Independent Predictors Of Events Research Articles

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.

A METHODOLOGICAL APPROACH TO IMPROVE REPRODUCIBILITY OF BRACHIAL FLOW MEDIATED DILATION: PP.6.228

Introduction: Brachial artery flow-mediated dilation (FMD) is the most widely used technique for assessing endothelial function. FMD is reduced in the presence of cardiovascular risk factors and diseases and it is an independent predictor of events. However, its major limitation is the relatively low reproducibility. One of the main challenges is to maintain a stable scan plane during examinations, especially when the forearm cuff is inflated/deflated. The aim of this study was to evaluate FMD reproducibility when resting diameter is calculated as the mean value obtained before (standard approach) or after cuff deflation. Methods: Thirty healthy subjects (age 25–45 years) underwent two FMD examinations 30 minutes apart. FMD was induced by 5 minutes forearm ischemia (by a paediatric cuff inflation) and assessed using a clamp to hold the ultrasound probe in the same position throughout the examination (15 minutes). Diameter was measured by a real-time automatic edge-detection system (FMD Studio, Institute of Clinical Physiology, Pisa, Italy). FMD was calculated as maximum percentage increase above resting diameter, which was considered the mean values obtained during 1 minute respectively before cuff inflation (D_PRE) or 9 minutes after cuff deflation (D_POST). FMD variability was assessed as intra-session coefficients of variation (CV). Results: In all subjects D-POST was measured 9 minutes after cuff deflation. Brachial artery diameter did not significantly differ (p = 0.22) when measured as D_PRE (3.56 ± 0.66 mm) and D_POST (3.57 ± 0.66 mm). FMD was 7.4 ± 3.8% when calculated with D_PRE and 7.1 ± 3.7% with D_POST (p = 0.85). The two FMD measurements were high correlated (r = 0.92; p < 0.0001). CV of FMD was 15.6 ± 10.9% according to D_PRE and 9.2 ± 5.9% with D_POST calculation. Conclusions: These results suggest that changes in brachial artery imaging caused by cuff inflation/deflation might be responsible for the higher FMD variability observed with the standard calculation with D_PRE diameter. Despite FMD calculation with D_POST requires a longer time (approximately 5 minutes) to perform the examinations, this approach could ensure a more reproducible measure of conduit artery endothelial function.

Is the E/V p index useful for evaluating prognosis in chronic heart failure with atrial fibrillation? A pilot study.

The ratio of transmitral peak E wave velocity to color flow propagation velocity (E/V p index) has proved to be a significant predictor of prognosis in cardiac diseases with sinus rhythm. However, its usefulness in patients with atrial fibrillation (AF) and heart failure has not yet been established. The aim of this study was to determine the feasibility of using the E/V p index for the prediction of mortality and heart failure hospitalization in this group. We studied 66 ambulatory patients with stable congestive heart failure (CHF) functional class I-III and AF. Patients were divided into group A and B according to an E/V p index <1.5 and ≥1.5, respectively. During follow-up (average 430days) events were more common in group B (75 vs. 17%, log rank test; hazard ratio (HR) =6.8). By means of multivariate logistic regression analysis, E/V p proved to be an independent predictor of events (p=0.0012). In our patients with stable CHF and AF the E/V p index is a significant predictor of clinical outcome.

162 Role of Exercise Stress Echocardiography to Predict Outcome in Asymptomatic Patients with Aortic Valve Stenosis: a Multicenter Prospective Study

Abnormal exercise test defined as the occurrence of exercise limiting symptoms, fall in blood pressure below baseline, or complex ventricular arrhythmias is useful to predict clinical events in asymptomatic patients with aortic stenosis (AS). Whether exercise stress echocardiography (ESE) provides incremental prognostic information beyond that obtained from standard exercise testing remains uncertain. This study aimed at determine if ESE adds any incremental predictive value to resting echocardiography in the subset of patients who have a normal exercise response. In this multicenter prospective study, 186 asymptomatic patients with at least moderate AS and preserved LV ejection fraction (LVEF≥50%) were assessed by Doppler-echocardiography at rest and during a maximum ramp semi-supine bicycle exercise test. Fifty one (27%) patients had an abnormal exercise test and were excluded from the present analysis. Among the 135 patients with normal exercise test, 65 had an event (aortic valve replacement or cardiovascular death) at a mean follow-up of 13±11 months. The independent predictors of events were: LV hypertrophy (hazard ratio [HR] = 2.49; 95% confidence interval [CI]: 1.46-4.31; P = 0.0008), resting mean gradient > 35 mmHg (HR = 3.39; 95%CI: 2.00-5.93; P <0.0001) and exercise-induced increase in mean gradient > 20 mmHg (HR = 2.35; 95%CI: 1.29-4.17; P = 0.005). The latter factor also remained an independent predictor (HR = 2.39; 95%CI: 1.28-4.35; P = 0.007) of events in the subset of patients with severe AS. The exercise-induced increase in transvalvular gradient may be helpful to improve risk stratification in asymptomatic AS patients with normal exercise response. These results thus suggest that ESE provides additional prognostic information over that obtained from standard exercise testing and resting echocardiography.

005 Prognostic value of high sensibility C reactive protein after acute coronary syndrome

Inflammation plays an important role in the initiation and progression of atherosclerosis and in the pathogenesis of acute cardiovascular (CV) events. Recent studies focused on the measurement of high sensitivity C-reactive protein (hsCRP) as predictors of CV events. hsCRP has been reported to have prognostic value immediately after ACS and to be associated with CV risk in patients with stable and unstable angina pectoris. To evaluate the association of hsCRP levels with recurrent cardiovascular events in a large prospective study of stable post-ACS patients. Patients with an ACS were enrolled in our department between 2002 and 2007. HsCRP was measured at three month after the ACS together with a global evaluation of atherosclerosis burden and risk factors. Optimal medical treatment, a therapeutic and dietary education program was started during the acute phase and adjusted at 3 months. 1202 patients with hsCRP < 15 mg/l were included and the first 795 patients were followed for an average of 22 months. 94% and 75% of the patients received a combination of b–blocker, anti- aggregates and cholesterol-lowering drugs respectively at 3 and 22 months. LDL-cholesterol, HbA1c, waist circumference, systolic blood pressure, metabolic syndrome, tobacco consumption, and atherosclerosis burden were higher in the 2nd and 3th tertile of hsCRP (p<0.001), at 3 months. hsCRP was associated with recurrence of total CV events (12,0%) (HR 1.34, CI 1.02-1.75) but was not an independent predictor of events after adjustment to traditional CV risk factors (HR 1.19, CI 0.91-1.56). hsCRP did not significantly improve the c-statistics of the Framingham risk evaluation. Hs CRP is associated with cardiovascular risk factors, but is not an independent predictor of totals events in post-ACS patients receiving optimized secondary prevention.

Baseline and 6-month B-type natriuretic peptide changes are independent predictors of events in patients with advanced heart failure awaiting cardiac transplantation

To assess the prognostic role of B-type natriuretic peptide (BNP) measured at baseline and after 6 months in advanced heart failure patients, candidates for heart transplantation. Ninety-nine patients with BNP evaluation (mean age 50.8 years, 85% men) were admitted in the heart transplantation waiting list; 39% were in New York Heart Association functional class IV; with hemodynamic patterns of severe heart failure, the cause was ischemic in 45% and idiopathic in 44%. In order to identify more severe patients, BNP values and changes at 6 months were dichotomized according to their upper tertile (>1100 and >or=70 pg/ml, respectively). Median baseline BNP was 719 pg/ml. After a median of 45 months, 40 events were observed (three cardiac assist device implants, 16 urgent heart transplantations, 13 sudden deaths and eight deaths from heart failure). The event rate was 10.0 and 32.3 per 100 person-years in patients with low and high BNP, respectively. In a bivariable Cox regression, BNP at entry in the list and change in BNP at 6 months were independent predictors of events, with hazard ratios of 4.10 (95% confidence interval 2.14-7.88, P<0.001) and 4.55 (95% confidence interval 2.36-8.80, P<0.001), respectively. Furthermore, the risk increased from neither BNP/BNP change, to one of them and to both of them present. Both high baseline and further increase in BNP levels during midterm follow-up are strong predictors of events in patients with advanced heart failure awaiting heart transplantation.

Small, dense low‐density lipoproteins (LDL) are predictors of cardio‐ and cerebro‐vascular events in subjects with the metabolic syndrome

Small, dense low-density lipoproteins (LDL) are a feature of the metabolic syndrome (MS) but their predictive role still remains to be established. We performed a 2-year follow-up study in 124 subjects with MS (63 +/- 6 years), as defined by the American Heart Association/National Heart, Lung and Blood Institute guidelines, to assess clinical and biochemical predictors of cerebro- and cardio-vascular events. Beyond traditional cardiovascular risk factors, we measured LDL size and subclasses by gradient gel electrophoresis. Clinical events were registered in the 25% of subjects. At univariate analysis subjects with events had increased prevalence of elevated fasting glucose (P = 0.0117), smoking (P = 0.0015), family history of coronary artery disease (P = 0.0033) and higher levels of total- and LDL-cholesterol (P = 0.0027 and P = 0.0023, respectively); LDL size was lower (P < 0.0001), due to reduced larger subclasses and increased small, dense LDL (all P < 0.0001). At multivariate analysis the following were independent predictors of events (univariate odd ratios were calculated): low HDL-cholesterol (OR 15.4, P = 0.0238), elevated fasting glucose (OR 12.1, P = 0.0102), elevated small, dense LDL (OR 11.7, P = 0.0004), elevated blood pressure (OR 9.2, P = 0.0392), smoking (OR 4.8, P = 0.0054). This is the first study that assessed the predictive role of small, dense LDL beyond traditional cardiovascular risk factors in subjects with MS.

The predictive role of atherogenic dyslipidemia in subjects with non-coronary atherosclerosis

Background Recent findings have suggested that subjects with non-coronary atherosclerosis may show elevated prevalence of atherogenic dyslipidemia, including higher triglyceride levels, reduced HDL-cholesterol concentrations and increased levels of small, dense low-density lipoproteins (LDL). These three lipid abnormalities constitute the so-called “atherogenic-lipoprotein-phenotype” (ALP) but its predictive role in these patients still remains to be established. Methods We performed a 2-year follow-up study to assess clinical and biochemical predictors of cardiovascular events in 44 male patients (64 ± 5 years, BMI: 27 ± 3), 26 with peripheral arterial disease and 18 with abdominal aortic aneurysm. Beyond traditional cardiovascular risk factors, we measured LDL size and subclasses by gradient gel electrophoresis. Results Clinical events were registered in the 43% of patients. At univariate analysis we found that patients with events had increased prevalence of hypertension ( p = .0098), diabetes ( p = .0089), family history of cardiovascular diseases ( p = .0089), of elevated small, dense LDL ( p = .0222) and ALP ( p = .0224). At multivariate analysis (including all clinical and laboratory variables) we found the following independent predictors of events: hypertension (OR 8.9, p = .0347), diabetes (OR 9.4, p = .0270), elevated small, dense LDL (OR 6.9, p = .0488) and ALP (OR 8.7, p = .0497). Conclusions This is the first study that evaluated the predictive role of ALP beyond traditional cardiovascular risk factors in patients with peripheral arterial disease or abdominal aortic aneurysm. We confirmed that hypertension and diabetes are strong predictors of cardiovascular events in these subjects but ALP seems to be an independent predictor too. Yet, the therapeutical consequences of these findings need to be tested by future studies.

Clinical Assessment and Rest and Stress Echocardiography for Prediction of Long‐Term Prognosis in African Americans with Known or Suspected Coronary Artery Disease

There is limited information on noninvasive risk stratification of African Americans, a high-risk group for cardiovascular events. We investigated the value of clinical assessment and echocardiography for the prediction of a long-term prognosis in African Americans. Dobutamine echocardiography was performed in 324 African Americans. Two-dimensional measurements were performed at rest, and rest and stress wall motion was assessed. A retrospective follow-up was conducted for cardiac events: myocardial infarction (MI) or cardiac death (CD). The mean age was 59 +/- 12 years, and 83% of patients had hypertension. The follow-up was obtained in 318 (98%) patients for a mean of 5.3 years. The events occurred in 107 (33%) subjects. The independent predictors of events were history of MI (P = 0.001, risk ratio [RR] 2.04), ischemia (P = 0.007, RR 1.97), fractional shortening (P = 0.033, RR 0.08), and left atrial (LA) dimension (P = 0.034, RR 1.39). An LA size of 3.6 cm and a fractional shortening of 0.30 were the best cutoff values for the prediction of events. Prior MI, ischemia, LA size >3.6 cm, and fractional shortening <0.30 were each considered independent risk predictors for events. The event rates were 13%, 21%, 38%, 59%, and 57% in patients with 0, 1, 2, 3, and 4 risk predictors, respectively. Event-free survival progressively worsened with an increasing number of predictors: 0 or 1 versus 2 predictors, P < 0.001; 2 versus 3 or 4 predictors, P = 0.003. The long-term prognosis of African Americans can be accurately predicted by clinical assessment combined with rest and stress echocardiography.

The role of dysfunctional HDL in atherosclerosis

This review focuses on HDL function in modulating LDL oxidation and LDL-induced inflammation. Dysfunctional HDL has been identified in animal models and humans with chronic inflammatory diseases including atherosclerosis. The loss of antiinflammatory function correlated with a loss of function in reverse cholesterol transport. In animal models and perhaps in humans, dysfunctional HDL can be improved by apoA-I mimetic peptides that bind oxidized lipids with high affinity.

Prognostic Value of Multislice Computed Tomography and Gated Single-Photon Emission Computed Tomography in Patients With Suspected Coronary Artery Disease

This study was designed to determine whether multislice computed tomography (MSCT) coronary angiography has incremental prognostic value over single-photon emission computed tomography myocardial perfusion imaging (MPI) in patients with suspected coronary artery disease (CAD). Although MSCT is used for the detection of CAD in addition to MPI, its incremental prognostic value is unclear. In 541 patients (59% male, age 59 +/- 11 years) referred for further cardiac evaluation, both MSCT and MPI were performed. The following events were recorded: all-cause death, nonfatal infarction, and unstable angina requiring revascularization. In the 517 (96%) patients with an interpretable MSCT, significant CAD (MSCT > or =50% stenosis) was detected in 158 (31%) patients, and abnormal perfusion (summed stress score [SSS]: > or =4) was observed in 168 (33%) patients. During follow-up (median 672 days; 25th, 75th percentile: 420, 896), an event occurred in 23 (5.2%) patients. After correction for baseline characteristics in a multivariate model, MSCT emerged as an independent predictor of events with an incremental prognostic value to MPI. The annualized hard event rate (all-cause mortality and nonfatal infarction) in patients with none or mild CAD (MSCT <50% stenosis) was 1.8% versus 4.8% in patients with significant CAD (MSCT > or =50% stenosis). A normal MPI (SSS <4) and abnormal MPI (SSS > or =4) were associated with an annualized hard event rate of 1.1% and 3.8%, respectively. Both MSCT and MPI were synergistic, and combined use resulted in significantly improved prediction (log-rank test p value <0.005). MSCT is an independent predictor of events and provides incremental prognostic value to MPI. Combined anatomical and functional assessment may allow improved risk stratification.

Persistent Impairment of Endothelial Vasomotor Function Has a Negative Impact on Outcome in Patients With Coronary Artery Disease

We assessed the hypothesis that changes in endothelial vasomotor function in response to optimized therapy for atherosclerotic coronary artery disease predict future cardiovascular events. Although endothelial vasomotor dysfunction is a predictor of cardiovascular events, it remains unclear whether reversibility of endothelial dysfunction in response to risk factor reduction provides prognostic information. This study included 251 patients with newly diagnosed coronary artery disease and an impaired flow-mediated dilation (FMD) of the brachial artery (FMD <5.5%). Measurement of FMD was repeated after 6 months for individualized and optimized therapy to reduce risk factors according to American College of Cardiology/American Heart Association guidelines. Patients were followed up for 36 months or until 1 of the following events occurred: cardiac death, nonfatal myocardial infarction, recurrent and refractory angina pectoris requiring coronary revascularization, or ischemic stroke. FMD was persistently impaired (<5.5%) in 104 (41%) patients after 6 months of optimized therapy, whereas it improved (FMD > or =5.5%) in the remaining 147 (59%) patients. During 36 months of follow-up, events occurred in 27 (26%) patients with persistently impaired FMD and in 15 (10%) patients with improved FMD (p < 0.01 by chi-square test). Multivariate Cox hazards analysis showed that persistent impairment of FMD was an independent predictor of events (hazard ratio: 2.9, 95% confidence interval: 1.5 to 6.2, p < 0.01). Baseline FMD before the optimized therapy to reduce risk factor had no significant prognostic information. Persistent impairment of endothelial vasomotor function despite optimized therapy to reduce risk factors has an adverse impact on outcome in coronary artery disease patients.

Incremental value of renal function in risk prediction with the Seattle Heart Failure Model

Impaired renal function portends poor heart failure (HF) outcomes. The Seattle Heart Failure Score (SHFS), a multimarker risk assessment tool, however does not incorporate renal function. In this study, we assessed the incremental value of renal function over the SHFS in patients with advanced HF on contemporary optimal treatment. Blood urea nitrogen (BUN), serum creatinine (sCr), BUN/sCr ratio, and estimated glomerular filtration rate were assessed in survival models with SHFS as the base model among 443 patients with HF (52 +/- 12 years, male 68.5%, white 52.4%, ejection fraction 0.18 +/- 0.08). Incremental value of renal function was assessed by changes in the likelihood ratio chi(2) and the area under the receiver operating characteristic curves for 1-, 2-, and 3-year event prediction. During a median follow-up of 21 months, 108 (24.5%) of 443 patients had an event (death [n = 92], urgent transplantation [n = 13], or ventricular assist device implantation [n = 3]). All renal parameters individually were associated with outcome (BUN, P < .001; sCr, P < .001; BUN/sCr ratio, P = .006; and estimated glomerular filtration rate, P = .006); however, only BUN was an independent predictor of events in multivariable analyses. Addition of BUN improved the predictive ability of SHFS (Deltalikelihood ratio chi(2) 5.03, P = .025); however, the increase in the area under the receiver operating characteristic curve was marginal (year 1, 0.786 to 0.791; year 2, 0.732 to 0.741; year 3, 0.745 to 0.754; all P > .2). Among the various renal function parameters, BUN had the strongest association with outcomes in patients with advanced HF. However, the incremental value of renal function over the SHFS for risk determination was marginal.

Elevated Serum C-Reactive Protein Levels Predict Cardiovascular Events in the Japanese Coronary Artery Disease (JCAD) Study

Accumulating evidence indicates that C-reactive protein (CRP) is an independent predictive factor for atherosclerotic vascular disease in Caucasians. Accordingly, this study sought to investigate the relationship between the serum level of CRP and cardiovascular events of Japanese patients with coronary artery disease (CAD). The Japanese CAD (JCAD) study enrolled 15,628 patients who had significant diameter stenosis (>or=75%) in at least 1 coronary artery. Of these, 6,802 patients had their baseline serum CRP data available. Patients were followed up for a mean of 2.7 years (follow-up rate 88.3%). The primary endpoint of the JCAD study was all events. Baseline covariates possibly influencing the event rate were adjusted between the 2 groups with and without elevated serum CRP level. Kaplan-Meier analysis demonstrated a 30% higher all-events rate in patients with a serum level of CRP >or=0.1 mg/dl (P=0.0002). Cox proportional hazard analysis also showed that a serum level of CRP >or=0.1 mg/dl was an independent predictor of all events (P=0.0001), and of cardiac events and cardiac death (P=0.0005). Elevated serum level of CRP is an independent predictor of cardiovascular events in JCAD patients.

Abstract 5733: Coronary Flow Reserve obtained by Transthoracic Echocardiography in Patients with Normal Coronary Arteries and Systolic Dysfunction, Normal Function and Coronary Artery Disease and Normal Function and Normal Coronary Arteries

Coronary Flow Reserve (CFR) has already been shown a reliable marker of physiological significance of coronary artery disease (CAD) and has recently been demonstrated to be an independent predictor of events in patients with dilated cardiomyopathy (DCM). Objective: To determine CFR in patients (pts) with DCM without obstructive CAD and in pts with normal systolic function and with obstructive CAD. Methods: We prospectively studied 67 pts with normal systolic function (mean age 46+/− 12 years, 48% male, left ventricular ejection fraction (EF) &gt;65%) and 47 pts with DCM (mean age 59 +/− 11 years, 52% male, EF&lt;35%) who underwent coronary angiography within 6 months from stress echocardiography. Diastolic velocity flow in the mid left anterior descending coronary artery was obtained by transthoracic echocardiography with use of intravenous commercially available contrast agent (Definity, Bristol-Myers Squibb) at baseline and during adenosine infusion (140 mcg/Kg/min, for 6 minutes). CFR was determined as the ratio of peak diastolic velocity in hyperemic/baseline conditions. All pts underwent quantitative coronary angiography (QCA). Results: Feasibility for assessing CFR was 83% in pts with normal function and 91% in DCM. Among the 56 pts in the final study with normal function, 25 had significant CAD and 31 had normal coronary arteries. Peak diastolic velocities in each group are described in Table . CFR was 2.86+/−0.58 ín pts with normal function and no CAD, 1.57+/−0.32 in pts with normal function and CAD, and 2.14+/−0.49 in pts with DCM and no CAD (p&lt;0.01 between groups). Sensitivity, specificity and accuracy for detecting CAD in pts with normal function was 96%, 94% and 95%, respectively. However, when considering the group with DCM, sensitivity was 74%, specificity 66% and accuracy 69%. Conclusions: CFR can accurately detect pts with CAD when systolic function is normal. Pts with DCM have diminished CFR that lowers the predictive value of this parameter to detect CAD.

Prognostic Value of Dobutamine Stress Echocardiography With Early Injection of Atropine With Versus Without Chronic Beta-Blocker Therapy in Patients With Known or Suspected Coronary Heart Disease

Although a new protocol of dobutamine stress echocardiography with the early injection of atropine (EA-DSE) has been demonstrated to be useful in reducing adverse effects and increasing the number of effective tests and to have similar accuracy for detecting coronary artery disease (CAD) compared with conventional protocols, no data exist regarding its ability to predict long-term events. The aim of this study was to determine the prognostic value of EA-DSE and the effects of the long-term use of beta blockers on it. A retrospective evaluation of 844 patients who underwent EA-DSE for known or suspected CAD was performed; 309 (37%) were receiving beta blockers. During a median follow-up period of 24 months, 102 events (12%) occurred. On univariate analysis, predictors of events were the ejection fraction (p <0.001), male gender (p <0.001), previous myocardial infarction (p <0.001), angiotensin-converting enzyme inhibitor therapy (p = 0.021), calcium channel blocker therapy (p = 0.034), and abnormal results on EA-DSE (p <0.001). On multivariate analysis, the independent predictors of events were male gender (relative risk [RR] 1.78, 95% confidence interval [CI] 1.13 to 2.81, p = 0.013) and abnormal results on EA-DSE (RR 4.45, 95% CI 2.84 to 7.01, p <0.0001). Normal results on EA-DSE with beta blockers were associated with a nonsignificant higher incidence of events than normal results on EA-DSE without beta blockers (RR 1.29, 95% CI 0.58 to 2.87, p = 0.54). Abnormal results on EA-DSE with beta blockers had an RR of 4.97 (95% CI 2.79 to 8.87, p <0.001) compared with normal results, while abnormal results on EA-DSE without beta blockers had an RR of 5.96 (95% CI 3.41 to 10.44, p <0.001) for events, with no difference between groups (p = 0.36). In conclusion, the detection of fixed or inducible wall motion abnormalities during EA-DSE was an independent predictor of long-term events in patients with known or suspected CAD. The prognostic value of EA-DSE was not affected by the long-term use of beta blockers.

HDL-cholesterol level provides additional prognosis in acute coronary syndromes

In the setting of acute coronary syndromes, plasma lipids have not been defined as prognostic variables, however little research has been dedicated to this specific issue. In order to test the independent predictive value for in-hospital events of low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol and triglycerides measured at hospital admission, 97 individuals with unstable angina or non-ST-elevation acute myocardial infarction were evaluated. In-hospital events, defined as death, non-fatal myocardial infarction or recurrent unstable angina, were significantly predicted by HDL-cholesterol (C-statistics = 0.69; 95% CI = 0.55–0.83, P = 0.018), contrary to LDL-cholesterol (C-statistics = 0.40; 95% CI = 0.24–0.56, P = 0.23) and triglycerides (C-statistics = 0.48; 95% CI = 0.31–0.65, P = 0.83). The best HDL-cholesterol cut-off point was 32 mg/dl, with a 33% incidence of events in patients with HDL-cholesterol ≤ 32 mg/dl, compared with only 9% in those with HDL-cholesterol > 32 mg/dl ( P = 0.003). Logistic regression analysis showed HDL-cholesterol ≤ 32 mg/dl (OR = 3.6; 95% CI = 1.0–14; P = 0.05) and TIMI Risk Score (OR = 2.3; 95% CI = 1.4–2.9, P = 0.001) as the independent predictors of events. Furthermore, the addition of HDL-cholesterol to TIMI Risk Score improved its C-statistic from 0.81 to 0.85. In conclusion, as opposed to LDL-cholesterol and triglycerides, HDL-cholesterol level adds prognostic value to the prediction of in-hospital recurrent events during non-ST-elevation acute coronary syndromes.

Stress cardiac single-photon emission computed tomographic imaging late after coronary artery bypass surgery for risk stratification and estimation of time to cardiac events

We assessed predictors and temporal characteristics of cardiac risk in patients undergoing stress single-photon emission computed tomography after coronary artery bypass grafting. Stress cardiac tomography was performed in 362 patients 5 years after coronary artery bypass grafting. Cardiac death and myocardial infarction were considered as events. Cox proportional hazards analysis was used to identify predictors of events and parametric survival analysis to predict time to events. During a median follow-up of 27 months, 22 cardiac events occurred (6.1% cumulative event rate). At multivariable Cox analysis, ischemia at cardiac tomography (hazards ratio 3.7, 95% confidence interval 1.5-9.1; P = .004), and diabetes (hazards ratio 3.6, 95% confidence interval 1.5-8.5; P = .006) resulted in independent predictors of events. Event-free survival was 96% in patients with normal cardiac tomography, 86% in those with abnormal tomography without ischemia, and 70% in those with (log-rank 10.6, P for trend = .008). The parametric survival model revealed that the cardiac risk was greater for all time intervals and accelerated more over time in patients with ischemia than in those without (chi(2) 21.4, P < .0001). Patients without diabetes and normal cardiac tomography remained below a defined risk level (5%) for the entire follow-up period. Stress cardiac tomography performed 5 years after coronary artery bypass grafting is useful to characterize the risk of cardiac events and its temporal variation. Parametric survival model estimates the predicted time to risk and the level of risk at specific time intervals after coronary artery bypass grafting.

Coronary calcium measurement improves prediction of cardiovascular events in asymptomatic patients with type 2 diabetes: the PREDICT study

The PREDICT Study is a prospective cohort study designed to evaluate coronary artery calcification score (CACS) as a predictor of cardiovascular events in type 2 diabetes (T2DM). A total of 589 patients with no history of cardiovascular disease and with established T2DM had CACS measured, as well as risk factors, including plasma lipoprotein, apolipoprotein, homocysteine and C-reactive protein concentrations, homeostasis model assessment insulin resistance (HOMA-IR), and urine albumin creatinine ratio. Participants were followed for a median of 4 years and first coronary heart disease (CHD) and stroke events were identified as primary endpoints. There were 66 first cardiovascular events (including 10 strokes). CACS was a highly significant, independent predictor of events (P < 0.001), with a doubling in CACS being associated with a 32% increase in risk of events (29% after adjustment). Hazard ratios relative to CACS in the range 0-10 Agatston units (AU) were: CACS 11-100 AU, 5.4 (P = 0.02); 101-400 AU 10.5 (P = 0.001); 401-1000 AU, 11.9 (P = 0.001), and >1000 AU, 19.8 (P < 0.001). Only HOMA-IR predicted primary endpoints independently of CACS (P = 0.01). The areas under the receiver operator characteristic curve for United Kingdom Prospective Diabetes Study (UKPDS) risk engine primary endpoint risk and for UKPDS risk plus CACS were 0.63 and 0.73, respectively (P = 0.03). Measurement of CACS is a powerful predictor of cardiovascular events in asymptomatic patients with T2DM and can further enhance prediction provided by established risk models.

Reduced positive affect (anhedonia) predicts major clinical events following implantation of coronary‐artery stents

Emotional distress has been related to clinical events in patients with coronary artery disease, but the influence of positive affect (i.e. mood states such as activity, joy and cheerfulness) has received little attention. Therefore, we wanted to investigate the role of positive affect on clinical outcome after percutaneous coronary intervention (PCI) with stent implantation in these patients. Prospective follow-up study. At baseline, patients from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry completed measures of positive affect, depression and anxiety post-PCI. Patients with reduced positive affect scored 1 SD below the mean score. University Hospital; Thoraxcenter of the Department of Cardiology. 874 patients (72% men; 62.2 +/- 10.9 years) from the RESEARCH registry. Main outcome measure. Death or myocardial infarction (MI) 2 years post-PCI. At follow-up, there were 52 clinical events (deaths n = 27, MIs n = 25). Reduced positive affect and depression/anxiety were associated with poor prognosis, but reduced positive affect was the only independent predictor of events. The incidence of death/MI in adequate versus reduced positive affect patients was 4% (29/663) vs. 11% (23/211); HR = 2.55 (95% CI 1.46-4.34, P = 0.001), adjusting for clinical variables. Reduced positive affect and diabetes were independent prognostic factors, and patients with one (HR = 2.84, 95% CI 1.58-5.10) or both (HR = 5.61, 95% CI 2.25-13.99) of these factors had a higher risk when compared with nondiabetic patients with adequate positive affect, P < or = 0.003. Reduced positive affect independently predicted death/MI following stent implantation, and improved risk stratification above and beyond diabetes.