombosis.
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Hemodynamic Parameters Are Prognostically Important in Cardiogenic Shock But Similar Following Early Revascularization or Initial Medical Stabilization. Chest 2007; 132:1794-803. [DOI: 10.1378/chest.07-1336] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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A Meta-Analysis of 16 Randomized Trials of Sirolimus-Eluting Stents Versus Paclitaxel-Eluting Stents in Patients With Coronary Artery Disease. J Am Coll Cardiol 2007; 50:1373-80. [PMID: 17903638 DOI: 10.1016/j.jacc.2007.06.047] [Citation(s) in RCA: 192] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Revised: 06/15/2007] [Accepted: 06/26/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Our purpose was to make a synthesis of the available evidence on the relative efficacy and safety of 2 drug-eluting stents (DES)--sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES)--in patients with coronary artery disease. BACKGROUND It is not known whether there are differences in late outcomes between the 2 most commonly used DES: SES and PES. METHODS Sixteen randomized trials of SES versus PES with a total number of 8,695 patients were included in this meta-analysis. A full set of individual outcome data from 5,562 patients was also available. Mean follow-up period ranged from 9 to 37 months. The primary efficacy end point was the need for reintervention (target lesion revascularization). The primary safety end point was stent thrombosis. Secondary end points were death and recurrent myocardial infarction (MI). RESULTS No significant heterogeneity was found across trials. Compared with PES, SES significantly reduced the risk of reintervention (hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.63 to 0.87, p < 0.001) and stent thrombosis (HR 0.66; 95% CI 0.46 to 0.94, p = 0.02) without significantly impacting on the risk of death (HR 0.92; 95% CI 0.74 to 1.13, p = 0.43) or MI (HR 0.84; 95% CI 0.69 to 1.03, p = 0.10). CONCLUSIONS Sirolimus-eluting stents are superior to PES in terms of a significant reduction of the risk of reintervention and stent thrombosis. The risk of death was not significantly different between the 2 DES, but there was a trend toward a higher risk of MI with PES, especially after the first year from the procedure.
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Abstract
BACKGROUND Whether the two drug-eluting stents approved by the US Food and Drug Administration-a sirolimus-eluting stent and a paclitaxel-eluting stent-are associated with increased risks of death, myocardial infarction, or stent thrombosis compared with bare-metal stents is uncertain. Our aim was to compare the safety and effectiveness of these stents. METHODS We searched relevant sources from inception to March, 2007, and contacted investigators and manufacturers to identify randomised controlled trials in patients with coronary artery disease that compared drug-eluting with bare-metal stents, or that compared sirolimus-eluting stents head-to-head with paclitaxel-eluting stents. Safety outcomes included mortality, myocardial infarction, and definite stent thrombosis; the effectiveness outcome was target lesion revascularisation. We included 38 trials (18,023 patients) with a follow-up of up to 4 years. Trialists and manufacturers provided additional data on clinical outcomes for 29 trials. We did a network meta-analysis with a mixed-treatment comparison method to combine direct within-trial comparisons between stents with indirect evidence from other trials while maintaining randomisation. FINDINGS Mortality was similar in the three groups: hazard ratios (HR) were 1.00 (95% credibility interval 0.82-1.25) for sirolimus-eluting versus bare-metal stents, 1.03 (0.84-1.22) for paclitaxel-eluting versus bare-metal stents, and 0.96 (0.83-1.24) for sirolimus-eluting versus paclitaxel-eluting stents. Sirolimus-eluting stents were associated with the lowest risk of myocardial infarction (HR 0.81, 95% credibility interval 0.66-0.97, p=0.030 vs bare-metal stents; 0.83, 0.71-1.00, p=0.045 vs paclitaxel-eluting stents). There were no significant differences in the risk of definite stent thrombosis (0 days to 4 years). However, the risk of late definite stent thrombosis (>30 days) was increased with paclitaxel-eluting stents (HR 2.11, 95% credibility interval 1.19-4.23, p=0.017 vs bare-metal stents; 1.85, 1.02-3.85, p=0.041 vs sirolimus-eluting stents). The reduction in target lesion revascularisation seen with drug-eluting stents compared with bare-metal stents was more pronounced with sirolimus-eluting stents than with paclitaxel-eluting stents (0.70, 0.56-0.84; p=0.0021). INTERPRETATION The risks of mortality associated with drug-eluting and bare-metal stents are similar. Sirolimus-eluting stents seem to be clinically better than bare-metal and paclitaxel-eluting stents.
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Abstract
OBJECTIVE To assess the effect of outpatient cardiac rehabilitation in important patient subgroups. DESIGN Prospective cohort study. SUBJECTS Consecutive patients from March 1999 until July 2003. METHODS This study assessed the results of symptom-limited bicycle stress testing and health-related quality of life (Profil der Lebensqualität Chronisch Kranker) at baseline and after a 3-month rehabilitation program, and complications and drop-outs during outpatient cardiac rehabilitation. RESULTS Of 1061 patients, 155 (15%) women, 87 (8%) men aged >or= 75 years, 162 (15%) had diabetes mellitus and 88 (8%) did not speak the local language. Reasons for outpatient cardiac rehabilitation included acute coronary artery disease (87%), valvular heart disease (9%) and congestive heart failure (1%). Mean age was 62 years (standard deviation 11). Patients increased both their age- and body-weight-adjusted workload (p < 0.0001) and quality of life (p < 0.0001) during the program. Although the initial workload achieved was lower than for normal patients (p < 0.0001), it increased in all subgroups during outpatient cardiac rehabilitation (p < 0.0001). Baseline quality of life was lower in women, but increased in most dimensions for all subgroups assessed. CONCLUSION Important subgroups, such as women, elderly men, diabetic patients and ethnic minorities, are under-represented in outpatient cardiac rehabilitation, although they benefit similarly to other patients. Due to lower baseline quality of life, women may need special medical attention prior to outpatient cardiac rehabilitation.
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Abstract
BACKGROUND The long-term effects of treatment with sirolimus-eluting stents, as compared with bare-metal stents, have not been established. METHODS We performed an analysis of individual data on 4958 patients enrolled in 14 randomized trials comparing sirolimus-eluting stents with bare-metal stents (mean follow-up interval, 12.1 to 58.9 months). The primary end point was death from any cause. Other outcomes were stent thrombosis, the composite end point of death or myocardial infarction, and the composite of death, myocardial infarction, or reintervention. RESULTS The overall risk of death (hazard ratio, 1.03; 95% confidence interval [CI], 0.80 to 1.30) and the combined risk of death or myocardial infarction (hazard ratio, 0.97; 95% CI, 0.81 to 1.16) were not significantly different for patients receiving sirolimus-eluting stents versus bare-metal stents. There was a significant reduction in the combined risk of death, myocardial infarction, or reintervention (hazard ratio, 0.43; 95% CI, 0.34 to 0.54) associated with the use of sirolimus-eluting stents. There was no significant difference in the overall risk of stent thrombosis with sirolimus-eluting stents versus bare-metal stents (hazard ratio, 1.09; 95% CI, 0.64 to 1.86). However, there was evidence of a slight increase in the risk of stent thrombosis associated with sirolimus-eluting stents after the first year. CONCLUSIONS The use of sirolimus-eluting stents does not have a significant effect on overall long-term survival and survival free of myocardial infarction, as compared with bare-metal stents. There is a sustained reduction in the need for reintervention after the use of sirolimus-eluting stents. The risk of stent thrombosis is at least as great as that seen with bare-metal stents.
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Oral Hypoglycemics: Increased Postoperative Mortality in Coronary Risk Patients. Cardiology 2007; 107:296-301. [PMID: 17264509 DOI: 10.1159/000099065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Accepted: 08/30/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Diabetes mellitus (DM), particularly if insulin-dependent, is a predictor of increased perioperative risk, whereas stringent metabolic control with insulin is beneficial in the critically ill. METHODS The impact of oral hypoglycemics (OH) vs. insulin on outcome was determined as a secondary retrospective analysis of a cohort study in patients with coronary artery disease (CAD) and DM undergoing major non-cardiac surgery. Primary end-point was 2-year all-cause mortality; secondary endpoints were perioperative myocardial ischemia and 2-year cardiac mortality. RESULTS Of 173 patients, DM was diagnosed in 42 (24%) based on pre-existing treatment with OH (15%) or insulin (9%). During follow-up, 40/173 (23%) patients died. All-cause mortality was similar in the non-diabetic (20%) and insulin groups (19%) but significantly higher in the OH group (42%; p = 0.025). Cardiac mortality tended to be higher in the OH group compared with the insulin and non-diabetic groups (27 vs. 19% and 11%, respectively; p = 0.066). Multivariate analysis revealed renal failure (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 1.8-13.0), treatment with OH (OR = 3.3, 95% CI = 1.2-9.0), peripheral vascular surgery (OR = 2.7, 95% CI = 1.2-6.0), and prior diuretic therapy (OR = 2.6, 95% CI = 1.1-5.7) being independently associated with 2-year all-cause death. No difference existed in postoperative ischemia among the different groups. CONCLUSIONS Long-term mortality after major non-cardiac surgery is elevated in patients with CAD and diabetes mellitus only if they are treated with OH, but not if they are treated with insulin. Further evaluation of the impact of perioperative anti-diabetic treatment on morbidity and mortality in CAD is warranted.
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Abstract
BACKGROUND It is unclear whether stable, high-risk patients with persistent total occlusion of the infarct-related coronary artery identified after the currently accepted period for myocardial salvage has passed should undergo percutaneous coronary intervention (PCI) in addition to receiving optimal medical therapy to reduce the risk of subsequent events. METHODS We conducted a randomized study involving 2166 stable patients who had total occlusion of the infarct-related artery 3 to 28 days after myocardial infarction and who met a high-risk criterion (an ejection fraction of <50% or proximal occlusion). Of these patients, 1082 were assigned to routine PCI and stenting with optimal medical therapy, and 1084 were assigned to optimal medical therapy alone. The primary end point was a composite of death, myocardial reinfarction, or New York Heart Association (NYHA) class IV heart failure. RESULTS The 4-year cumulative primary event rate was 17.2% in the PCI group and 15.6% in the medical therapy group (hazard ratio for death, reinfarction, or heart failure in the PCI group as compared with the medical therapy group, 1.16; 95% confidence interval [CI], 0.92 to 1.45; P=0.20). Rates of myocardial reinfarction (fatal and nonfatal) were 7.0% and 5.3% in the two groups, respectively (hazard ratio, 1.36; 95% CI, 0.92 to 2.00; P=0.13). Rates of nonfatal reinfarction were 6.9% and 5.0%, respectively (hazard ratio, 1.44; 95% CI, 0.96 to 2.16; P=0.08); only six reinfarctions (0.6%) were related to assigned PCI procedures. Rates of NYHA class IV heart failure (4.4% vs. 4.5%) and death (9.1% vs. 9.4%) were similar. There was no interaction between treatment effect and any subgroup variable (age, sex, race or ethnic group, infarct-related artery, ejection fraction, diabetes, Killip class, and the time from myocardial infarction to randomization). CONCLUSIONS PCI did not reduce the occurrence of death, reinfarction, or heart failure, and there was a trend toward excess reinfarction during 4 years of follow-up in stable patients with occlusion of the infarct-related artery 3 to 28 days after myocardial infarction. (ClinicalTrials.gov number, NCT00004562 [ClinicalTrials.gov].).
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Value of repeated cardiac magnetic resonance imaging in patients with suspected arrhythmogenic right ventricular cardiomyopathy. J Cardiovasc Magn Reson 2006; 8:361-6. [PMID: 16669179 DOI: 10.1080/10976640500527082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AIM Diagnosis of early stages of arrhythmogenic right ventricular cardiomyopathy (ARVC) with minimal structural abnormalities is challenging. The purpose of this study was to assess the value of repeated cardiac magnetic resonance imaging (CMR) in patients referred for right ventricular arrhythmias and clinical suspicion of ARVC. METHODS AND RESULTS Prospective follow-up study of 18 patients (8 females) studied with CMR for suspected ARVC. Patients with implanted defibrillators (ICD) were excluded. Mean follow-up was 37 +/- 16 (12-59) months. Patients were assigned to 2 categories (ARVC likely or ARVC unlikely) according to a CMR-score based on right ventricular abnormalities. Clinical follow-up revealed no disease progression in 17 patients (94%). In 1 patient, an ICD was implanted because of disease progression. Of 9 patients with initial findings suggestive of ARVC, follow-up CMR remained positive in 3 and was diagnosed as normal in 6, mainly due to the inability to confirm the presence of fatty infiltrates at follow-up (5 of 6 patients). Initially, 9 patients had a normal CMR and 8 of those remained normal during follow-up. CONCLUSION Repeated CMR after an average follow-up of 3 years was normal in 6 of 9 patients with clinical findings consistent with early stages of ARVC at the time of baseline CMR. Thus, CMR diagnosis of early stage ARVC is difficult and should be made with caution.
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Stunning and left ventricular function—How long is the ventricle knocked out? Int J Cardiol 2006; 112:223-8. [PMID: 16293326 DOI: 10.1016/j.ijcard.2005.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Revised: 06/15/2005] [Accepted: 09/21/2005] [Indexed: 11/28/2022]
Abstract
PURPOSE Little is known about the relation between severity of ischemia and duration of myocardial stunning. The aim of this study was therefore to characterize the impact of ischemia on myocardial stunning and on its duration. METHODS 310 patients (pts) who underwent myocardial perfusion SPECT (MPS) were evaluated. MPS acquired with a rest Thallium/stress Technetium-99m sestamibi protocol were scored with respect to % myocardium ischemic. Left ventricular post-stress ejection fraction (psEF) was evaluated by the widely used QGS algorithm. Resting LVEF (rEF) was assessed by invasive ventriculography. Patient groups were then compared with respect to different extents of ischemia and different time intervals between stress and imaging (< or = 60 min and > 60 min after stress). RESULTS 21% of pts had a normal MPS, 8% had evidence of scar, 37% had evidence of ischemia, and 34% had evidence of scar plus ischemia. Pts with normal MPS had a significantly higher psEF than pts with ischemia, 61+/-8% and 56+/-8%, respectively (p=0.006), whereas rEF was not different. Overall, pts with < or = 10% myocardium ischemic had significantly higher psEF than pts with > 10% myocardium ischemic, 53+/-11% and 49+/-9%, respectively (p=0.006), whereas rEF was not different. In pts with evidence of ischemia who underwent imaging < or = 60 min after stress testing, pts with < or = 10% myocardium ischemic had higher psEF than pts with > 10% myocardium ischemic, 60+/-7% and 53+/-8%, respectively (p=0.037). In contrast, pts with evidence of ischemia who underwent imaging > 60 min after stress testing had similar psEF irrespective of extent of ischemia (53%+/-8 in pts with < or = 10% ischemia and 54%+/-8 in pts with > 10% myocardium ischemic, p=0.12). CONCLUSIONS Ischemia had a significant impact on psEF in patients who underwent imaging less than 1 h after stress. More than one hour after stress testing stunning seems to be less relevant in the interpretation of psEF.
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Early clinical experience with CardioCard - a credit card-sized electronic patient record. Swiss Med Wkly 2006; 136:539-43. [PMID: 16983596 DOI: 2006/33/smw-11478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
QUESTIONS UNDER STUDY CardioCard is a CDROM of credit card size containing medical information on cardiac patients. Patient data acquired during hospital stay are stored in PDF format and secured by a password known to patients only. In a consecutive series of patients, we assessed acceptance and utility of this new information medium. METHODS AND RESULTS A questionnaire was sent to all patients who had received CardioCard over a one-year period. The questionnaire was returned by 392 patients (73%). 44% of patients had the card with them all the time. The majority of patients (73%) considered the CardioCard useful (8% not useful, 19% no statement) and most (78%) would even agree to bear additional costs. Only 5% worried about data security. In contrast, 44% would be concerned of data transmission via internet. During an observation period of 6 (SD 3) months, data were accessed by 27% of patients and 12% of their physicians. The proportion of card users was lower among older patients: < or = 50 years (y), 39%; 51.60 y, 38%; 61.70 y, 26%; >70 y, 16% and particularly among older women: 61.70 y, 9%; >70 y, 5%. Technical problems during data access occurred in 34%, mostly due to incorrect handling. CONCLUSIONS A majority of patients considered CardioCard as useful and safe. Lack of hardware equipment or insufficient computer knowledge, but not safety issues were the most important limitations. As patients expressed concerns regarding protection of privacy if data were accessible via internet, this would remain a strong limiting factor for online use.
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Early clinical experience with CardioCard - a credit card-sized electronic patient record. Swiss Med Wkly 2006; 136:539-43. [PMID: 16983596 DOI: 10.4414/smw.2006.11478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
QUESTIONS UNDER STUDY CardioCard is a CDROM of credit card size containing medical information on cardiac patients. Patient data acquired during hospital stay are stored in PDF format and secured by a password known to patients only. In a consecutive series of patients, we assessed acceptance and utility of this new information medium. METHODS AND RESULTS A questionnaire was sent to all patients who had received CardioCard over a one-year period. The questionnaire was returned by 392 patients (73%). 44% of patients had the card with them all the time. The majority of patients (73%) considered the CardioCard useful (8% not useful, 19% no statement) and most (78%) would even agree to bear additional costs. Only 5% worried about data security. In contrast, 44% would be concerned of data transmission via internet. During an observation period of 6 (SD 3) months, data were accessed by 27% of patients and 12% of their physicians. The proportion of card users was lower among older patients: < or = 50 years (y), 39%; 51.60 y, 38%; 61.70 y, 26%; >70 y, 16% and particularly among older women: 61.70 y, 9%; >70 y, 5%. Technical problems during data access occurred in 34%, mostly due to incorrect handling. CONCLUSIONS A majority of patients considered CardioCard as useful and safe. Lack of hardware equipment or insufficient computer knowledge, but not safety issues were the most important limitations. As patients expressed concerns regarding protection of privacy if data were accessible via internet, this would remain a strong limiting factor for online use.
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Abstract
Since the implementation of highly active antiretroviral therapy (HAART) there is a dramatic decline in morbidity and mortality due to reduction of opportunistic infections in HIV-infected patients resulting in improved prognosis. Unfortunately, patients receiving HAART are at risk for metabolic complications, which may induce the development of coronary artery and cerebrovascular disease, particularly in young patients and in the presence of additional cardiovascular risk factors. A 30-years old female HIV-infected patient who developed an acute myocardial infarction is described.
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Abstract
AIMS To explore variations in invasive care of the elderly with acute coronary syndromes across international practice. METHODS AND RESULTS Using combined populations from the SYMPHONY and 2nd SYMPHONY trials, we describe 30-day cardiac catheterization in elderly (> or = 75 years; n = 1794) vs. younger patients (< 75 years; n = 14,043) after multivariable adjustment and by region of enrolment. The use of cardiac catheterization and revascularization were not protocol-specified. Elderly patients (median age 78 years) were more often female and more frequently had hypertension, diabetes, prior myocardial infarction, and prior coronary bypass surgery. Overall, they underwent less cardiac catheterization than younger patients [53 vs. 63%; adjusted OR 0.53 (0.46, 0.60)]. The absolute rate of cardiac catheterization in the elderly varied from 77% (vs. 91% in younger patients) in the US cohort to 27% (vs. 41% in younger patients) in the non-US cohort. Revascularization of elderly who underwent cardiac catheterization was also higher in US than non-US cohorts (71.3 vs. 53.6%). There was a significant interaction between the patient age and the use of catheterization across US and non-US regions of enrolment, as well as differences in the predictors of catheterization in the elderly. Despite these findings, after adjustment, 90-day rates of death and death or myocardial infarction (MI) were not significantly different in elderly who underwent catheterization compared with those who did not. CONCLUSION Although older age is universally predictive of lower use of cardiac catheterization, marked variation in catheterization of the elderly exists across international practice. Demonstrated differences in patterns of use suggest a lack of consensus regarding optimal use of an invasive strategy in the elderly.
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Use of B-type natriuretic peptide in the detection of myocardial ischemia. Am Heart J 2006; 151:1223-30. [PMID: 16781223 DOI: 10.1016/j.ahj.2005.06.045] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Accepted: 06/30/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Exercise electrocardiography (ECG) has high specificity but limited sensitivity for the detection of myocardial ischemia. The aim of this study was to determine whether measurement of B-type natriuretic peptide (BNP) can improve the diagnostic accuracy of exercise ECG. METHODS A total of 256 consecutive patients with suspected myocardial ischemia referred for rest/ergometry myocardial perfusion single-photon emission computed tomography were enrolled. Levels of BNP were determined before and 1 minute after maximal exercise. RESULT Inducible myocardial ischemia on perfusion images was detected in 127 patients (49.6%). Median BNP levels at rest and after peak exercise were higher in patients with than without inducible ischemia (71 pg/mL vs 38 pg/mL, P < .001; and 88 vs 52 pg/mL, P < .001, respectively). Compared with patients in the lowest peak exercise BNP quartile, those in the highest quartile of peak exercise BNP had more than 3 times the risk of inducible ischemia (adjusted relative risk 3.3, 95% CI 1.3-8.6, P = .015). Using 110 pg/mL as a cutoff, the combination of exercise ECG and peak exercise BNP level distinguished between ischemic and nonischemic patients more accurately than the exercise ECG alone (67% vs 60%, P = .024). Although the increase in accuracy was similar for the combination of exercise ECG with baseline BNP or DeltaBNP, overall, peak exercise BNP seemed to be the preferred measurement. CONCLUSIONS B-type natriuretic peptide levels are associated with inducible myocardial ischemia. The use of BNP levels improves the diagnostic accuracy of exercise ECG.
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Coronary stent infection: a rare but severe complication of percutaneous coronary intervention. Swiss Med Wkly 2006; 135:483-7. [PMID: 16208586 DOI: 2005/33/smw-11142] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
During the last two decades, the number of percutaneous coronary interventions (PCI) has steadily increased in Switzerland, as has the use of coronary stents. However, reports of coronary stent infections are very rare. In the present article we review all published cases of coronary stent infections. All patients presented with symptoms of infection within the first four weeks after PCI. Clinical hallmarks of stent infection were fever and chest pain. Blood cultures were positive in all patients. Despite the use of intravenous antibiotics in all except one patient and surgical drainage of the infectious focus in the majority of affected individuals mortality was high (40%). Thus, coronary stent infection, although exceedingly rare, represents a life-threatening complication and should be considered in the differential diagnosis of patients presenting with fever during the first few weeks after PCI.
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[Pain killers--killing the pain or the patient?]. PRAXIS 2006; 95:273-6. [PMID: 16523991 DOI: 10.1024/0369-8394.95.8.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Over the last years, the coxibes were widely used as potent and well tolerated pain killers. This was in part due to the better gastrointestinal tolerability of the coxibes. On the other hand the higher cox-2 selectivity is consistent with a higher cardio-vascular event rate in patients with coxibe therapy which has been demonstrated by several studies. Side effects are probably caused by the interaction of the following factors: impact on thrombocytes, coagulation, blood vessel physiology, and blood pressure. Of note, the reported cardio-vascular adverse event rates in trials evaluating coxibes and older non-steroidal anti-inflammatory drugs was very low. Furthermore, there were no difference in fatal event rates. This underscores the need to carefully deliberate about the beneficial and potentially harmful use of these drugs. In daily practice it therefore might be suitable to still use these drugs to alleviate pain in selected patients.
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Long-term prognostic value of the preoperative 12-lead electrocardiogram before major noncardiac surgery in coronary artery disease. Am Heart J 2006; 151:508-13. [PMID: 16442922 DOI: 10.1016/j.ahj.2005.04.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2004] [Accepted: 04/28/2005] [Indexed: 12/16/2022]
Abstract
BACKGROUND Knowledge of the prognostic information of preoperative 12-lead electrocardiogram (ECG) recordings in patients with coronary artery disease (CAD) undergoing noncardiac surgery is limited. METHODS The prognostic information derived from the preoperative ECGs of 172 CAD patients undergoing major noncardiac surgery was analyzed to determine its predictive value for long-term outcome. Primary end point was all-cause mortality; secondary end point was major adverse cardiac events (MACE) at 2 years. RESULTS Prevalence of ECG abnormalities was 53% for T-wave alterations; 46% for Q waves; 38% for ST deviations; and, depending on the criterion used, 2% to 19% for left ventricular hypertrophy. During follow-up, 40 (23%) patients died and 31 (18%) had MACE. After adjustment for clinical baseline findings, including current medication with beta-blockers, ST depressions (odds ratio [OR] 4.5, 95% confidence interval [CI] 1.9-10.5) and faster heart rate (HR) (OR 1.6, 95% CI 1.1-2.4, per 10 beats per minute [bpm] increase) were independent predictors of all-cause mortality. Faster HR (OR 1.7, 95% CI 1.1-2.6, per 10-bpm increase) was also an independent predictor of MACE. The predictive value of ECG variables did not change after adjustment for occurence of perioperative ischemia. CONCLUSION In CAD patients, the preoperative ECG contains important prognostic information and is predictive of long-term outcome independent of clinical findings and perioperative ischemia.
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