Hard Cardiac Events Research Articles

Prognostic value of combined magnetic resonance myocardial perfusion imaging and late gadolinium enhancement

Late gadolinium enhancement (LGE) and myocardial perfusion study by cardiac magnetic resonance (CMR) have a diagnostic and prognostic value in patients with suspected coronary artery disease (CAD). The purpose of this study was to determine the prognostic value of combined myocardial perfusion CMR and LGE in patients with known or suspected CAD. We studied patients with known or suspected CAD. All patients underwent CMR for functional study, myocardial perfusion and LGE. Myocardial ischemia by CMR was defined as a perfusion defect in patients without LGE or a perfusion defect beyond the LGE area. Patients were followed up for cardiovascular outcomes including hard cardiac events (cardiac death or non-fatal myocardial infarction) and major adverse cardiac events (MACE) which included cardiac death, non-fatal myocardial infarction, hospitalization for unstable angina, and heart failure. There were a total of 587 men and 645 women. Average age was 64.6 ± 11.1 years. LGE was detected in 326 patients (26.5%). Myocardial ischemia by CMR was detected in 423 patients (34.3%). Average follow-up duration was 34.9 ± 15.6 months. Univariate analysis showed that age, diabetes, use of beta blocker, left ventricular ejection fraction, left ventricular mass, wall motion abnormality, LGE, and myocardial ischemia are predictors for hard cardiac events and MACE. Multivariable analysis revealed that myocardial ischemia was the strongest predictor for hard cardiac events and MACE. Other independent predictors were age, use of beta blocker, and left ventricular mass. Myocardial ischemia by CMR has an incremental prognostic value for cardiac events in patients with known or suspected CAD.

Prognostic value of coronary computed tomographic angiography in patients with arterial hypertension

Patients with arterial hypertension have a high risk of developing coronary artery disease (CAD), but noninvasive diagnosis of CAD remains difficult. We assessed the ability of coronary CT angiography (CCTA) to detect CAD and to predict subsequent cardiac events in hypertensive patients. We compared 906 hypertensive patients without known CAD undergoing CCTA with 906 matched normotensive patients. Besides calcium score and the degree of the most severe stenosis, the number of coronary segments with atherosclerotic changes was recorded. The primary endpoint was the occurrence of hard cardiac events defined as all cause death, nonfatal myocardial infarction or unstable angina requiring hospitalization. During a median follow-up of 29 months, there were 17 hard cardiac events in the hypertensive group and 13 events in the control group. The best predictor of events in hypertensive patients was the degree of the most severe stenosis (C-index 0.705, P < 0.001, both corrected for clinical risk). The annual event rate was 0.3% for patients without obstructive CAD and 1.5% for patients with obstructive CAD. In hypertensive patients without known CAD, coronary CT angiography allows for the identification of patients at high risk for incident cardiac events.

Cardiometabolic Risk in Community-Dwelling Persons With Chronic Spinal Cord Injury

The purpose of this study was to describe cardiometabolic risk factors and risk clustering in people with spinal cord injury (SCI). This was a cross-sectional study of 121 subjects aged 18 to 73 years (mean, 37 ± 12 years) with chronic, motor complete SCI between C5 and T12. Assessments included demographic, social, and medical history; physical, anthropometric, and blood pressure assessments; fasting serum assays including total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), triglycerides, and hemoglobin A1c; calculated low-density lipoprotein cholesterol (LDL-C); and an oral glucose tolerance test. Framingham risk scores (FRSs) for each subject were calculated on the basis of Third National Cholesterol Education Program Adult Treatment Panel algorithm. According to FRSs, 90.1%, 8.3%, and 1.7% were classified in the low-, medium-, and high-risk groups, respectively. The most prevalent cardiometabolic risk factors were overweight/obesity (74%), elevated LDL-C (64%), low HDL-C (53%), elevated systolic blood pressure (SBP, 33%), and elevated TC (30%). Stratification by level of injury demonstrated significant differences between paraplegic and tetraplegic participants in SBP (120 vs 99 mm Hg, P = .0001), 2-hour glucose (101.37 vs 137.93 mg/dL, P = .0001), and 2-hour insulin (47.45 vs 94.36 μIU/mL, P = .024). In addition, triglycerides, fasting insulin, body mass index, LDL-C, hemoglobin A1c, and insulin resistance were significantly associated with FRS. Ten percent of young people with SCI are at moderate to high risk for long-term hard cardiac events. Overweight/obesity, LDL-C, HDL-C, SBP, and TC were the most prevalent risk factors. Carbohydrate metabolism is preferentially affected in persons suffering from tetraplegia, indicating a need for impairment-specific risk assessment.

Efficacy of Paclitaxel-Eluting Stent in Patients With Impaired Glucose Tolerance - Comparison With Sirolimus-Eluting Stent -

Experimental and clinical studies have shown that paclitaxel-eluting stent (PES) attenuates the effect of diabetes on re-stenosis after percutaneous coronary intervention. Although impaired glucose tolerance (IGT) is a pre-diabetic phase characterized as post-prandial hyperglycemia and hyperinsulinemia, the efficacy of PES in these pre-diabetic patients remains unknown. The purpose of the present study was therefore to compare the efficacy of PES in IGT patients with that of sirolimus-eluting stent (SES). A total of 370 IGT patients with coronary artery disease were examined (SES, n=229; PES, n=141). The incidence of major adverse cardiovascular events (MACE; all-cause death, non-fatal myocardial infarction or repeat revascularization) was compared between the 2 groups. The PES group had lower body mass index, total cholesterol and low-density lipoprotein cholesterol levels and higher prevalence of previous myocardial infarction than the SES group. The incidence of repeat revascularization in the PES group was similar to that in the SES group (22% vs. 19%, P=0.71). The incidence of hard cardiac events such as all-cause death and non-fatal myocardial infarction were also similar between the 2 groups. Finally, there were no significant differences in MACE between the SES and PES groups (23% vs. 21%, P=0.76). In patients with IGT, the efficacy of PES was similar to that of SES, and any advantage of PES over SES was not observed in these pre-diabetic patients.

Prognostic Value of a Nine-Minute Treadmill Test in Patients Undergoing Myocardial Perfusion Scintigraphy

Exercise capacity is an important predictor of risk in known or suspected coronary disease. A negative treadmill test to 9 minutes of the Bruce protocol is often used in the screening process for vocational licensing; myocardial perfusion scintigraphy is an alternative for those unable to exercise, with apparent incremental prognostic power above exercise testing alone. We compared exercise test and myocardial perfusion scintigraphic (MPS) findings and risk of hard cardiac events (median 4 years) in patients completing ≥ 9-minute treadmill exercise. Patients undergoing myocardial perfusion scintigraphy who completed a 9-minute Bruce protocol exercise were identified over a 2-year period. Follow-up was performed by telephone, with case-note review when necessary; this was 97% complete. Five hundred sixteen patients were identified (73% men, median age 53 year). One hundred eighty-one (35%) had known coronary disease. One hundred forty-nine (29%) had a "high-risk" exercise test result (limiting chest pain or ST-segment depression), and 69 (13%) had high-risk MPS findings (>10% myocardium ischemic or ejection fraction <40%). Of 367 patients with a reassuring exercise test result, 38 (10.4%) had high-risk MPS findings. Of 149 with a high-risk exercise test, 118 (79%) had reassuring MPS findings. At median follow-up of 49 months, there were 8 cardiac events (1.6%). Only 2 patients with high-risk exercise test results (1.4%) and 1 with high-risk MPS findings (1.5%) had an event. In conclusion, for patients able to manage a 9-minute Bruce protocol, presence/absence of symptoms or electrocardiographic changes is a poor predictor of MPS findings. Irrespective of test findings, however, subsequent cardiac risk is extremely low. Ability to complete a 9-minute Bruce protocol treadmill exercise may itself provide adequate prognostic reassurance for most purposes.

Cardiovascular determinants and prognostic significance of CC Chemokine Ligand-18 (CCL18/PARC) in patients with stable coronary artery disease

Chemokines are important mediators of angiogenesis, hematopoiesis and leucocyte trafficking. CC Chemokine Ligand-18 (CCL18)/ pulmonary and activation-regulated chemokine (PARC) is a circulating chemokine that plays a role in injury healing, physiological homing of mononuclear blood cells and inflammatory responses. CCL18/PARC is also expressed in atherosclerotic plaques. We prospectively evaluated CCL18/PARC levels and their cardiovascular and biological determinants in a large cohort of 285 patients with stable coronary heart disease who were subsequently followed for 3years for hard cardiac events. It was found that CCL18/PARC levels were associated with decreased cardiac function, decreased exercise capacity and increased inflammatory parameters including interleukin-6 (IL-6) and hs-CRP. More importantly high CCL18/PARC levels were an independent predictor of future cardiovascular events. Therefore, CCL18/PARC is a potential diagnostic and prognostic parameter in patients with stable coronary artery disease.

Independent and incremental value of stress echocardiography over clinical and stress electrocardiographic parameters for the prediction of hard cardiac events in new-onset suspected angina with no history of coronary artery disease

Recent data have shown that exercise electrocardiogram (ECG) has no incremental prognostic value over clinical and rest ECG parameters in chest pain patients without a history of coronary artery disease (CAD). The incremental prognostic value of stress echocardiography (SE) in this population is unknown. Accordingly, 547 consecutive patients (68 ± 4.9 years) with chest pain but no previous history of CAD, referred for SE (exercise and dobutamine), were identified. Patients were followed up for death and acute myocardial infarction (AMI). At a median follow-up period of 28 months, there were a total of 35 hard cardiac events (5 deaths and 30 non-fatal AMI). Among the prognostic clinical, resting/stress ECG, and SE data, univariate predictors were the Framingham risk score (P = 0.025), diabetes (P = 0.06), hypercholesterolaemia (P = 0.06), stress ECG ischaemia (P = 0.044), stress heart rate (P = 0.019), and SE-determined ischaemic burden (stress-rest wall thickening score index; P < 0.001). In a multivariate model, ischaemic burden was the only independent predictor of events (P < 0.001). SE also showed incremental prognostic value over and above clinical (Framingham's risk score) and stress ECG changes in a global χ(2) model. This was true also for patients undergoing only exercise SE (n = 347). SE provides both independent and incremental prognostic value for the prediction of hard cardiac events in chest pain patients without a previous history of CAD-over and above clinical, ECG, and stress ECG data.

Incremental Prognostic Value of Coronary CT Angiography in Patients With Suspected Coronary Artery Disease

Multidetector CT coronary angiography (MDCTCA) is capable of detecting coronary artery disease (CAD) with a high diagnostic accuracy. In particular, this technique is credited with having a negative predictive value close to 100%. However, data about the prognostic value of MDCTCA are currently lacking. We sought to determine the prognostic value of MDCTCA in patients with suspected but undocumented CAD and, in particular, the incremental prognostic value as compared with clinical risk and calcium scoring. A total of 441 patients (age, 59.7+/-11.6 years) with suspected CAD underwent MDCTCA to evaluate the presence and severity of the disease. Patients were followed up as to the occurrence of hard cardiac events (cardiac death, nonfatal myocardial infarction, and unstable angina requiring hospitalization). Coronary lesions were detected in 297 (67.3%) patients. During a mean follow-up of 31.9+/-14.8 months, 44 hard cardiac events occurred in 40 patients. CT calcium scoring showed a statistically significant incremental prognostic value as compared to a baseline clinical risk model (P=0.018), whereas MDCTCA provided an additional incremental prognostic value as compared with a baseline clinical risk model plus calcium scoring if considering both nonobstructive versus obstructive CAD (P=0.016) or, better, plaque composition (calcified versus noncalcified and/or mixed plaques, P=0.0001). During follow-up, an excellent prognosis was noted in patients with normal coronary arteries, with an annualized incidence rate of 0.88% if compared with those with mild CAD (3.89%) and with patients with significant coronary disease (8.09%). The presence of noncalcified or mixed plaques, regardless of lesion severity, was found to be the strongest predictor of events (P<0.0001) as a potential marker of plaque vulnerability. MDCTCA provides independent and incremental prognostic information as compared to baseline clinical risk factors and calcium scoring in patients with suspected CAD.

Stress imaging in patients with diabetes; routine practice?

Over the past years, echocardiography has been shown to play a crucial role in the accurate evaluation of left ventricular function particularly in patients suspected for ischemic heart disease [1–3]. The ability to rapidly perform bedside echocardiography with Echo-Doppler imaging places this modality in the heart of clinical research to understand cardiac function and to quantify various associated abnormalities [4–8]. Echocardiography has found a major niche in visualizing left ventricular function both at rest and during stress. Widespread use of dobutamine-echocardiography has contributed to more frequent recognition of wall motion disturbances due to coronary artery disease [9–11]. Its applicability in prognostic assessment of such patients has been repeatedly confirmed, particularly in diabetic subjects [12]. Coronary artery disease is the leading cause of morbidity and mortality in patients with diabetes mellitus. In fact, patients with diabetes have the same risk of myocardial infarction as do non-diabetic subjects with a history of infarction. Present data indicate a substantially elevated risk of cardiovascular disease even before a clinical diagnosis of type-2 diabetes has been made. Identifying patients with diabetes suspected for coronary artery disease who will benefit from medical and/or invasive intervention to prevent cardiovascular events is a challenge in both symptomatic and asymptomatic patients. The decision to evaluate patients with diabetes who are asymptomatic for coronary artery disease presents the greatest challenge; investigation will reveal 10–15% of these patients to have coronary artery disease. Current diagnostic tools include exercise tolerance testing [13–18], stress myocardial perfusion imaging [19–26], stress MRI [27–57], and stress echocardiography [12]. In the current issue of the International Journal of Cardiovascular Imaging, Innocenti et al. [58] studied 322 type-2 diabetic patients who underwent dobutamine-stress echocardiography for known or suspected coronary artery disease. Indications to dobutamine-stress echocardiography were evaluation of symptoms suggesting presence of coronary artery disease or assessment of known coronary artery disease. End-points of the study were all-cause mortality, cardiac death, and non-fatal myocardial infarction. During dobutamine-stress echocardiography, viability and inducible ischemia developed in 65 (20%) and 192 (60%) subjects, respectively. Severe ischemia (defined as an asynergic area including more than 40% of all segments combined with a rate pressure product <17000) appeared in 88 (27%) of patients. Presence of diabetic treatment or microvascular diabetic complications did not affect prognosis, while longer diabetes duration was associated with higher all-cause mortality at univariate analysis. At multivariate analysis, advanced age, decreased left ventricular ejection fraction, and peripheral vascular disease independently determined increased all-cause mortality. New hard cardiac events occurred more frequently in presence of peripheral vascular disease, viability and severe ischemia. The authors concluded that in diabetic patients with known or suspected coronary artery disease, presence of viability and severe ischemia during dobutamine-stress echocardiography are independently associated with a higher occurrence of hard cardiac events. The clinical variables showed a weak prognostic role, except for age and presence of peripheral vascular disease. These findings emphasize the role of stress echocardiography in patients with type-2 diabetes. It should, however, be realized, that the value of stress imaging in diabetic patients is dependent on the presence and nature of symptoms. In symptomatic patients, myocardial perfusion imaging provides similar diagnostic and prognostic accuracies as in patients without diabetes [59]. However, the utility of screening patients with type-2 diabetes for asymptomatic coronary artery disease remains controversial [60–62]. For instance, the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study [62] assessed whether routine screening for coronary artery disease identified patients with type-2 diabetes as being at high cardiac risk and whether it affects their cardiac outcomes. A total of 1123 participants with type-2 diabetes and no symptoms of coronary artery disease were randomly assigned to be screened with adenosine-stress radionuclide myocardial perfusion imaging or no screening. It was found that in patients with diabetes, the cardiac event rates were low and were not significantly reduced by screening for myocardial ischemia over almost 5 years. Therefore, findings from the DIAD study indicate that routine screening of asymptomatic patients with diabetes is not justified. Notwithstanding, the current study [58] shows that dobutamine-stress echocardiography has a major role in the evaluation of diabetic patients. In symptomatic diabetic patients with known or suspected coronary artery disease, advanced age and reduced left ventricular function are independent predictors of total mortality. Presence of viability and severe ischemia during dobutamine-stress echocardiography are independently associated with higher occurrence of new major cardiac events. Therefore, dobutamine-stress echocardiography is an important prognostic imaging modality in assessing cardiovascular risk in symptomatic diabetic patients.

Depression, anxiety, and platelet reactivity in patients with coronary heart disease

There is considerable epidemiological evidence supporting the association between chronic emotional stress and coronary heart disease (CHD). Emotional factors that have been linked to atherosclerosis and adverse cardiac events include primarily negative affective disorders such as depression, anxiety, anger, and hostility.1,2 It is now well established that depression is related not only to the incidence of CHD but also to the prognosis of patients with established disease. In a meta-analysis concerned with the role of depression in the development of coronary artery disease, Rugulies found that individuals with clinical depression have >2.5 times the risk of a myocardial infarction or coronary death as the general population.3 In patients with established coronary disease, not only is major depression a significant predictor of mortality following acute myocardial infarction, but the level of depressive symptoms has a dose–response relationship with cardiac mortality over several years of follow-up.4 The importance of other affective disorders in the development and progression of CHD is less well established. Large-scale prospective studies have demonstrated a significant link between anxiety and sudden cardiac death,5 but studies documenting an association between anxiety and the development of coronary artery disease have been inconclusive. In patients with known CHD, Suls and Bunde found a relatively weak association between anxiety and hard cardiac events.6 More recent studies, however, have demonstrated that anxiety is an independent predictor of major cardiac events in patients with stable coronary disease.7,8 Hostility and anger are felt to represent the potentially harmful aspects of Type A behaviour, and their relationships to CHD have therefore received considerable attention. While some studies have reported that hostility is an important risk factor for CHD,6 numerous studies have found no association between hostility and cardiovascular disease after adjusting for confounding factors.9 … *Corresponding author. Tel: +1 410 614 6258, Fax: +1 410 955 3478, Email: iwittste{at}jhmi.edu

Relation between prognosis and myocardial perfusion imaging from the difference of end-point criterion for exercise stress testing: A sub-analysis of the J-ACCESS study

The presence and severity of coronary artery disease may be underestimated in patients who do not reach significant end-points of stress testing during myocardial perfusion imaging. We examined how the effect of the level of exercise may affect the ability of the quantitative gated single-photon emission computed tomography (SPECT) imaging to predict the future cardiac events (cardiac death, non-fatal myocardial infarction and severe heart failure). Of the 4629 consecutively registered patients for J-ACCESS (Japanese-assessment of cardiac event and survival study by quantitative gated SPECT), 2821 patients who underwent the exercise test were selected, and divided into two groups, which reached a target heart rate (group; n=925) or not (n=1896). Leg fatigue was the most common reason for stopping the exercise test in non-reaching groups, we conducted a study comparing group with leg fatigue group (group II). During a 3-year follow-up period, total of 25 cardiac events (2.7%) occurred in group I and total of 73 events (3.9%) occurred in group II. The incidence of cardiac death was slightly but significantly higher in group II (P.04). A summed stress score (SSS) was able to separate the high-risk from low-risk patients in group II. The maximal heart rate was not an independent predictor for cardiac events. In Cox multivariate regression analysis, higher age (70 years), history of DM, EDV at rest and LVEF at rest were predictor of cardiac major events (cardiac death, myocardial infarction, heart failure), and higher age (70 years), ESV at rest were independent predictor of cardiac hard events (cardiac death, myocardial infarction) in group II. Exercise SPECT imaging provides the useful prognostic information in patients who do not reach a significant end-point due to the leg fatigue. In such patients, those with normal SSS score and normal resting ESV have also a most favorable prognosis.

Prognostic Value of Exercise Myocardial Scintigraphy in Patients with Coronary Chronic Total Occlusions

To evaluate the prognostic value of exercise myocardial scintigraphy in patients undergoing incomplete revascularization by means of percutaneous coronary intervention (PCI) with at least a residual chronic total occlusion (CTO) left untreated. Of 569 consecutive patients with multivessel disease undergoing myocardial scintigraphy after incomplete revascularization by PCI between March 1997 and December 2004, 126 (79% male, 64+/-10 years) with >or= 1 residual CTO fulfilled the eligibility criteria and entered in the study. Hard events defined as cardiac death and myocardial infarction, soft events defined as incidence of unstable angina and PCI procedures, and their composite were assessed at a median follow-up period of 44 months. Hard events were observed in six patients (4.8%). All of them had severely abnormal perfusion defects detected by myocardial scintigraphy. Soft events occurred in 0 (0%), 10 (7.9%), and 15 (11.9%) patients with normal, mildly abnormal, and severely abnormal perfusion, respectively. In the Kaplan-Meier analysis, the log-rank test was statistically significant across patients stratified by summed stress score either in terms of hard, soft and hard, or soft events. Univariate and multivariate Cox proportional-hazards showed an incremental significant information when the scintigraphic variables were added to clinical, angiographic, left ventricular ejection fraction, and Duke treadmill score, for prediction of the composite of hard and soft cardiac events (P < 0.006). Among patients with a residual CTO left untreated after PCI, myocardial perfusion imaging provides significant independent information concerning the subsequent risk of cardiac events.

Prognostic Value of Coronary Computed Tomographic Angiography in Diabetic Patients Without Known Coronary Artery Disease

OBJECTIVEDiabetic patients have a high prevalence of coronary artery disease (CAD), but timely diagnosis of CAD remains challenging. We assessed the ability of coronary computed tomography angiography (CCTA) to detect CAD in diabetic patients and to predict subsequent cardiac events.RESEARCH DESIGN AND METHODSWe analyzed 140 diabetic patients without known CAD undergoing CCTA; 1,782 patients without diabetes were used as a control group. Besides calcium scoring and the degree of the most severe stenosis, the atherosclerotic burden score counting the number of segments having either a nonstenotic plaque or a stenosis was recorded. The primary end point was a composite of hard cardiac events defined as all-cause death, nonfatal myocardial infarction, or unstable angina requiring hospitalization.RESULTSDuring a mean follow-up of 33 months, there were seven events in the diabetic group and 24 events in the control group. The best predictor in diabetic patients was the atherosclerotic burden score: the annual event rate ranged from 0.5% for patients with <5 lesions to 9.6% for patients with >9 lesions, resulting in a hazard ratio (HR) of 1.3 (95% CI 1.1–1.7) for each additional lesion (P = 0.005). For comparison, in nondiabetic patients the annual event rate ranged from 0.3 to 2.2%, respectively, resulting in an HR of 1.2 (95% CI 1.1–1.3, P < 0.001). The atherosclerotic burden score improved the prognostic value of conventional risk factors significantly (P < 0.001).CONCLUSIONSIn diabetic patients without known CAD, CCTA can identify a patient group at particularly high risk for subsequent hard cardiac events.

Clinical significance of ischemic electrocardiographic changes during stress myocardial perfusion imaging: sub-analysis of the J-ACCESS study

The cardiac event rate among the countries varies according to ethnicity. Some reports have identified that ischemic heart disease often occurs at a low incidence and is often milder in Japan compared to other countries. Therefore, the present study was designed to determine the clinical significance and prediction for cardiac events in patients who showed ischemic ECG changes during stress myocardial perfusion SPECT. Among 4,670 registered patients for Japanese-assessment of cardiac event and survival (J-ACCESS) study, patients with conduction abnormality on baseline were excluded and revascularization within 60 days of SPECT study were censored from the prognostic portion of analysis. Stress and rest myocardial perfusion SPECT imaging with (99m)Tc-tetrofosmin were performed and occurrence and nature of cardiac events were investigated at 1, 2 and 3 years after registration. Both PCI and CABG, as well as recurrent angina and non-severe heart failure were classified as soft events. Cardiac death, non-fatal MI and heart failure requiring hospitalization were classified as major cardiac events, and hard events comprised cardiac death and non-fatal MI. A total of 3,125 patients performed exercise (n = 2,383) or vasodilator (n = 742) stress MPI and significant ischemic ECG changes were obtained in 538 during exercise and 35 during vasodilator stress. Kaplan-Meier analysis revealed that the patients with both ischemic ECG changes and reversible perfusion defect on MPI had significantly higher incidence for major cardiac events, such as cardiac death, non-fatal MI and severe heart failure (P = 0.0038), and for cardiac hard events, such as cardiac death and non-fatal MI (P = 0.0028), in exercise stress. Interestingly, patients without reversible perfusion defect showed significantly fewer events despite presence of ischemic ECG changes. Ischemic ECG changes during exercise stress are well associated with higher incidence of cardiac events in patients demonstrated reversible perfusion defect on MPI.

Prognostic value of exercise echocardiography in patients with atrial fibrillation

Non-invasive imaging techniques for the detection of coronary artery disease (CAD) may have technical problems in patients with atrial fibrillation (AF). Although the prognostic value of exercise echocardiography (ExEcho) has been well established in several subgroups of patients, it has not yet been specifically evaluated in these patients. From a population of 8095 patients with known or suspected CAD referred for ExEcho, 419 had AF at the time of the tests. Ischaemia was defined as the development of new or worsening wall motion abnormalities with exercise. Endpoints were hard cardiac events (i.e. cardiac death or non-fatal myocardial infarction). Mean age was 68.4 +/- 8.5 years, and 256 patients (61.1%) were men. Ischaemia was detected in 92 patients (22%). Over a mean follow-up of 3.10 +/- 2.98 years, 59 hard cardiac events occurred. The 5-year hard cardiac event rate was 37.3% in patients with ischaemia, when compared with 14.5% in patients without ischaemia (P < 0.001). In multivariate analysis, ischaemia on ExEcho remained an independent predictor of hard cardiac events (hazard ratio 1.99, 95% confidence interval 1.06-3.74, P = 0.03), and also provided incremental value over clinical, resting echocardiographic and treadmill exercise data for the prediction of hard cardiac events (P = 0.04). ExEcho provides significant prognostic information for predicting hard cardiac events in patients with AF.

Prognostic value of dobutamine stress echocardiography in diabetic patients

CAD is the main cause of morbidity and mortality in diabetic patients; we need reliable clinical parameters to stratify cardiovascular risk in these patients. We thus assessed prognostic value of clinical parameters, rest and stress echocardiographic data in diabetic patients, with known or suspected CAD. We studied 322 type 2 diabetic patients, who underwent dobutamine stress echocardiography (DSE) for known or suspected CAD; for prognostic assessment, end-points were all-cause mortality and hard cardiac events (cardiac death and non fatal myocardial infarction). During DSE, viability and inducible ischemia developed in 65 (20%) and 192 (60%) subjects, respectively; a severe ischemia (an asynergic area including more than 40% of all segments combined with a rate pressure product < 17,000) appeared in 88 (27%). Presence of a diabetic treatment or microvascular diabetic complications didn't influence prognosis, while a longer diabetes duration was associated with a higher all-cause mortality at univariate analysis. At multivariate analysis, an advanced age (RR = 1.108, CI: 1.039-1.182, P = 0.002), a lower left ventricular ejection fraction (RR = 0.956, CI: 0.919-0.994, P = 0.025) and, tendentially, peripheral vascular disease (RR = 2.942, CI: 0.985-8.785, P = 0.053) independently determined an increased all-cause mortality. New hard cardiac events occurred more frequently in presence of peripheral vascular disease (RR = 2.975, CI: 1.339-6.608, P = 0.007), viability (RR = 3.427, CI: 1.400-8.390, P = 0.007) and severe ischemia (RR = 3.245, CI: 1.503-7.005, P = 0.003). In diabetic patients with known or suspected CAD, presence of viability and severe ischemia during DSE are independently associated with higher occurrence of hard cardiac events.

Fragmented QRS complex and late gadolinium enhancement characterization of unrecognized myocardial scar provided complementary prognosis of cardiac death in patients with suspected coronary artery disease

Introduction Fragmentation of the QRS complex (FQRS) on the resting electrocardiogram has been shown to be associated with post-infarct arrhythmogenesis and increased incidence of hard cardiac events. Late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR) imaging can detect subendocardial unrecognized myocardial infarction which has been shown to indicate high risk for cardiac death.

Long-term prognostic value of early poststress 99mTc-tetrofosmin lung uptake during exercise (SPECT) myocardial perfusion imaging

The aim of this study was to determine the long-term prognostic value of early poststress lung/heart ratio (LHR) of (99m)Tc-tetrofosmin radioactivity. We studied 276 patients (aged 62.2 + or - 8.9 years, 168 men) with stress/rest (99m)Tc-tetrofosmin myocardial gated-SPECT and coronary angiography. To evaluate myocardial ischaemia, we calculated the summed stress score, summed rest score and summed difference score indices. For the eLHR calculation, an anterior image was acquired, 4-6 min after radiotracer injection at stress (eLHR was defined as mean counts per pixel in the lung region of interest divided by the mean counts per pixel in the myocardial region of interest). Cardiovascular death and nonfatal myocardial infarction were considered as hard cardiac events, and late revascularization procedures as soft cardiac events. The Cox proportional hazards model in a stepwise method was used to determine the independent predictors for hard and soft cardiac events. During the follow-up period hard cardiac events occurred in 28 patients (10.1%) and soft cardiac events in 32 patients (11.6%). Implying multiple Cox regression analysis, eLHR was found to be a significant independent predictor for both soft and hard cardiac events. The hazard ratio (for a 0.1 unit increase) was 4.41 (95% CI 1.52-12.73, p=0.006) for soft cardiac events and 4.22 (95% CI 2.07-8.62, p<0.001) for hard cardiac events. The other significant prognostic factors were use of beta-blockers, the summed stress score and the use of nitrates for soft events, and exercise duration and the summed stress score for hard cardiac events. Early poststress (99m)Tc-tetrofosmin LHR has an independent and powerful value in predicting hard and soft cardiac events.

Comparison Between Myocardial Contrast Echocardiography and 99mTechnetium Sestamibi Single Photon Emission Computed Tomography Determined Myocardial Viability in Predicting Hard Cardiac Events Following Acute Myocardial Infarction

The extent of residual myocardial viability (MV) after acute myocardial infarction (AMI) is an important determinant of the outcome. Single photon emission computed tomography (SPECT) is widely used to assess MV after an AMI. However, myocardial contrast echocardiography (MCE), a relatively new technique for the assessment of MV, has better spatial and temporal resolution than SPECT. The present study evaluated whether MV determined by MCE is comparable to that determined using SPECT for the prediction of hard cardiac events after an AMI. Accordingly, 99 patients who had undergone simultaneous rest low-power MCE and nitrate-enhanced SPECT 7 days after an AMI were followed up for cardiac death and AMIs. Both MCE perfusion (1 = normal; 2 = reduced; and 3 = absent) and SPECT tracer uptake (0 = normal; 1 = mildly reduced; 2 = moderately reduced; 3 = severely reduced; and 4 = absent) were scored on a 16-segment left ventricular model. The contrast perfusion index and SPECT perfusion index were calculated by adding the respective scores in the 16 segments and dividing by 16. The contrast perfusion index and SPECT perfusion index were used as a measure of the residual MV on MCE and SPECT, respectively. Of the 99 patients recruited, 95 were available for the follow-up examination (follow-up 46 +/- 16 months). A total of 15 events (16%) occurred (8 cardiac deaths and 7 AMIs). Of the clinical, biochemical, echocardiographic, and SPECT markers of prognosis, the only independent predictors of cardiac death and cardiac death or AMI were age and MV as determined by MCE (p = 0.01 and p = 0.002, respectively). In conclusion, MV determined by MCE at rest was superior to nitrate-enhanced SPECT for the prediction of hard cardiac events after AMI.

Cardiovascular events in Japanese asymptomatic patients with type 2 diabetes: a 1-year interim report of a J-ACCESS 2 investigation using myocardial perfusion imaging

Diabetic patients have a high risk for cardiovascular events. The role of myocardial perfusion imaging was investigated in asymptomatic diabetic patients to evaluate short-term prognosis in a Japanese population. A total of 506 asymptomatic patients ≥ 50 years of age who had carotid artery maximum intima-media thickness ≥ 1.1 mm, urinary albumin excretion of ≥ 30 mg/g creatinine, with additional criteria of abdominal obesity, low HDL cholesterol, high triglyceride level, and hypertension were enrolled and followed up over a 3-year period. Gated SPECT with stress-rest protocol was performed and analyzed by summed defect scores and QGS software. One-year cardiovascular events were analyzed. Myocardial ischemia was observed in 17% of patients, and abnormal perfusion findings of ischemia and/or scar were observed in 32% of patients. By the end of the 1-year follow-up, 33 (6.5%) cardiovascular events occurred including 6 all-cause deaths. Patients with summed stress score (SSS) >8 had a higher incidence of either death or cardiovascular events. Event-free survival rates for SSS 0-3, 4-8, 9-13, and ≥ 14 were 0.96, 0.95, 0.82, and 0.76, respectively. Multivariate Cox regression analysis showed that significant variables were SSS, history of cerebrovascular accident, and electrocardiographic abnormality at rest. The 1-year interim summary showed that cardiovascular events were significantly higher in patients with SPECT abnormality, although hard cardiac event rate was relatively low. Targeted treatment strategy is required for asymptomatic but potentially high-risk diabetic patients.