The discontinuation of statin therapy in patients with acute coronary syndromes has been associated with an increase of adverse coronary events. Patients who undergo major surgery frequently are not ...able to take oral medication shortly after surgery. Because there is no intravenous formula for statins, the interruption of statins in the postoperative period is a serious concern. The objective of this study was to assess the effect of perioperative statin withdrawal on postoperative cardiac outcome. Also, the association between outcome and type of statin was studied. In 298 consecutive statin users who underwent major vascular surgery, detailed cardiac histories were obtained, and medication use was noted. Postoperatively, troponin levels were measured on days 1, 3, 7, and 30 and whenever clinically indicated by electrocardiographic changes. End points were postoperative troponin release, myocardial infarction, and a combination of nonfatal myocardial infarction and cardiovascular death. Multivariate analyses and propensity score analyses were performed to assess the influence of type of statin and the discontinuation of statins for these end points. Statin discontinuation was associated with an increased risk for postoperative troponin release (hazard ratio 4.6, 95% confidence interval 2.2 to 9.6) and the combination of myocardial infarction and cardiovascular death (hazard ratio 7.5, 95% confidence interval 2.8 to 20.1). Extended-release fluvastatin was associated with fewer perioperative cardiac events compared with atorvastatin, simvastatin, and pravastatin. In conclusion, the present study showed that statin withdrawal in the perioperative period is associated with an increased risk for perioperative adverse cardiac events. Furthermore, there seemed to be better outcomes in patients who received statins with extended-release formulas.
Magnetic Resonance Cardiac Vein Imaging: Relation to Mitral Valve Annulus and Left Circumflex Coronary Artery Amedeo Chiribiri, Sebastian Kelle, Uwe Köhler, Laurens F. Tops, Bernhard Schnackenburg, ...Rodolfo Bonamini, Jeroen J. Bax, Eckart Fleck, Eike Nagel This study demonstrates the capability of contrast-enhanced 3-dimensional navigator cardiovascular magnetic resonance to evaluate noninvasively the anatomical relation between the coronary sinus–great cardiac vein, the mitral valve annulus, and the left circumflex coronary artery. Cardiac computed tomography has been previously studied in this regard. The coronary sinus is generally located adjacent to the left atrial wall not the mitral annulus, and in 80% of the patients' studies, the left circumflex courses between the coronary sinus and mitral annulus. These anatomic relationships and their variability have important implications for percutaneous therapies for mitral regurgitation that involve the coronary sinus.
Currently, left ventricular (LV) ejection fraction (EF) and/or LV volumes are the established predictors of mortality in patients with coronary artery disease (CAD) and severe LV dysfunction. With ...contrast-enhanced magnetic resonance imaging (MRI), precise delineation of infarct size is now possible. The relative merits of LVEF/LV volumes and infarct size to predict long-term outcome are unknown. The purpose of this study was to determine the predictive value of infarct size assessed with contrast-enhanced MRI relative to LVEF and LV volumes for long-term survival in patients with healed myocardial infarction. Cine MRI and contrast-enhanced MRI were performed in 231 patients with healed myocardial infarction. LVEF and LV volumes were measured and infarct size was derived from contrast-enhanced MRI. Nineteen patients (8.2%) died during a median follow-up of 1.7 years (interquartile range 1.1 to 2.9). Cox proportional hazards analysis revealed that infarct size defined as spatial extent (hazard ratio HR 1.3, 95% confidence interval CI 1.1 to 1.6, chi-square 6.7, p = 0.010), transmurality (HR 1.5, 95% CI 1.1 to 1.9, chi-square 8.9, p = 0.003), or total scar score (HR 6.2, 95% CI 1.7 to 23, chi-square 7.4, p = 0.006) were stronger predictors of all-cause mortality than LVEF and LV volumes. In conclusion, infarct size on contrast-enhanced MRI may be superior to LVEF and LV volumes for predicting long-term mortality in patients with healed myocardial infarction.
Akinesis becoming dyskinesis (AKBD) at high-dose dobutamine stress echocardiography (DSE) has been disregarded as a marker of myocardial ischemia. However, its prognostic significance is unknown.
We ...sought to assess the long-term outcome of patients with AKBD during DSE.
A total of 731 patients (age 62 +/- 15 years, 628 men) with two or more akinetic left ventricular segments at rest underwent DSE and were followed up for a mean period of 5 +/- 2.7 years. The end points considered during follow-up were hard cardiac events (cardiac death and nonfatal myocardial infarction) and heart failure.
Dyskinesis in two or more segments at peak stress developed in 60 patients (8%). Resting wall-motion score index was 2.6 +/- 0.56 in patients with AKBD versus 2.3 +/- 0.55 in patients without AKBD (P = .0002). Ischemia occurred in 197 patients (27%). During follow-up, 254 patients (35%) developed hard cardiac events and 204 patients (28%) developed heart failure. In all, 226 patients (31%) died of various causes (cardiac death in 172 patients). The annualized hard cardiac event rate was 11% in patients with AKBD and 6% in patients without (P = .03). The incidence of heart failure was significantly higher in patients with AKBD than without (47% vs 26%, P < .001). Independent predictors of hard cardiac events were age (hazard ratio HR 1.03 confidence interval {CI} = 1.01-1.04), previous myocardial infarction (HR 1.4 CI = 1.1-1.9), diabetes mellitus (HR 1.8 CI = 1.3-2.5), resting wall-motion score index (HR 1.11 CI = 1.01-1.04), and AKBD (HR 1.6 CI = 1.1-2.4).
AKBD at peak DSE is associated with increased risk of cardiac events in patients with akinetic segments at baseline echocardiogram.
Speckle-Tracking Radial Strain Reveals Left Ventricular Dyssynchrony in Patients With Permanent Right Ventricular Pacing Laurens F. Tops, Matthew S. Suffoletto, Gabe B. Bleeker, Eric Boersma, Ernst ...E. van der Wall, John Gorcsan III, Martin J. Schalij, Jeroen J. Bax In the present study, speckle-tracking radial strain analysis was used to assess the effects of right ventricular (RV) pacing on the timing of regional left ventricular (LV) wall strain. After long-term RV pacing, a marked heterogeneity in time-to-peak strain among the LV walls was noted, with early activation in the (antero)septal and late activation in the posterolateral segments. In 57% of the patients, this resulted in the presence of LV dyssynchrony with a concomitant worsening in LV function and New York Heart Association functional class. Upgrade to biventricular pacing resulted in partial reversal of these detrimental effects of RV pacing.
Sex-specific thresholds of computed tomography (CT)–derived aortic valve calcification (AVC) or AVC density (AVCd) to identify severe aortic stenosis (AS) have been established in populations that ...consisted mainly of Caucasians with a tricuspid aortic valve. The objective of this study was to evaluate the accuracy (i.e., sensitivity and specificity) of previously established thresholds to identify severe AS in patients with bicuspid aortic valve (BAV) and according to ethnicity: Caucasian vs. Asian.
We built a multicenter registry of echocardiographic and CT data collected in BAV patients with at least mild AS and preserved left ventricular ejection fraction from 7 different centers. Anatomic severity of AS obtained by CT-derived AVC and AVCd was compared to hemodynamic severity of AS obtained by echocardiography.
Among 485 BAV patients (60% men, 73% Asians), the best thresholds of AVC and AVCd to identify severe AS in BAV patients were 2315 arbitrary units (AU) (sensitivity Se/specificity Spe = 82/78%) in men, 1103 AU (Se/Spe = 80/82%) in women, and 561 AU/cm2 (Se/Spe = 86/91%) in men, and 301 AU/cm2 (Se/Spe = 83/82%) in women, respectively. According to ethnicity, thresholds for severe AS in Caucasian patients were, respectively, in men and women: 2208 AU (Se/Spe = 83/83%) and 1230 AU (Se/Spe = 87/82%) for AVC and 474 AU/cm2 (Se/Spe = 88/83%) and 358 AU/cm2 (Se/Spe = 80/82%) for AVCd. In Asian patients, they were 2582 AU (Se/Spe = 76/78%) and 924 AU (Se/Spe = 84/80%) for AVC and 640 AU/cm2 (Se/Spe = 82/89%) and 255 AU/cm2 (Se/Spe = 86/80%) for AVCd.
The optimal thresholds to identify hemodynamically severe AS in BAV patients are similar in Caucasians but appear to be higher in Asian men, compared with thresholds previously reported in tricuspid aortic valve patients. Nonetheless, the thresholds currently proposed in the guidelines have good accuracy and can be applied in BAV patients to confirm AS severity.
Reply Schuijf, Joanne D., MSc; Pundziute, Gabija, MD; Bax, Jeroen J., MD, PhD
Journal of the American College of Cardiology,
2007, Letnik:
49, Številka:
20
Journal Article
Reduced Aortic Elasticity and Dilatation Are Associated With Aortic Regurgitation and Left Ventricular Hypertrophy in Nonstenotic Bicuspid Aortic Valve Patients Heynric B. Grotenhuis, Jaap Ottenkamp, ...Jos J. M. Westenberg, Jeroen J. Bax, Lucia J. M. Kroft, Albert de Roos The objectives of this study were to assess aortic wall elasticity and aortic dimensions and their impact on aortic valve competence and left ventricular function in patients with a nonstenotic bicuspid aortic valve. The main findings were reduced aortic elasticity and aortic root dilatation, and associated aortic regurgitation and left ventricular hypertrophy in patients with nonstenotic bicuspid aortic valve.
Plasma N-terminal pro–B-type natriuretic peptide (NT–pro-BNP) levels improve preoperative cardiac risk stratification in vascular surgery patients. However, single preoperative measurements of ...NT–pro-BNP cannot take into account the hemodynamic stress caused by anesthesia and surgery. Therefore, the aim of the present study was to assess the incremental predictive value of changes in NT–pro-BNP during the perioperative period for long-term cardiac mortality. Detailed cardiac histories, rest left ventricular echocardiography, and NT–pro-BNP levels were obtained in 144 patients before vascular surgery and before discharge. The study end point was the occurrence of cardiovascular death during a median follow-up period of 13 months (interquartile range 5 to 20). Preoperatively, the median NT–pro-BNP level in the study population was 314 pg/ml (interquartile range 136 to 1,351), which increased to a median level of 1,505 pg/ml (interquartile range 404 to 6,453) before discharge. During the follow-up period, 29 patients (20%) died, 27 (93%) from cardiovascular causes. The median difference in NT–pro-BNP in the survivors was 665 pg/ml, compared to 5,336 pg/ml in the patients who died (p = 0.01). Multivariate Cox regression analyses, adjusted for cardiac history and cardiovascular risk factors (age, angina pectoris, myocardial infarction, stroke, diabetes mellitus, renal dysfunction, body mass index, type of surgery and the left ventricular ejection fraction), demonstrated that the difference in NT–pro-BNP level between pre- and postoperative measurement was the strongest independent predictor of cardiac outcome (hazard ratio 3.06, 95% confidence interval 1.36 to 6.91). In conclusion, the change in NT–pro-BNP, indicated by repeated measurements before surgery and before discharge is the strongest predictor of cardiac outcomes in patients who undergo vascular surgery.
PDF
