Increase In Major Adverse Cardiac Events Research Articles

Left Atrial Passive Emptying Function During Dobutamine Stress MR Imaging Is a Predictor of Cardiac Events in Patients With Suspected Myocardial Ischemia

The aim of this study was to determine the prognostic value of assessing left atrial function during dobutamine stress testing. Left ventricular diastolic dysfunction precedes systolic wall motion abnormalities in the ischemic cascade. Severity of left ventricular diastolic function during cardiac stress is not characterized well by current clinical imaging protocols but may be an important prognostic factor. We hypothesized that abnormal early left atrial emptying measured during dobutamine stress cardiac magnetic resonance will reflect these diastolic changes and may be associated with cardiovascular outcomes. We enrolled 122 consecutive patients referred for dobutamine stress cardiac magnetic resonance for suspected myocardial ischemia. Left atrial volumes were retrospectively measured by the biplane area-length method at left ventricular end-systole (VOL(max)) and before atrial contraction (VOL(bac)). Left atrial passive emptying fraction defined by (VOL(max) - VOL(bac)) × 100%/VOL(max) and the absolute percent increase in left atrial passive emptying fraction during dobutamine stress (ΔLAPEF) were quantified. Twenty-nine major adverse cardiac events (MACE) occurred during follow-up (median 23 months). By Kaplan-Meier analysis, patients with ΔLAPEF <10.8 (median) experienced higher incidence of MACE than did patients with a ΔLAPEF >10.8 (p = 0.004). By univariable analysis, ΔLAPEF was strongly associated with MACE (unadjusted hazard ratio for every 10% decrease = 1.56, p < 0.005). By multivariable analysis, every 10% decrease in ΔLAPEF carried a 57% increase in MACE, after adjustment to presence of myocardial ischemia and infarction. Reduced augmentation of left atrial passive emptying fraction during dobutamine stress demonstrated strong association with MACE. We speculate that reduced left atrial passive emptying reserve during inotropic stress may represent underlying diastolic dysfunction and warrants further investigation.

A History of Prior Bare Metal Stent Restenosis Is Associated with Major Adverse Cardiac Events in Subsequent Bare Metal Stenting of de novo Coronary Lesions

Objective: To investigate the risk of major adverse cardiac events (MACE) in patients with a history of bare metal stent (BMS) restenosis who undergo subsequent bare metal stenting of a geographically distinct, de novo coronary lesion. Methods: We conducted a retrospective review of 72 BMS procedures performed in geographically distinct, de novo coronary lesions in patients with a history of previous BMS placement at least 3 months prior to the second, index stent procedure. Patients with a history of in-stent restenosis (ISR) were compared with those who had no ISR in their initial stent. Results: Restenosis in the initial BMS was associated with a significant increase in MACE after placement of the index BMS (OR 20.0, 95% CI 3.86–103.58, p < 0.0001). This association was independent of traditional clinical and angiographic risk factors for restenosis. Conclusions: Restenosis of a previously placed BMS is strongly associated with MACE after placement of a subsequent BMS in a de novo coronary lesion.

Detecting Unrecognized Myocardial Infarction: The Importance of Imaging

Prior studies have suggested that approximately half of all myocardial infarctions (MIs) are unrecognized and only diagnosed by Q waves on electrocardiogram (ECG) [1]. However, ECG is relatively insensitive for small MI or non-Q-wave MI. Late gadolinium-enhanced cardiac magnetic resonance imaging (CMR) quantifies scar or MI size as validated against histopathology in animal models of MI [2]. It correlates highly with levels of biomarkers in humans post-MI [3]. This technique is presently the most sensitive cardiac imaging technique available for sizing MI. It has been shown to be more sensitive than nuclear approaches, especially for smaller, non-Q-wave infarctions [4]. A recent study demonstrated the prognostic significance of identifying late gadolinium enhancement (LGE) as a marker of infarct scar in patients suspected of having underlying coronary artery disease (CAD) [5]. In this study, more than 20% of patients studied with suspected CAD but no known MI had LGE on CMR. LGE showed the strongest unadjusted association with major adverse cardiac events (MACE) and cardiac mortality, above ejection fraction, left ventricular (LV) end-diastolic and end-systolic index, segmental wall motion abnormality, noninvasive assessment of ischemia, and angiographic stenosis. A threshold effect was observed in which even very small scars (< 2% of LV mass) were associated with a more than sevenfold increase in MACE. This study suggested that any scar as demonstrated by LGE by CMR carries prognostic significance.

Correlates of Adverse Events During Saphenous Vein Graft Intervention With Distal Embolic Protection: A PRIDE Substudy

We sought to identify correlates of 30-day adverse events among patients undergoing percutaneous coronary intervention (PCI) of saphenous vein grafts (SVG). Although the use of distal embolic protection devices during SVG intervention reduces major adverse cardiac events (MACE), many patients still experience MACE despite distal embolic protection, and the major predictors of MACE among these patients are not well-characterized. Correlates of 30-day MACE and peri-procedural creatine kinase-myocardial band (CK-MB) elevation were assessed among 631 patients undergoing SVG intervention with distal embolic protection enrolled in the PRIDE (PRotection during saphenous vein graft Intervention to prevent Distal Embolization) study, a randomized comparison of the TriActiv System (Kensey-Nash Corp., Exton, Pennsylvania) with an active control group (Guardwire [Medtronic, Santa Clara, California] or Filterwire [Boston Scientific, Minneapolis, Minnesota]). Baseline covariates associated with MACE were longer lesion length, greater angiographically assessed estimated plaque volume, and higher SVG degeneration score. Graft age and angina class were not associated with adverse events. Angiographic lesion length was significantly correlated with more complex angiographic metrics such as estimated plaque volume and the SVG degeneration score. In multivariable analyses, angiographic lesion length was the strongest independent correlate of MACE (odds ratio [OR] 2.81 [95% confidence interval (CI) 1.82 to 4.34]/log-increase in lesion length, p < 0.001) with a graded increase in MACE observed with increasing lesion lengths. Similarly, the strongest independent correlate of CK-MB elevation was lesion length (OR 2.54 [95% CI 1.59 to 4.04]/log-increase in lesion length, p < 0.001). The associations between lesion length and both MACE and CK-MB elevation were consistent among the studied embolic protection devices (TriActiv, Guardwire, or Filterwire). Angiographic lesion length was the strongest correlate of short-term adverse events among patients undergoing SVG intervention with distal embolic protection, with incremental effects noted at even relatively short lesion lengths.

Minimally invasive direct coronary artery bypass versus percutaneous coronary stenting for stenosis of the left anterior descending artery

We read with great interest a meta-analysis by Jaffery et al. [1] of randomized control trials (RCTs) comparing minimally invasive direct coronary artery bypass (MIDCAB) versus percutaneous coronary stenting (PCS) for stenosis of the proximal left anterior descending artery (LAD). Between PCS and MIDCAB, there was no difference in major adverse cardiac events (MACE), i.e. the composite end point of mortality, myocardial infarction, and target vessel revascularization: relative risk (RR) (95% confidence interval [CI]), 1.81 (0.80, 4.06). Excluding a trial with drug eluting stents (DES) by Hong et al. (reference number of the article by Jaffery et al. [1] [R-No] 22), however, resulted in a significantly higher risk of PCS in comparison to MIDCAB for MACE: RR (95% CI), 2.27 (1.32, 3.90). By searching Medline, etc. from January 1990 to January 2006, Jaffery et al. [1] finally identified five eligible RCTs by Cisowski et al. (published in 2002) (R-No 20), Drenth et al. (2002) (R-No 21), Thiele et al. (R-No 24), Hong et al. (R-No 22), and Reeves et al. (R-No 23). Cisowski et al. [2] and Drenth et al. [3], however, updated the results of their RCTs (R-No 20, 21). Furthermore, our comprehensive search identified another RCT by Kim et al. [4]. Therefore, we performed a meta-analysis of currently available RCTs by Cisowski et al. [2], Drenth et al. [3], Thiele et al. (R-No 24), Hong et al. (R-No 22), and Reeves et al. (R-No 23), and Kim et al. [4]. Three and two of the six individual trials demonstrated a statistically significant and nonsignificant benefit of MIDCAB over PCS for MACE: RR (95% CI), 4.00 (1.20, 13.32) [2]; 2.80 [1.09, 7.20] [3]; 1.76 (1.21, 2.55) (R-No 24); 2.00 (0.38, 10.43) (R-No 23); and 3.00 [0.86, 10.43] [4]. Merely one trial demonstrated a statistically nonsignificant MACE reduction with PCS (using DES) over MIDCAB: RR (95% CI), 0.46 (0.18, 1.17) (R-No 22). Pooled analysis of all the six trials demonstrated a statistically significant 83% increase in MACE with PCS relative to MIDCAB in a random-effect model: RR (95% CI), 1.83 (1.02, 3.26). There was significant trial heterogeneity of results by standard x tests ( p = 0.0459) but no evidence of significant publication bias by an adjusted rank-correlation test ( p = 0.5730). In conclusion, ourmeta-analysis of currently available RCTs showed that PCS was fraught with significantly increased risk of MACE in comparison to MIDCAB even including the trial with DES. References