Abstract
BackgroundRisk prediction for patients with suspected coronary artery disease is complex due to the common occurrence of prior cardiovascular disease and extensive risk modification in primary care. Numerous markers have the potential to predict prognosis and guide management, but we currently lack robust ‘real-world’ evidence for their use.MethodsProspective, multicentre observational study of consecutive patients referred for elective coronary angiography. Clinicians were blinded to all risk assessments, consisting of conventional factors, radial artery pulse wave analysis, 5-minute heart rate variability, high-sensitivity C-reactive protein and B-type natriuretic peptide (BNP). Blinded, independent adjudication was performed for all-cause mortality and the composite of death, myocardial infarction or stroke, analysed with Cox proportional hazards regression.ResultsFive hundred twenty-two patients were assessed with median age 66 years and 21% prior revascularization. Median baseline left ventricular ejection fraction was 64%, and 62% had ≥ 50% stenosis on angiography. During 5.0 years median follow-up, 30% underwent percutaneous and 16% surgical revascularization. In multivariate analysis, only age and BNP were independently associated with outcomes. The adjusted hazard ratio per log unit increase in BNP was 2.15 for mortality (95% CI 1.45–3.19; p = 0.0001) and 1.27 for composite events (1.04–1.54; p = 0.018). Patients with baseline BNP > 100 pg/mL had substantially higher mortality and composite events (20.9% and 32.2%) than those with BNP ≤ 100 pg/mL (5.6% and 15.5%). BNP improved both classification and discrimination of outcomes (p ≤ 0.003), regardless of left ventricular systolic function. Conversely, high-sensitivity C-reactive protein, pulse wave analysis and heart rate variability were unrelated to prognosis at 5 years after risk modification and treatment of coronary disease.ConclusionsConventional risk factors and other markers of arterial compliance, inflammation and autonomic function have limited value for prediction of outcomes in risk-modified patients assessed for coronary disease. BNP can independently identify patients with subtle impairment of cardiac function that might benefit from more intensive management.Trial registrationClinicaltrials.gov, NCT00403351 Registered on 22 November 2006
Highlights
The prediction of adverse cardiovascular events and mortality is well described for patients without cardiovascular disease (CVD) [1, 2]
Conventional risk factors are often poorly associated with coronary artery disease (CAD) [3] or prognosis in those with established CVD [4, 5]
The Alternative Risk Markers in Coronary Artery Disease (ARM-CAD) longitudinal study population consists of 526 patients recruited prior to elective coronary angiography, with a median follow-up period of 5.0 years (IQR 3.5–6.0)
Summary
The prediction of adverse cardiovascular events and mortality is well described for patients without cardiovascular disease (CVD) [1, 2]. Conventional risk factors are often poorly associated with coronary artery disease (CAD) [3] or prognosis in those with established CVD [4, 5]. This leaves limited scope for identifying patients at high risk that might benefit from more intensive management. Heart rate variability (HRV) is a marker of autonomic function [9], but with unknown effectiveness for risk prediction [10]. Risk prediction for patients with suspected coronary artery disease is complex due to the common occurrence of prior cardiovascular disease and extensive risk modification in primary care. Numerous markers have the potential to predict prognosis and guide management, but we currently lack robust ‘real-world’ evidence for their use
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
