Prognosis In Cardiac Patients Research Articles

Abstract 9796: The Presence of Post-bronchodilator Airflow Limitation Deteriorates Cardiac Prognosis in Patients With Chronic Heart Failure

Background: Chronic obstructive pulmonary disease has begun to gather attention as important comorbidity in patients with cardiovascular disease. However, it is undetermined whether airflow limitation is associated with cardiac prognosis of patients with chronic heart failure (CHF). The aim of the present study was to examine whether post-bronchodilator pulmonary function can predict cardiac prognosis in patients with CHF. Methods and Results: We performed post-bronchodilator spirometry in consecutive 198 patients with CHF. Airflow limitation is assessed by the ratio of post-bronchodilator forced expiratory volume in the first 1 second and forced vital capacity (FEV 1 /FVC), and by the ratio of FEV 1 and predicted FEV 1 (%FEV 1 ). %FEV 1 but not FEV 1 /FVC was decreased with advancing New York Heart Association (NYHA) functional class. There were 45 cardiac events including 3 cardiac deaths and 42 re-hospitalizations for exacerbation of CHF during a median follow-up period of 446 days. Both FEV 1 /FVC and %FEV 1 were significantly lower in patients with cardiac events than in event-free patients (67.6 ± 12.5% v.s. 73.5 ± 9.4%, P <0.001; 66.6 ± 16.5% v.s. 80.6 ± 19.9%, P <0.0001, respectively). The receiver operating characteristic curve showed the area under the curve of FEV 1 /FVC and %FEV 1 for cardiac events were 0.667 and 0.701, respectively. Mean pulmonary arterial pressure and mean pulmonary arterial wedge pressure significantly correlated with %FEV 1 but not FEV 1 /FVC. Multivariate Cox proportional hazard analysis showed that %FEV 1 was an independent predictor of cardiac events after adjustment of possible confounders (hazard ratio per 1SD increase: 0.558; 95% confidence interval, 0.312-0.978). The patients were divided into tertiles of %FEV 1 . Kaplan-Meier analysis showed that patients in the lowest tertile had the highest event rate. Conclusion: Post-bronchodilator airflow limitation may deteriorate cardiac prognosis in patients with CHF.

The Presence of Post-bronchodilator Airflow Limitation is Associated with Poor Cardiac Prognosis in Patients with Chronic Heart Failure

The Presence of Post-bronchodilator Airflow Limitation is Associated with Poor Cardiac Prognosis in Patients with Chronic Heart Failure

Combination of heart-type fatty acid binding protein and QRS prolongation can risk-stratify patients with chronic heart failure

Background: It was reported that abnormal prolongation of QRS duration is associated with cardiac prognosis in patients with chronic heart failure (CHF). QRS prolongation represents left ventricular hypertrophy, bundle brunch block, and intra ventricular conduction disturbance. We and others reported that elevated levels of heart-type fatty acid binding protein (H-FABP), which is a marker of ongoing myocardial damage, can predict poor outcomes in CHF patients. The aim of this study was to elucidate whether a combination of markers for ongoing myocardial damage and electrical disturbance can risk-stratify CHF patients. Methods and results: We measured the QRS duration and serum H-FABP levels in 348 consecutive CHF patients at admission. Patients were prospectively followed during a median follow up period of 520 days. There were 132 cardiac events, including 28 cardiac deaths and 104 re-hospitalizations for worsening heart failure. Cut off value for H-FABP levels was determined from median value (4.7 ng/ml). All patients were stratified into 4 groups according to serum H-FABP level and QRS duration (≥120 ms). Multivariate analysis demonstrated that high H-FABP (hazard ratio 1.76, p=0.0142) and QRS prolongation (hazard ratio 1.55, p=0.0418) were independent predictors of cardiac events. Kaplan-Meier analysis demonstrated that the combination of high H-FABP level and QRS prolongation could reliably stratify patients for cardiac events (log rank test p<0.0001). The high H-FABP and QRS prolongation group had higher risk for cardiac events compared with the other groups. ![Figure][1] Conclusion: The combination of high H-FABP and QRS prolongation can risk stratify CHF patients. [1]: pending:yes

The Impact of Renal Tubular Damage, as Assessed by Urinary β 2 –Microglobulin–Creatinine Ratio, on Cardiac Prognosis in Patients With Chronic Heart Failure

Renal dysfunction was reported to be closely associated with clinical outcomes in patients with chronic heart failure (CHF). Renal tubulointerstitial damage has been shown to be an important factor in the development of renal dysfunction as well as glomerular damage. However, the impact of renal tubular damage on clinical outcomes in patients with CHF remains to be determined. Urinary β2-microglobulin-creatinine ratio was measured in 315 patients with CHF. Renal tubular damage was defined as a urinary β2-microglobulin-creatinine ratio ≥ 300 μg/g, as previously reported. Patients were prospectively followed up for a median period of 1097 days. There were 91 cardiac events, including 16 cardiac deaths and 75 rehospitalizations for worsening heart failure. Log10 urinary β2-microglobulin-creatinine ratio was increased with worsening New York Heart Association functional class. Multivariate analysis revealed that renal tubular damage was an independent predictor of cardiac events. Kaplan-Meier analysis demonstrated that the rate of cardiac events was higher in patients with renal tubular damage compared with those without it. Patients were divided into 4 groups according to the presence of chronic kidney disease and renal tubular damage. The Cox proportional hazard analysis revealed that comorbidity of chronic kidney disease and renal tubular damage was associated with the highest risk for cardiac events compared with other groups. Renal tubular damage was related to the severity of heart failure and was associated with poor outcomes in patients with CHF. Renal tubular damage could add clinical information to chronic kidney disease in patients with CHF.

In reply to the Letter to the Editor of Dr. Kawada: “Depression and 7-year mortality for patients treated with percutaneous coronary intervention”

In our recent study on the relationship between depression and 7-year mortality in patients treated with percutaneous coronary intervention (PCI), we adjusted for the distressed (Type D) personality in multivariable analyses. As Dr. Kawada correctly stated in his letter to the editor [1], we did not find a significant association between Type D personality and all-cause mortality, which is in contrast to some [2–5], but not all previous studies [6–8]. In the meta-analysis by Grande et al., the authors concluded that although there is a significant association between Type D personality and prognosis in cardiac patients, the strength of this effect has been declining over the years and that therefore, the effect of Type D might have been overestimated in previous studies [9].

Social support, depression, and heart disease: a ten year literature review

Background: Coronary heart disease is the major cause of morbidity and mortality in the world. Psychosocial factors such as depression and low social support are established risk factors for poor prognosis in patients with heart disease. However, little is known about the hypothetical relationship pattern between them.Purpose: The purposes of this narrative review are (1) to appraise the 2002–2012 empirical evidence about the multivariate relationship between depression, social support and health outcomes in patients with heart disease; (2) to evaluate the methodological quality of included studies.Method: PubMed and PsychINFO were searched for quantitative studies assessing the multiple effects of low social support and depression on prognosis outcomes in patients with heart disease. The following search terms were used: social relation*, cardiac disease, support quality, relationship, and relational support.Results: Five studies (three prospective cohort studies, one case-control study, and one randomization controlled trial) were selected and coded according to the types of support (social and marital). The majority of findings suggests that low social support/being unmarried and depression are independent risk factors for poor cardiac prognosis. However, all analyzed studies have some limitations. The majority of them did not focus on the quality of marital or social relationships, but assessed only the presence of marital status or social relationship. Moreover, some of them present methodological limitations.Conclusion: Depressive symptoms and the absence of social or marital support are significant risk factors for poor prognosis in cardiac patients and some evidence supports their independence in predicting adverse outcomes. Cardiac rehabilitation and prevention programs should thus include not only the assessment and treatment of depression but also a specific component on the family and social contexts of patients.

Severity of Peripheral Arterial Disease is Associated With Aortic Pressure Augmentation and Subendocardial Viability Ratio

Peripheral arterial disease (PAD) is associated with increased cardiovascular mortality that correlates with peripheral perfusion impairment as assessed by the ankle-brachial arterial pressure index (ABI). Furthermore, PAD is associated with arterial stiffness and elevated aortic augmentation index (AIx). The purpose of this study was to investigate whether ABI impairment correlates with AIx and subendocardial viability ratio (SEVR), a measure of cardiac perfusion during diastole. AIx and SEVR were assessed by radial applanation tonometry in 65 patients with stable PAD (Rutherford stage I-III) at a tertiary referral center. AIx corrected for heart rate and SEVR were tested in a multivariate linear and logistic regression model to determine the association with ABI. Mean ABI was 0.8±0.2, AIx 31%±7%, and SEVR 141%±26%. Multiple linear regression with AIx as a dependent variable revealed that AIx was significantly negatively associated with ABI (β=-11.5; 95% confidence interval [CI], -18.6 to -4.5; P=.002). Other variables that were associated with AIx were diastolic blood pressure (β=0.2; 95% CI, 0.1-0.4; P<.001), height (β=-46.2; 95% CI, -62.9 to -29.4; P<.001), body mass index (β=-0.4; 95% CI, -0.8 to -0.1; P=.023), and smoking (β=3.6; 95% CI, 0.6-6.6; P=.019). Multiple regression with SEVR as a dependent variable showed a significant correlation with ABI (β=33.2; 95% CI, 2.3-64.1; P=.036). Severity of lower limb perfusion impairment is related to central aortic pressure augmentation and to subendocardial viability ratio. This may be a potential pathophysiologic link that impacts cardiac prognosis in patients with PAD.

Type D Personality and Heart Disease: Walking the Line Between Enthusiasm and Disbelief

After many years of enthusiastic reports on the prognostic potential of the type D construct in patients with coronary heart disease, a critical discussion of methodological shortcomings of type D research was initiated recently. In their letter, de Voogd and colleagues summarize some of the critical issues we mentioned in our meta-analysis, issues that have been well documented elsewhere [2]. We agree with de Voogd and colleagues that small sample sizes, overfitted regression models, and the predominant use of dichotomized type D categories are methodological shortcomings of many primary studies on the effects of type D on prognosis in cardiac patients. That may lead to a higher probability for an overestimation of effects and spurious results, but it does not generate positive results per se. We also agree that a meta-analysis cannot overcome methodological shortcomings of primary studies. Therefore, we conducted sensitivity analyses and carefully described potential weaknesses and strengths of the included primary studies. Our meta-analytic conclusion that there is a prognostic association of type D with mortality was qualified by three other important points: (1) studies with lower methodological quality report have larger effects, (2) the effects decline considerably over time (as reported previously for other personality constructs such as the type A behavior pattern and also for biomedical research [1]), and (3) type D personality may not be associated with prognosis in chronic heart failure patients. Despite the overall significant meta-analytic risk estimate, these caveats raise doubt regarding the prognostic value of type D. Moreover, our work underscores the necessity and utility of quantitative reviews to identify problems in a body of literature. The assertion by de Voogd et al. to banish the concept of type D personality seems premature based upon the available evidence. Aside from additional prospective studies, the most straightforward approach would be to reanalyze primary data from available type D studies with appropriate regression models and in an individual patient data metaanalysis to obtain greater statistical precision [2]. Such research incorporating narrative reviews and quantitative meta-analysis will provide the most defensible conclusion whether type D personality is associated with prognosis in CHD patients or not.

Type D personality and three-month psychosocial outcomes among patients post-myocardial infarction

ObjectiveType D personality has been proposed as a risk factor for poor prognosis in cardiac patients. Recent studies which have adopted a dimensional approach to Type D (negative affectivity×social inhibition) found no effect of Type D on mortality, after controlling for its constituent elements. To-date, no study has determined if Type D is associated with psychosocial outcomes in post-myocardial infarction (MI) patients when conceptualised as a dimensional variable. MethodsParticipants were 192 MI patients (138 males, 54 females, mean age 66.0years) who provided demographic and clinical information, and completed measures of Type D one-week post-MI. Three months later, 131 of these MI patients completed measures of disability and quality of life. ResultsUsing regression analyses, adjusted for demographic and clinical data, Type D emerged as a significant predictor of disability and quality of life in MI patients, when analysed using the traditional categorical approach. However, Type D did not predict disability and quality of life when it was analysed using the interaction of negative affectivity and social inhibition. Negative affect emerged as a significant predictor of both disability (β=.433, t(130)=3.53, p<.01), and quality of life (β=−.624, t(130)=−5.68, p<.001). ConclusionsThe results suggest that Type D is not associated with short-term psychosocial outcome in MI patients, after controlling for its constituent elements. However, negative affect was significantly associated with both disability and quality of life. Future research should conceptualise Type D as the interaction between negative affectivity and social inhibition, rather than as a typology.

Type D personality is associated with maladaptive health-related behaviours

Type D personality (the combination of negative affect and social inhibition) is associated with poor prognosis in cardiac patients. The current study aims to investigate the relationship between Type D and health-related behaviours. In a cross-sectional study, 200 healthy participants completed measures of Type D personality, and health-related behaviours. The results showed that Type D individuals engaged in more unhealthy behaviours including smoking, poor diet and lack of physical activity than non-Type D individuals. The association between Type D personality and maladaptive health behaviours may represent one mechanism to explain the link between Type D and ill-health.

Validity of Type D personality in Iceland: association with disease severity and risk markers in cardiac patients

Type D personality has been associated with poor prognosis in cardiac patients. This study investigated the validity of the Type D construct in Iceland and its association with disease severity and health-related risk markers in cardiac patients. A sample of 1,452 cardiac patients completed the Type D scale (DS14), and a subgroup of 161 patients completed measurements for the five-factor model of personality, emotional control, anxiety, depression, stress and lifestyle factors. The Icelandic DS14 had good psychometric properties and its construct validity was confirmed. Prevalence of Type D was 26–29%, and assessment of Type D personality was not confounded by severity of underlying coronary artery disease. Regarding risk markers, Type D patients reported more psychopharmacological medication use and smoking, but frequency of previous mental problems was similar across groups. Type D is a valid personality construct in Iceland, and is associated with health-related risk markers, but not cardiac disease severity.

Thyroid Replacement Therapy and Heart Failure

Heart failure (HF) is a major public health and economic problem in Western countries and is one of the most common causes of hospitalization and death. Coronary artery disease is the underlying cause in more than two thirds of chronic HF patients. By 2020, the World Health Organization projects that ischemic heart disease alone will be the most important global cause of morbidity and mortality. The estimated increases in HF-related morbidity and mortality suggest that our understanding of the pathophysiological mechanisms of this syndrome is inadequate. Interest in the role of thyroid hormones (THs) in HF has increased in recent years. The driving considerations can be summarized as follows: (1) the known effects of THs on contractile and relaxation properties of the heart; (2) experimental findings offering strong support for the hypothesis that TH signaling is critical in preserving cardiac structure and performance under normal conditions and after cardiac injury; and (3) evidence that mildly altered TH function is strongly associated with a worsening prognosis in cardiac patients in general and in HF patients in particular. Diastolic function and systolic function are clearly influenced by THs.1 Ventricular contractile function is also influenced by changes in hemodynamic conditions secondary to TH effects on peripheral vascular tone.1 TH homeostasis preserves positive ventricular-arterial coupling, leading to a favorable balance for cardiac work. A study in rats demonstrated that chronic hypothyroidism alone can eventually lead to HF.2 Other studies suggest reduced cardiac tissue triiodothyronine (T3) levels after myocardial infarction (MI) or with development of hypertension by upregulating type 3 deiodinase (D3), which leads to deactivation of T3 and T4 (thyroxine).3–6 This review highlights a growing body of evidence from animal studies and small-scale clinical trials suggesting that low cellular thyroid activity at the cardiac tissue level may adversely affect HF …

The Mediterranean diet contributes to the preservation of left ventricular systolic function and to the long-term favorable prognosis of patients who have had an acute coronary event

The effect of the cardioprotective Mediterranean diet on the development of cardiac abnormalities and prognosis of cardiac patients has rarely been investigated. We sought to evaluate the relation between the Mediterranean diet, the development of left ventricular systolic dysfunction (LVSD) at hospitalization, and the 2-y prognosis of patients who have had an acute coronary syndrome (ACS). During 2006-2009, 1000 consecutive patients with ACS were enrolled; of these patients, 459 had LVSD (ejection fraction <40%) at hospitalization [367 men with a mean (+/-SD) age of 64 +/- 14 y, and 92 women aged 71 +/- 12 y], whereas 541 had preserved left ventricular systolic function (421 men aged 62 +/- 12 y, and 120 women aged 67 +/- 12 y). Adherence to the Mediterranean diet was assessed by the validated Mediterranean Diet Score (MedDietScore; theoretical range: 0-55). The MedDietScore was associated with less likelihood of developing LVSD at hospitalization [odds ratio (OR) per 1/55 unit: 0.93; 95% CI: 0.88, 0.99; P = 0.04], less likelihood of remodeling (ie, ejection fraction <50% at 3 mo follow-up; OR: 0.90; 95% CI: 0.78, 1.03: P = 0.06), and less likelihood of recurrent cardiovascular disease events during the 2 y of follow-up (OR: 0.88; 95% CI: 0.80, 0.98; P = 0.04), after adjustment for various confounders. Greater adherence to the Mediterranean diet seems to preserve left ventricular systolic function and is associated with better long-term prognosis of patients who have had an ACS.

The type-D scale (DS14) – Norms and prevalence of type-D personality in a population-based representative sample in Germany

The DS14 ( Denollet, 2005) is the most accepted and widely used diagnostic instrument for the assessment of the type-D pattern, which has been established as a predictor of adverse clinical events and cardiac prognosis in patients with heart disease. Despite an increasing number of applications of the DS14 in non-cardiac and healthy samples, psychometric properties of the DS14 item and subscale scores have not been tested explicitly for non-cardiac samples, and population-based norms have been missing until now. The present study aimed to analyse the psychometric properties of the item and subscale scores and the factorial structure of the DS14, as well as to examine prevalence rates and to provide population-based norms for the German general population from a population-based representative sample of 2495 subjects. The analyses document sound psychometric properties. A confirmatory factor analysis demonstrated the best fit for a two-factor structure. The prevalence of the type-D personality in the German population was 31%. In comparison, most studies report lower prevalence rates in cardiac patients. The present findings support the use of the DS14 to assess the traits of negative affectivity and social inhibition and to classify type-D personality in epidemiologic research and individual diagnostics as well.

Brief Depression Screening with the PHQ-2 Associated with Prognosis Following Percutaneous Coronary Intervention with Paclitaxel-Eluting Stenting

BACKGROUNDDepression is associated with adverse prognosis in cardiac patients, warranting the availability of brief and valid instruments to identify depressed patients in clinical practice.OBJECTIVESWe examined whether the two-item Patient Health Questionnaire (PHQ-2) was associated with adverse events in percutaneous coronary intervention (PCI) patients treated with paclitaxel-eluting stenting (using the continuous score and various cutoffs), overall and by gender.DESIGNProspective follow-up study.PARTICIPANTSConsecutive PCI patients (n = 796) seen at a university medical centre.MEASUREMENTSPHQ-2 at baseline. The study endpoint was an adverse event, defined as a combination of death or non-fatal myocardial infarction (MI) at follow-up (mean of 1.4 years).RESULTSAt follow-up, 47 patients had experienced an adverse event. Using the continuous score of the PHQ-2 and the recommended cutoff ≥3, depressive symptoms were not associated with adverse events (ps > 0.05). Using a cutoff ≥2, depressive symptoms were significantly associated with adverse events (HR: 1.89; 95% CI: 1.06–3.35) and remained significant in adjusted analysis (HR: 1.90; 95% CI: 1.05–3.44). Depressive symptoms were associated with an increased risk of adverse events in men (HR: 2.69; 95% CI: 1.36–5.32) but not in women (HR: 0.76; 95% CI: 0.24–2.43); these results remained in adjusted analysis.CONCLUSIONSDepression screening with a two-item scale and a cutoff score of ≥2 was independently associated with adverse events at follow-up. The PHQ-2 is a brief and valid measure that can easily be used post PCI to identify patients at risk for adverse health outcomes.

Combined approach with Doppler echocardiography and B-type natriuretic peptide to stratify prognosis of patients with decompensated systolic heart failure

Based on the importance of left ventricular (LV) diastolic function in stratification of the cardiac prognosis in patients with systolic heart failure (SHF), we attempted to identify the prognostic impact of Doppler echocardiographic examinations and plasma B-type natriuretic peptide (BNP) concentration. Of 73 patients admitted with decompensated SHF (ejection fraction <45%), 58 were included. Among these, 21 patients had ischemic heart disease and 27 non-ischemic dilated cardiomyopathy. In all patients, Doppler echocardiographic examinations and measurements of the plasma B-type natriuretic peptide concentration were simultaneously performed before discharge. Patients were followed up for 36 months after discharge. Primary end point for the follow-up was readmission for acute decompensated heart failure or cardiac death. During the mean follow-up period of 28±12 months, 16 patients (27.6%) were readmitted with decompensated heart failure. Based on the stepwise multivariate Cox regression analysis, mitral E/A ratio (chi-square=6.5, relative risk=1.7, p=0.01) and BNP (chi-square=3.9, relative risk=1.7, p=0.04) were identified as independent predictors of primary endpoints. Based on ROC analysis, the optimal cutoff point of E/A was 1.05 (AUC=0.836, p=0.002) and that of plasma BNP concentration was ≥254.5 pg/ml (AUC=0.768, p=0.002). In high-risk patients with E/A ≥1, event-free survival rates were significantly lower in patients with BNP <254.5 pg/ml (p<0.001). The complementary assessment of Doppler transmitral flow and plasma BNP concentration may be reliable in identifying the prognosis of patients with SHF.

P.2.g.005 Occurrence of sexual dysfunction during the maintenance treatment with newer antidepressants (naturalistic study)

The DS14 (Denollet, 2005) is the most accepted and widely used diagnostic instrument for the assessment of the type-D pattern, which has been established as a predictor of adverse clinical events and cardiac prognosis in patients with heart disease. Despite an increasing number of applications of the DS14 in non-cardiac and healthy samples, psychometric properties of the DS14 item and subscale scores have not been tested explicitly for non-cardiac samples, and population-based norms have been missing until now. The present study aimed to analyse the psychometric properties of the item and subscale scores and the factorial structure of the DS14, as well as to examine prevalence rates and to provide population-based norms for the German general population from a population-based representative sample of 2495 subjects. The analyses document sound psychometric properties. A confirmatory factor analysis demonstrated the best fit for a two-factor structure. The prevalence of the type-D personality in the German population was 31%. In comparison, most studies report lower prevalence rates in cardiac patients. The present findings support the use of the DS14 to assess the traits of negative affectivity and social inhibition and to classify type-D personality in epidemiologic research and individual diagnostics as well.

Safety and Efficacy of Sertraline for Depression in Patients with CHF (SADHART-CHF): A randomized, double-blind, placebo-controlled trial of sertraline for major depression with congestive heart failure

Sertraline, a selective serotonin-reuptake inhibitor, has demonstrated substantial mood improvement in patients with post myocardial infarction or with unstable angina. The impact of sertraline on the prognosis and depression of patients with chronic heart failure (HF) and comorbid major depressive disorder (MDD) is unknown. This is a prospective, randomized, double-blind, placebo-controlled study designed to assess the safety and efficacy of sertraline in the treatment of MDD in patients with HF. The study is designed also to examine the effects of treating depression on cardiac events and morbidity/mortality in patients with HF. Approximately 500 men and women who are >or=45 years of age with current MDD and chronic systolic HF, characterized by left ventricular ejection fraction <or=45% and New York Heart Association class >or=II, comprise the study population. Eligible participants are randomized to either sertraline or placebo for a 12-week acute treatment phase. All patients, regardless of acute treatment phase completion, are followed routinely until the last subject completes 6-month follow-up. Quality of life and certain physiologic parameters, as well as pro-inflammatory and HF biomarkers, that may reflect the impact of sertraline in this particular population are measured at baseline and at the end of the acute treatment phase. Because of the high prevalence of depression and its significant adverse impact on prognosis of patients with ischemic heart disease (IHD) and HF, the Safety and Efficacy of Sertraline for Depression in Patients with Chronic Heart Failure (SADHART-CHF) trial aims to assess the effects of sertraline on response of depression as well as on the cardiac prognosis of patients with HF.

Type-D personality mechanisms of effect: The role of health-related behavior and social support

ObjectiveTo (a) investigate the prevalence of type-D personality (the conjoint effects of negative affectivity and social inhibition) in a healthy British and Irish population; (b) to test the influence of type-D on health-related behavior, and (c) to determine if these relationships are explained by neuroticism. MethodsA cross-sectional design was employed; 1012 healthy young adults (225 males, 787 females, mean age 20.5 years) from the United Kingdom and Ireland completed measures of type-D personality, health behaviors, social support, and neuroticism. ResultsThe prevalence of type-D was found to be 38.5%, significantly higher than that reported in other European countries. In addition, type-D individuals reported performing significantly fewer health-related behaviors and lower levels of social support than non-type-D individuals. These relationships remained significant after controlling for neuroticism. ConclusionThese findings provide new evidence on type-D and suggest a role for health-related behavior in explaining the link between type-D and poor clinical prognosis in cardiac patients.

Angiographically silent left main disease detected by intravascular ultrasound: a marker for future adverse cardiac events

Background Concomitant moderate obstructive left main (LM) disease is associated with future cardiac events and poor prognosis in patients undergoing percutaneous intervention (PCI). Whether prognosis is similarly effected by LM disease not detected by angiography, but evident on intravascular ultrasound (IVUS) imaging, is not known. The purpose of this study was to evaluate the long-term prognosis of patients with angiographically insignificant LM coronary artery disease undergoing PCI. Methods and results One hundred and seven consecutive patients undergoing PCI with angiographically normal or mild LM disease had 2- and 3-dimensional IVUS imaging. IVUS images were digitized, and 3-dimensional reconstruction was performed. Percent diameter and area stenosis by angiography were 4.8% ± 3.5% and 18.2% ± 9.8%, respectively. IVUS mean luminal area and area stenosis were 17.9 ± 5.6 mm 2 and 30.2% ± 14.7%, respectively. Long-term follow-up was available in 102 (95%) patients at a median of 29 (range 8–52) months. Major adverse cardiac events, defined as death (6), myocardial infarction (4), repeat PCI (13), or CABG (16), were associated with female sex ( P = .04), diabetes ( P = .02), angiographic minimum lumen diameter ( P = .04), and IVUS minimum ( P = .01) and mean ( P = .01) lumen area. Multivariate predictors of late cardiac events were diabetes (hazard ratio 2.69, P = .014) and minimum lumen area by IVUS (hazard ratio 0.59, P = .015). Conclusions Despite being angiographically silent, LM disease detected by IVUS is an independent predictor of cardiac events and may serve as a marker for such events. These data extend the spectrum of LM disease severity and its relationship to cardiac prognosis in patients undergoing PCI.