Objectives The aim of this study was to evaluate the independent prognostic significance of ischemia change in stable coronary artery disease (CAD). Background Recent randomized trials in stable CAD ...have suggested that revascularization does not improve outcomes compared with optimal medical therapy (MT). In contrast, the nuclear substudy of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial found that revascularization led to greater ischemia reduction and suggested that this may be associated with improved unadjusted outcomes. Thus, the effects of MT versus revascularization on ischemia change and its independent prognostic significance requires further investigation. Methods From the Duke Cardiovascular Disease and Nuclear Cardiology Databanks, 1,425 consecutive patients with angiographically documented CAD who underwent 2 serial myocardial perfusion single-photon emission computed tomography scans were identified. Ischemia change was calculated for patients undergoing MT alone, percutaneous coronary intervention, or coronary artery bypass grafting. Patients were followed for a median of 5.8 years after the second myocardial perfusion scan. Cox proportional hazards regression modeling was used to identify factors independently associated with the primary outcome of death or myocardial infarction (MI). Formal risk reclassification analyses were conducted to assess whether the addition of ischemia change to traditional predictors resulted in improved risk classification for death or MI. Results More MT patients (15.6%) developed ≥5% ischemia worsening compared with those undergoing percutaneous coronary intervention (6.2%) or coronary artery bypass grafting (6.7%) (p < 0.001). After adjustment for established predictors, ≥5% ischemia worsening remained a significant independent predictor of death or MI (hazard ratio: 1.634; p = 0.0019) irrespective of treatment arm. Inclusion of ≥5% ischemia worsening in this model resulted in significant improvement in risk classification (net reclassification improvement: 4.6%, p = 0.0056) and model discrimination (integrated discrimination improvement: 0.0062, p = 0.0057). Conclusions In stable CAD, ischemia worsening is an independent predictor of death or MI, resulting in significantly improved risk reclassification when added to previously known predictors.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objectives The aim of this study was to determine whether single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is an effective method of risk stratification for ...sudden cardiac death (SCD) in patients with coronary artery disease (CAD) and left ventricular ejection fraction (LVEF) >35%. Background Most victims of SCD have an LVEF >35%. Methods The study population included 4,865 patients with CAD and LVEF >35% who underwent gated SPECT MPI. We used Cox proportional hazard modeling to examine the relationship between patient characteristics and SCD. Results The median age of the population was 63 years (25th, 75th percentile: 54, 71 years), and the median LVEF was 56% (25th, 75th percentile: 50%, 64%). The median follow-up for all patients was 6.5 years (25th, 75th percentile: 3.6, 9.3 years). During follow-up, there were 161 SCDs (3.3%). After multivariable adjustment, LVEF, the Charlson index, hypertension, smoking, antiarrhythmic drug therapy, and the summed stress score (SSS) were associated with SCD (all p < 0.05). For each 3-U increase in the SSS, the hazard ratio for SCD was 1.13 (95% confidence interval: 1.04 to 1.23). The addition of perfusion data to the clinical history and LVEF was associated with increased discrimination for SCD events ( c -index 0.728). Risk stratification with a derived SPECT nomogram did not result in statistically significant net reclassification improvement (p = 0.26) or integrated discrimination improvement (p = 0.38). Conclusions Among patients with CAD and LVEF >35%, the extent of stress MPI perfusion defects is associated with an increased risk of SCD. Future large prospective studies should address the role of perfusion imaging in the identification of high-risk patients with LVEF >35% who might benefit from ICD implantation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background This post hoc analysis of the HF-ACTION cohort explores the primary and secondary results of the HF-ACTION study by etiology and severity of illness. Methods HF-ACTION randomized stable ...outpatients with reduced left ventricular (LV) function and heart failure (HF) symptoms to either supervised exercise training plus usual care or to usual care alone. The primary outcome was all-cause mortality or all-cause hospitalization; secondary outcomes included all-cause mortality, cardiovascular mortality or cardiovascular hospitalization, and cardiovascular mortality or HF hospitalization. The interaction between treatment and risk variable, etiology or severity as determined by risk score, New York Heart Association class, and duration of cardiopulmonary exercise test was examined in a Cox proportional hazards model for all clinical end points. Results There was no interaction between etiology and treatment for the primary outcome ( P = .73), cardiovascular (CV) mortality or CV hospitalization ( P = .59), or CV mortality or HF hospitalization ( P = .07). There was a significant interaction between etiology and treatment for the outcome of mortality ( P = .03), but the interaction was no longer significant when adjusted for HF-ACTION adjustment model predictors ( P = .08). There was no significant interaction between treatment effect and severity, except a significant interaction between cardiopulmonary exercise duration and training was identified for the primary outcome of all-cause mortality or all-cause hospitalization. Conclusion Consideration of symptomatic (New York Heart Association classes II to IV) patients with HF with reduced LV function for participation in an exercise training program should be made independent of the cause of HF or the severity of the symptoms.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background The association of sustained ventricular tachycardia/fibrillation (VT/VF) with mortality in patients undergoing primary percutaneous coronary intervention (PCI) may vary with baseline ...patient risk and may be associated with higher mortality in patients who have high-risk baseline features but not in the low-risk patient cohort undergoing this procedure. Methods Among the 5,259 ST Elevation Myocardial Infarction (STEMI) patients presenting for primary PCI from the APEX AMI trial, we evaluated the association of VT/VF with outcomes according to underlying risk for 90-day mortality estimated using baseline variables and with a Cox regression model. Results Ventricular tachycardia/fibrillation occurred in 3.6% (63/1,736), 4.9% (87/1,788), and 8.1% (141/1,735) of patients in the low-, intermediate-, and high-tertiles of 90-day predicted death, respectively. Ninety-day death was between 3.2- and 4.8-fold higher in patients with VT/VF compared with those without it in the 3 risk groups (low risk 1.6% vs 0.5%, intermediate risk 5.7% vs1.2%, high risk 33.6% vs 7.7%). Both early (during cardiac catheterization) and late VT/VF (after cardiac catheterization) were associated with high risk of death regardless of baseline risk category. Conclusions The incidence of VT/VF and mortality increased as patients' baseline risk increased, and VT/VF remained an important prognostic marker for the increased risk of clinical adverse events and 90-day mortality irrespective of underlying baseline risk in patients undergoing primary PCI. Thus, even in otherwise low-risk patients, occurrence of VT/VF helps to further identify higher risk cohort that may warrant closer monitoring.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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