Abstract Approximately 50% of the patients with chronic obstructive coronary artery disease resulting in chronic contractile dysfunction have hibernating myocardium and may benefit from ...revascularization. This pooled analysis describes the relative merits of dobutamine echocardiography, thallium-201 and technetium-99m scintigraphy, positron emission tomography, and magentic resonance imaging, for the diagnosis of hibernating myocardium and prediction of patient outcomes.
Chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD) are both inflammatory conditions. Statins are commonly used in patients with PAD and have anti-inflammatory ...properties, which may have beneficial effects in patients with COPD. The relation between statin use and mortality was investigated in patients with PAD with and without COPD. From 1990 to 2006, we studied 3,371 vascular surgery patients. Statin use was noted at baseline and, if prescribed, converted to <25% (low dose) and ≥25% (intensified dose) of the maximum recommended therapeutic dose. The diagnosis of COPD was based on the Global Initiative for Chronic Obstructive Lung Disease guidelines using pulmonary function test. End points were short- (30-day) and long-term (10-year) mortality. A total of 330 patients with COPD (25%) used statins, and 480 patients (23%) without COPD. Statin use was independently associated with improved short- and long-term survival in patients with COPD (odds ratio 0.48, 95% confidence interval CI 0.23 to 1.00; hazard ratio 0.67, 95% CI 0.52 to 0.86, respectively). In patients without COPD, statins were also associated with improved short- and long-term survival (odds ratio 0.42, 95% CI 0.20 to 0.87; hazard ratio 0.76, 95% CI 0.60 to 0.95, respectively). In patients with COPD, only an intensified dose of statins was associated with improved short-term survival. However, for the long term, both low-dose and intensive statin therapy were beneficial. In conclusion, statin use was associated with improved short- and long-term survival in patients with PAD with and without COPD. Patients with COPD should be treated with an intensified dose of statins to achieve an optimal effect on both the short and long term.
Pre-Operative Risk Assessment and Risk Reduction Before Surgery Don Poldermans, Sanne E. Hoeks, Harm H. Feringa Perioperative myocardial infarctions are the predominant cause of morbidity and ...mortality in patients undergoing noncardiac surgery. Pre-operative management aims at optimizing the patient's condition by identification and modification of underlying cardiac risk factors and diseases. During recent decades, there has been a shift from the assessment and treatment of the underlying culprit coronary lesion toward a systemic medical therapy with beta-blockers, statins, and aspirin. The role of prophylactic coronary revascularization has been restricted to the same indications as the nonoperative setting. Therefore, pre-operative cardiac testing is recommended only if test results will change perioperative management.
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.
Objectives This study evaluated timing of β-blocker initiation before surgery and its relationship with: 1) pre-operative heart rate and high-sensitivity C-reactive-protein (hs-CRP) levels; and 2) ...post-operative outcome. Background Perioperative guidelines recommend β-blocker initiation days to weeks before surgery, on the basis of expert opinions. Methods In 940 vascular surgery patients, pre-operative heart rate and hs-CRP levels were recorded, next to timing of β-blocker initiation before surgery (0 to 1, >1 to 4, >4 weeks). Pre- and post-operative troponin-T measurements and electrocardiograms were performed routinely. End points were 30-day cardiac events (composite of myocardial infarction and cardiac mortality) and long-term mortality. Multivariate regression analyses, adjusted for cardiac risk factors, evaluated the relation between duration of β-blocker treatment and outcome. Results The β-blockers were initiated 0 to 1, >1 to 4, and >4 weeks before surgery in 158 (17%), 393 (42%), and 389 (41%) patients, respectively. Median heart rate at baseline was 74 (±17) beats/min, 70 (±16) beats/min, and 66 (±15) beats/min (p < 0.001; comparing treatment initiation >1 with <1 week pre-operatively), and hs-CRP was 4.9 (±7.5) mg/l, 4.1 (±.6.0) mg/l, and 4.5 (±6.3) mg/l (p = 0.782), respectively. Treatment initiated >1 to 4 or >4 weeks before surgery was associated with a lower incidence of 30-day cardiac events (odds ratio: 0.46, 95% confidence interval CI: 0.27 to 0.76, odds ratio: 0.48, 95% CI: 0.29 to 0.79) and long-term mortality (hazard ratio: 0.52, 95% CI: 0.21 to 0.67, hazard ratio: 0.50, 95% CI: 0.25 to 0.71) compared with treatment initiated <1 week pre-operatively. Conclusions Our results indicate that β-blocker treatment initiated >1 week before surgery is associated with lower pre-operative heart rate and improved outcome, compared with treatment initiated <1 week pre-operatively. No reduction of median hs-CRP levels was observed in patients receiving β-blocker treatment >1 week compared with patients in whom treatment was initiated between 0 and 1 week before surgery.
The current guidelines have recommended postponing noncardiac surgery (NCS) for ≥6 weeks after bare metal stent (BMS) placement and for ≥1 year after drug-eluting stent (DES) placement. However, much ...debate has ensued about these intervals. The aim of the present study was to assess the influence of different intervals between stenting and NCS and the use of dual antiplatelet therapy on the occurrence of perioperative major adverse cardiac events (MACEs). We identified 550 patients (376 with a DES and 174 with a BMS) by cross-matching the Erasmus Medical Center percutaneous coronary intervention (PCI) database with the NCS database. The following intervals between PCI-BMS (<30 days, <3 months, and >3 months) or PCI-DES (<30 days, <3 months, 3 to 6 months, 6 to 12 months, and >12 months) and NCS were studied. MACEs included death, myocardial infarction, and repeated revascularization. In the PCI-BMS group, the rate of MACEs during the intervals of <30 days, 30 days to 3 months, and >3 months was 50%, 14%, and 4%, respectively (overall p <0.001). In the PCI-DES group, the rate of MACE changed significantly with the interval after PCI (35%, 13%, 15%, 6%, and 9% for patients undergoing NCS <30 days, 30 days to 3 months, 3 to 6 months, 6 to 12 months, and >12 months, respectively, overall p <0.001). Of the patients who experienced a MACE, 45% and 55% were receiving single and dual antiplatelet therapy at NCS, respectively (p = 0.92). The risk of severe bleeding in patients with single and dual therapy at NCS was 4% and 21%, respectively (p <0.001). In conclusion, we found an inverse relation between the interval from PCI to NCS and perioperative MACEs. Continuation of dual antiplatelet therapy until NCS did not provide complete protection against MACEs.
Abstract Patients with chronic ischemic left ventricular dysfunction may have a substantial amount of viable, hibernating myocardium, which is a state of chronic contractile dysfunction with reduced ...blood flow at rest. Coronary revascularization in these patients may result in improvement of left ventricular function; in the absence of viability, left ventricular function will not improve postrevascularization. Various noninvasive imaging techniques are available for detection of viable myocardium, including magnetic resonance imaging, dobutamine stress echocardiography, and nuclear imaging with single photon emission computed tomography or positron emission tomography. Because these techniques probe different characteristics of viable myocardium, the sensitivities and specificities of the techniques are not precisely identical; in general, dobutamine stress echocardiography has the highest specificity, whereas the nuclear techniques have the highest sensitivity. The presence of myocardial viability also is related to prognosis: patients with viable myocardium who undergo revascularization have a good prognosis, whereas patients with viable myocardium who are treated medically have poor outcome. Accordingly, assessment of viability is important in the therapeutic decision-making process of patients with chronic ischemic left ventricular dysfunction.
Several observational studies have suggested a superior survival after mitral valve repair compared with replacement in patients undergoing surgery for infective endocarditis. The objective of this ...study was to systematically review the rate of morbidity and mortality associated with mitral valve repair or replacement in infective endocarditis.
A Medline search was conducted for literature and a systematic review of 24 studies, reporting prognosis of patients who underwent surgery for mitral valve endocarditis, was performed. Information on the patients, type of surgery, and follow-up was abstracted using standardized protocols.
A total of 470 patients (39%) underwent mitral valve repair and 724 patients (61%) underwent valve replacement. Lower in-hospital mortality (2.3% versus 14.4%, relative risk: 0.16, 95% confidence interval: 0.09 to 0.30, p < 0.0001) and long-term mortality (7.8% versus 40.5%, relative risk: 0.19, 95% confidence interval: 0.13 to 0.29, p < 0.0001) were observed among patients undergoing mitral valve repair compared with replacement. In addition, the rates of early reoperation (2.2% versus 12.7%, p < 0.0001), early cerebrovascular events (4.7% versus 11.5%, p = 0.045), late reoperation (4.7% versus 8.7%, p = 0.039), late recurrent endocarditis (1.8% versus 7.3%, p = 0.0013), and late cerebrovascular events (1.6% versus 24.4%, p < 0.0001) were significantly lower after mitral valve repair. Meta-regression analysis demonstrated that mitral valve repair over replacement was associated with a better early and late prognosis after surgery. Male sex and acute surgery were (nonsignificantly) predictive of worse early outcome.
A systematic review of literature showed that mitral valve repair is associated with good clinical in-hospital and long-term results among patients undergoing surgery for infective endocarditis.
Objective Datasets regarding patients with abdominal aortic aneurysm (AAA) have almost universally been restricted to single geographic regions. We aimed to obtain data on the risk factor profile and ...cardiovascular (CV) co-morbidity among multi-ethnic patients with known AAA in the global REACH (REduction of Atherothrombosis for Continued Health) Registry. Methods The REACH Registry is an international, prospective, observational out-patient registry enrolling out-patients ≥45 years of age with established coronary artery disease (CAD), cerebrovascular disease (CVD) or peripheral arterial disease (PAD) or with at least three atherothrombotic risk factors. This report includes observations pertaining to 68,236 out-patients enrolled in 44 countries. Main outcome measures Gender, ethnic origin, CV risk factors, established atherosclerotic disease (CAD, CVD and PAD) at baseline, and CV outcome events at 1-year were compared in patients with and without AAA. Results An AAA was reported in 1722 (2.5%) of 68,236 out-patients enrolled in the REACH Registry. Older age (73 ± 8 vs 68 ± 10, P < .0001), male gender (81% vs 63%, P < .0001), White ethnicity (79% vs 67%, P < .0001) and a history of smoking (81% vs 55%, P < .0001) were independently related to the diagnosis of AAA. There was a weaker association with hypertension or hypercholesterolemia, and an inverse relation with diabetes. Fatal and non-fatal coronary and cerebrovascular event rates were not different between the AAA and non-AAA cohorts, but individuals with AAA suffered increased rates of other cardiovascular deaths (1.39% vs 0.94%, P = .0135), hospitalizations for atherothrombotic events (14.1% vs 9.3%, P < .0001) due to increased rates of revascularization procedures, and new or worsening PAD (3.7% vs 1.3%, P < .0001) at 1-year follow-up. Conclusion This study, the largest published to date, presents the CV risk profile and outcome of patients with an established diagnosis of AAA from a cohort of patients with either overt manifestations of CV disease or multiple risk factors, and further defines these patients in a multi-ethnic, global context.
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