Known History Of Coronary Artery Disease Research Articles

Prevalence and Implications of Subclinical Coronary Artery Disease in Patients With Atrial Fibrillation

The objective of this study was to examine prevalence and clinical implications of subclinical coronary artery disease (CAD) detected by coronary artery calcium score (CACS) testing in patients with atrial fibrillation (AF). CACS was assessed in patients without history of CAD undergoing catheter ablation of AF. Age- and gender-matched patients with normal sinus rhythm (NSR) presenting with chest pain served as controls. Predicted arterial age using the Multi-Ethnic Study of Atherosclerosis registry was also compared to the chronologic age. A total of 860 patients (430 AF and 430 NSR, age 63 ± 10years, 65% men) were included. Subclinical CAD prevalence (CACS >0) was 74% (319 of 430) in the AF group. Compared to the patients with NSR, patients with AF had higher prevalence of Subclinical CAD (74% vs 63%; p <0.001). In multivariate analysis, AF was independently associated with Subclinical CAD (hazard ratio 1.60; p= 0.002) but only with persistent AF (hazard ratio 2.28; p <0.001). Predicted arterial age was greater than chronologic age in patients with AF (69 ± 12 vs 64 ± 9years). CACS-diagnosed subclinical CAD identified new potential candidates for statin therapy (12%; 33 of 267) and for oral anticoagulation (19%; 40 of 206) by addition of subclinical CAD to the CHA2DS2-VASc scores. In conclusion, in patients without known history of CAD, prevalence of subclinical CAD was significantly higher in those with persistent AF than those with NSR. AF was associated with subclinical CAD independently and complimentarily to clinical risk factors. Identifying subclinical CAD has potential clinical indications for prevention of CAD progression and stroke.

Abstract 491: Detection of Subclinical Coronary Artery Disease by Calcium Score in Patients With Atrial Fibrillation: Potential Clinical Implications

Background: Clinical implications of detecting subclinical coronary artery disease (CAD) in patients with atrial fibrillation (AF) are unclear. Methods: A total of 430 AF patients (age 63 ± 10 y, 65% male, 62% hypertensive, 16% diabetic, 42% dyslipidemic) without known CAD undergoing pre-procedural CT for catheter ablation were included. We evaluated the change in: 1) numbers of patients with CACS-diagnosed CAD who could potentially be on statin. 2) CHA2DS2-VASc score after incorporating CACS&gt;100 (related to increased risk of stroke) into the original definition of vascular diseases who could potentially be on anticoagulants. Results: 1) Prevalence of subclinical CAD (CACS&gt;0) was 74% (319/430) and 25% (106/430) had CACS&gt;100. There were 62% (267/430) who were not on statin. Of these patients, 71% (190/267) had subclinical CAD while 21% (34/163) of statin users had CACS of 0. 2) The median original CHA2DS2-VASc score was 2. After incorporating CACS&gt;100 into the original score, 24% (18/75) with the original score of 0 had the score changed to 1 (7/35 in persistent AF [PST-AF] and 11/40 in paroxysmal AF [PRX-AF]) (figure A) and 17% (22/131) with the original score of 1 had the score changed to ≥ 2 (10/83 in PST-AF and 12/48 in PRX-AF) (figure B). PRX-AF had more frequent increase in CHA2DS2-VASc score than PST-AF (p=0.035)(figure C). Conclusion: In AF patients without known history of CAD, detecting subclinical CAD by CACS potentially has important therapeutic implications for prevention forprogression of CAD and stroke.

Additive Prognostic Value of Coronary Artery Calcium Score Over Coronary Computed Tomographic Angiography Stenosis Assessment in Symptomatic Patients Without Known Coronary Artery Disease

The objective of this study was to examine the additive prognostic performance of coronary artery calcium score (CACS) over coronary computed tomography angiography (CCTA) stenosis assessment in symptomatic patients suspected for coronary artery disease (CAD) undergoing CCTA. A total of 805 symptomatic patients without known history of CAD who underwent coronary evaluation by multidetector cardiac CT were analyzed. Mean age of the cohort was 58 ± 13 years. A total of 44% (354 of 805) of the patients had a 0 CACS, 27% (215 of 805) had CACS 1 to 100, 14% (111 of 805) had CACS 101 to 400, and 15% (125 of 805) had CACS >400. CCTA showed normal coronary arteries in 43% (349 of 805) of patients, ≤50% stenosis in 42% (333 of 805), and >50% stenosis in 15% (123 of 805). Patients were followed for 2.3 ± 0.9 years. Major adverse cardiac event (MACE) was defined as cardiac death, nonfatal myocardial infarction, and late coronary revascularization. Overall incidence of MACE was 1.4% per year. Both CACS and CCTA stenosis were independently associated with increased MACE (p <0.05 for both). Addition of CACS into the model with clinical risk factors and CCTA stenosis significantly improved predictive performance for MACE from the model with clinical risk factors and CCTA stenosis only (global chi-square score 108 vs 70; p = 0.019). In conclusion; in symptomatic patients without known CAD, both CACS and CCTA stenosis were independently associated with increased cardiac events, and performing non-contrast-enhanced CACS evaluation in addition to contrast-enhanced CCTA improved predictive ability for future cardiac events compared to CCTA stenosis assessment alone.

Abstract 448: Association of CHADS2 and CHA2DS2-VASc Score with Coronary Atherosclerosis Burden in Nonvalvular Atrial Fibrillation

Background: This study is to examine association of CHADS2 and CHA2DS2-VASc score with coronary artery disease (CAD) in nonvalvular atrial fibrillation (AF) Method: A total of 676 consecutive nonvalvular AF patients without known history of CAD underwent coronary artery calcium score (CACS) evaluation by multi-detector cardiac computed tomography. Clinical characteristics and CACS were compared between different CHADS2 and CHA2DS2-VASc score groups. Results: The cohort comprised of 68% (461 of 676) male with a mean ± SD age of 63 ± 10 years. Median 10-year risk of CAD by Framingham score was 11% (range 2%-53%). Median CHADS2 score was 1 (range 0-6) and median CHA2DS2-VASc score was 2 (range 0-8). Mean ± SD CACS was 215 ± 504. Compared to CHADS2 score ≤ 1, those with CHADS2 score &gt; 1 had higher mean ± SD CACS (359 ± 738 VS 158 ± 359; p&lt;0.001). CHADS2 score &gt; 1 is associated with CACS &gt; 0 (OR 1.751; 95%CI 1.168, 2.624; p 0.007) and CACS &gt; 400 (OR 2.528; 95%CI 1.641, 3.896; p &lt; 0.001). Similarly, compared to CHA2DS2-VASc score ≤ 1, those with CHA2DS2-VASc score &gt; 1 had higher mean ± SD CACS (270 ± 586 VS 150 ± 376; p&lt;0.001). CHA2DS2-VASc score &gt; 1 is associated with CACS &gt; 0 (OR 1.713; 95%CI 1.217, 2.409; p 0.002) and CACS &gt; 400 (OR 2.683; 95%CI 1.678, 4.289; p &lt; 0.001). Receiver operating characteristics of CHADS2 and CHA2DS2-VASc score models for CACS &gt; 400 is shown in the figure. Conclusion: In nonvalvular AF patients, higher CHADS2 and CHA2DS2-VASc score are comparably associated with presence and severity of CAD.

Abstract 449: Increased Risk of Coronary Artery Disease in Patients with Persistent Type of Nonvalvular Atrial Fibrillation

Background: This study is to examine relationship between coronary artery disease (CAD) and types of atrial fibrillation (AF) Methods: A total of 403 nonvalvular atrial fibrillation patients without known history of CAD underwent coronary artery calcium score (CACS) evaluation by multi-detector cardiac computed tomography. Clinical characteristics and CACS were compared between patients with persistent type of AF and paroxysmal type of AF. Results: The cohort comprised of 65% (279 of 430) male with a mean (SD) age of 63(10) years. Prevalence of persistent AF was 60% (259 of 430). Mean (SD) 10-year risk of CAD by Framingham score was 14(7)%. Median CACS was 22 (range 0-5402) with 75% CACS&gt;0 (321 of 430). Compared to paroxysmal type, those with persistent type had higher prevalence of CAC&gt;0 as shown in Figure1 and more history of hypertension (p&lt;0.001) but less history of smoking (p0.004), statins use (p0.018) and warfarin use (p&lt;0.001). There was no statistically significant difference in mean age (p0.783) and CAD risk by Framingham score (p0.477) between two groups. In multivariate analysis, persistent type is an independent predictor for CACS&gt;0 (OR 1.938; 95%CI 1.197, 3.138; p0.007). Conclusion: In patients with AF, persistent type of AF is independently associated with CACS&gt;0. Our findings suggest potential benefit from evaluation of CAD in this population.

Myocardial oxygenation is reduced in end-stage renal failure: a novel blood oxygen level dependant (BOLD)-cardiac MRI study

Background Cardiovascular disease is the leading cause of mortality and morbidity in end-stage renal failure (ESRF) population, mostly from coronary artery disease (CAD). Majority of CAD in ESRF patients is asymptomatic and current cardiac stress imaging modalities are sub-optimal as risk predictors. Advances in cardiovascular magnetic resonance (CMR) with the novel blood oxygen level-dependent (BOLD) technique provides unprecedented capability to assess regional myocardial deoxygenation. We hypothesized that myocardial oxygenation would be reduced in ESRF patients and may form a novel strategy to assess myocardial ischemia. Methods Sixteen chronic renal failure (CRF) patients (7 on dialysis, 9 pre-dialysis) with no known history of CAD underwent CMR scanning at 3.0 T. Given known reductions in BOLD signals in hypertrophied myocardium, we also assessed a control group of HT patients with no history of CAD (n = 6) Myocardial function, rest and stress BOLD was performed. To measure oxygenation, using a T2-prepared BOLD sequence, myocardial Signal Intensity (SI) was measured at adenosine stress (140 μg/ kg/min) and at rest (corrected to RR interval). Comparison of myocardial SI analyses were performed using multivariate linear regression. Results

Stress echocardiography has superior accuracy and is more cost effective for predicting coronary artery disease in patients with suspected angina compared to exercise ECG

Purpose: Exercise ECG (ExECG) is widely used to assess patients with suspected coronary artery disease (CAD). However stress echocardiography (SE) is a well-established alternative technique for the assessment of these patients. We hypothesised that SE, due to its greater accuracy and feasibility, may be superior to ExECG, in terms of positive predictive value and cost effectiveness, when used as the initial test for the assessment of patients with no previous history of CAD presenting with suspected stable angina. Methods: Patients referred with recent onset chest pain during 2011, with no known history of CAD and with a pre-test likelihood of CAD greater than 10%, who underwent first line ExECG or SE were identified. The tests were classified as positive, negative or inconclusive for ischaemia. Coronary angiography (CA) was performed, with the knowledge of the functional test results, as indicated clinically. CAD was defined as the presence of >50% stenosis in at least one major epicardial vessel on CA. Cost to diagnosis of CAD was determined for each functional test by adding the initial cost, of the test to the cost of subsequent tests leading to and including CA. Follow up data on hard events, cardiac death and acute myocardial infarction (AMI), were collected on all patients for a period up to one year after the presentation of the last study patient. Results: We identified 457 patients who underwent ExECG (225 (49%) negative, 94 (21%) positive, 138 (30%) inconclusive) and 257 who underwent SE (213 (83%) negative, 38 (15%) positive, 6 (2%) inconclusive) as first line. The mean pre-test probability of CAD was 43±26% vs 51±28% respectively. Of 74 patients referred for CA on the basis of ExECG, CAD was present in 35 (47%) which was significantly (p=0.04) lower than in the SE group which predicted CAD in 28 out of 42 patients referred for CA (67%). The mean cost to diagnosis was £460 for the ExECG versus £385 for the SE group (p=0.02). No cardiac deaths were found in either group. There was no difference in event rate, (p=0.8 by log rank test) of AMI in patients who were discharged on the basis of a negative ExECG (4 (2%)) versus those with a negative SE (4 (2%)) over a period of 18±6 months. Conclusions: In a population with intermediate pre-test probability of CAD, SE was more accurate and more cost effective for predicting the presence of CAD compared to ExECG. This study suggests that SE rather than ExECG should be the initial test for the assessment of suspected stable angina in this population.

Feasibility of coronary artery wall thickening assessment in asymptomatic coronary artery disease using phase-sensitive dual-inversion recovery MRI at 3 T

ObjectivesThe purpose of this study was to (a) investigate the image quality of phase-sensitive dual-inversion recovery (PS-DIR) coronary wall imaging in healthy subjects and in subjects with known coronary artery disease (CAD) and to (b) investigate the utilization of PS-DIR at 3T in the assessment of coronary artery thickening in subjects with asymptomatic but variable degrees of CAD. Materials and MethodsA total of 37 subjects participated in this institutional review board-approved and HIPAA-compliant study. These included 21 subjects with known CAD as identified on multidetector computed tomography angiography (MDCT). Sixteen healthy subjects without known history of CAD were included. All subjects were scanned using free-breathing PS-DIR magnetic resonance imaging (MRI) for the assessment of coronary wall thickness at 3T. Lumen–tissue contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR) and quantitative vessel parameters including lumen area and wall thickness were measured. Statistical analyses were performed. ResultsPS-DIR was successfully completed in 76% of patients and in 88% of the healthy subjects. Phase-sensitive signed-magnitude reconstruction, compared to modulus-magnitude images, significantly improved lumen–tissue CNR in healthy subjects (26.73±11.95 vs. 14.65±9.57, P<.001) and in patients (21.45±7.61 vs. 16.65±5.85, P<.001). There was no difference in image CNR and SNR between groups. In arterial segments free of plaques, coronary wall was thicker in patients in comparison to healthy subjects (1.74±0.27mm vs. 1.17±0.14mm, P<.001), without a change in lumen area (4.51±2.42mm2 vs. 5.71±3.11mm2, P=.25). ConclusionsThis is the first study to demonstrate the feasibility of successfully obtaining vessel wall images at 3T using PS-DIR in asymptomatic patients with known variable degrees of CAD as detected by MDCT. This was achieved with a fixed subject-invariant planning of blood signal nulling. With that limitation alleviated, PS-DIR coronary wall MRI is capable of detecting arterial thickening and positive arterial remodeling at 3T in asymptomatic CAD.

Spasme coronaire et échographie de stress à la dobutamine : prévalence, profil clinique et échocardiographique et aspects évolutifs

ObjectivesTo assess the prevalence of coronary artery spasm during dobutamine stress chocardiography (DSE), to describe clinical and echocardiographic characteristics and prognosis. Patients and methodsWe evaluated all the patients with known or suspected coronary artery disease (CAD) referred to our echocardiography laboratory for dobutamine stress test between January 2004 and June 2012, (10013 exams). Those with abnormal DSE underwent coronary angiograms with a systematic methylergometrine intracoronary injection in case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients who had spontaneous occlusive coronary spasm or positive methylergometrine test but no significant stenoses were included. ResultsOne thousand and four patients had abnormal DSE, 78 (7.7%) fulfilled the inclusion criteria. There were 57 males and 21 females, mean age was 57.9 years, 37 patients had a known history of CAD. Twenty-four patients had a spasm on the left anterior artery (31%), 37 on the right coronary artery (47%) and 17 on the circumflex (22%). There was a good correlation between spastic arteries and dobutamine induced wall motion abnormalities territories. No complications occurred during the exams or during the provocation test. After 46 months mean follow up; one case of myocardial infarction with normal coronary arteries was noted and six patients experienced recurrent angina responding to treatment intensification. ConclusionCoronary artery spasm during DSE but is a rare and under-diagnosed finding; it has, though, to be recognized as it may partly explain some erroneously labelled “false positive” exams. Methylergometrine provocation test should be performed in such a situation to establish the diagnosis. Prognosis appears favourable.

Abstract P107: Diagnostic Accuracy of Coronary Artery Stenosis With 64-Multidetector Row Coronary Computed Tomographic Angiography in Veteran Patients Presenting With Chest Pain

Background: The ACCURACY trial was a prospective multicenter study using 64-multidetector row coronary computed tomographic angiography (CCTA) to evaluate its diagnostic performance for the detection and exclusion of coronary artery stenosis in patients presenting with chest pain without known coronary artery disease (CAD). We evaluated patients at a Veterans Administration Hospital (VAH) to assess if CCTA possesses high diagnostic accuracy for detection of obstructive CAD at both thresholds of 50% and 70% stenosis compared to invasive coronary angiography (ICA). Methods: We conducted a retrospective study of 44 patients at a VAH from November 2008 to November 2009. Baseline demographics are noted in Table 1 . Inclusion criteria were: age ≥ 21, no known history of CAD, and symptoms of typical or atypical chest pain. All patients underwent CCTA and subsequently had ICA performed within 1 month. CCTAs and ICAs were evaluated and scored for coronary stenosis by 2 independent blinded readers. A vessel based analysis was used to evaluate for ≥ 50% and ≥ 70% stenosis using a 15 segment American Heart Association coronary tree model. Results: A total of 176 vessels were analyzed. Compared to ICA, CCTA's sensitivity, specificity, positive predictive value, and negative predictive value (NPV) for detecting greater than 50% stenoses were, 85%, 89%, 54% and 98%, respectively, and 86%, 91%, 51%, 98%, respectively, for stenoses greater than 70%. There were no statistically significant differences for sensitivity, specificity or NPV compared to the findings in the ACCURACY trial. Conclusion: Among veteran patients presenting with chest pain and no prior history of CAD, CCTA appears to be an effective noninvasive alternative to exclude coronary artery stenosis. Table 1: Baseline Demographics Risk Factors ACCURACY Trial VHA patients p-value Age 57 ± 10 61 ± 9.9 0.016 Sex Male gender 59% 95% p &lt; 0.001 Race Caucasian African American Hispanic Other 87.8% 5.7% 3.5% 3.1% 86% 6.3% 3.8% 3.9% NS Body mass index (kg/m²) 31.4 ± 6.2 29.9 ± 6.1 NS Heart rate (beats/min) 60 ± 12 63.2 ± 9.2 NS Creatinine (mg/dl) 1.0 ± 0.2 0.97 ± 0.19 NS Agatston coronary artery calcium score 284 ± 538 916 ± 805 p &lt; 0.001 Diabetes 23.9% 21.6% NS Hypertension 67% 64% NS Hyperlipidemia 68.3% 66% NS Family History of coronary artery disease 73.5% 71.2% NS Smoker 55.7% 53.2% NS

Circulating surfactant protein-D and the risk of cardiovascular morbidity and mortality

Surfactant protein-D (SP-D) is a lung-specific protein that is detectable in human plasma. We determined the relationship of circulating SP-D to cardiovascular disease (CVD) and total mortality in subjects with and without CVD. Plasma SP-D levels were measured in 806 patients who underwent coronary angiography to assess its predictive value for cardiovascular mortality. Serum SP-D levels were also measured in a replication cohort to assess its relationship with CVD events in 4468 ex- and current smokers without a known history of coronary artery disease (CAD). Patients who died during follow-up had significantly higher plasma SP-D levels than those who survived (median 85.4 vs. 64.8 ng/mL; P < 0.0001). Those in the highest quintile of SP-D had 4.4-fold higher risk of CVD mortality than those in the lowest quintile (P < 0.0001) independent of age, sex, and plasma lipid levels. In a group of current and ex-smokers without a known history of CAD, serum SP-D levels were elevated in those who died or were hospitalized for CVD compared with those who did not (median 99.8 vs. 90.6 ng/mL; P = 0.0001). Circulating SP-D is a good predictor of cardiovascular morbidity and mortality and adds prognostic information to well-established risk factors such as age, sex, and plasma lipids and is a promising biomarker to link lung inflammation/injury to CVD.

Diagnostic performance of computed tomography angiography for differentiating ischemic vs nonischemic cardiomyopathy

BackgroundAlthough the use of computed tomography angiography (CTA) is considered “appropriate” to distinguish ischemic vs nonischemic etiology in patients with cardiomyopathy under the current clinical practice guideline, the evidence to support this has not been evaluated in larger scale studies. Thus, we conducted a meta-analysis of available studies published by October 2010 to address this question. MethodsStudies evaluating the diagnostic accuracy of CTA versus invasive coronary angiography (as the gold standard) for significant coronary artery disease (CAD) detection (ischemic cardiomyopathy) in patients with no known history of CAD with significantly depressed left ventricular function (ejection fraction; EF < 35%) were selected for the meta-analysis. Sensitivity, specificity, positive, and negative likelihood ratios were calculated on per patient and per segment basis using random effects model (DerSimonian-Laird Method) for computing summary estimates and receiver operator curve (ROC) analysis for evaluating overall diagnostic accuracy. ResultsSix studies comprising 452 patients met the selection criteria for the meta-analysis. The pooled patient population was 62 ± 3 years old, with 29% females, 16% diabetics, and 43% with a history of hypertension. Mean EF was 32% ± 1%. The pooled summary estimate of sensitivity of CTA for diagnosis of ischemic cardiomyopathy was 98% [95% confidence interval (CI); 94% to 99%] and specificity was 97% (CI 94% to 98%), yielding a negative likelihood ratio of 0.06 (CI 0.02 to 0.13) and positive likelihood ratio of 20.85 (CI 12 to 36). There was no significant heterogeneity between studies for these estimates. The receiver operator curve analysis showed a robust discriminate diagnostic accuracy of ischemic etiology with an area under curve of 0.99 (P < .00001). ConclusionCTA appears as a clinically applicable accurate diagnostic modality to exclude ischemic etiology in patients with cardiomyopathy of undetermined cause and this further supports the appropriateness of the use of CTA to determine the cause of new onset cardiomyopathy of unknown etiology.

Prognostic value of CT coronary angiography in diabetic and non-diabetic subjects with suspected CAD: importance of presenting symptoms

AimTo assess the prognostic relevance of 64-slice computed tomography coronary angiography (CT-CA) and symptoms in diabetics and non-diabetics referred for cardiac evaluation.MethodsWe followed 210 patients with diabetes type 2 (DM) and 203 non-diabetic patients referred for CT-CA for ruling out coronary artery disease (CAD). Patients were without known history of CAD and were divided into four categories on the basis of symptoms at presentation (none, atypical angina, typical angina and dyspnoea). Clinical end points were major cardiac events (MACE): cardiac-related death, non-fatal myocardial infarction, unstable angina and cardiac revascularizations. Cox proportional hazard models, with and without adjustment for risk factors and multiplicative interaction term (obstructive CAD × DM), were developed to predict outcome.ResultsDM patients with dyspnoea or who were asymptomatic showed a higher prevalence of obstructive CAD than non-diabetics (p ≤ 0.01). At mean follow-up of 20.4 months, DM patients had worse cardiac event-free survival in comparison with non-DM patients (90% vs. 81%, p = 0.02). In multivariate analysis, CT-CA evidence of obstructive CAD (in DM patients: HR: 6.4; 95% CI: 2.3–17.5; p < 0.001; in non-DM patients: HR: 7.4; 95% CI: 2.1–26.7; p = 0.002) and the presence of typical angina (in DM patients: HR: 2.9; 95% CI: 1.3–6.3; p = 0.007; in non-DM patients: HR: 2.7; 95% CI: 1.1–7.1; p = 0.03) were independent predictors of MACE in both groups. Furthermore, other independent outcome predictors included dyspnoea (HR: 3.8; 95% CI: 1.7–8.5; p = 0.001), the number of segments with any CAD (HR: 1.1; 95% CI: 1.001–1.2; p = 0.04) in DM patients and coronary calcium score >100 in non-DM patients (HR: 5.6; 95% CI: 1.4–21.5; p = 0.01). In Cox regression analysis of the overall population, interaction term obstructive CAD × DM resulted in non-significance.ConclusionsAmong DM patients, dyspnoea carried a high event risk with a MACE rate four times higher. CT-CA findings were strongly predictive of outcome and proved valuable for further risk stratification.

Prognostic Value of an Exaggerated Exercise Blood Pressure Response in Patients With Diabetes Mellitus and Known or Suspected Coronary Artery Disease

The prognostic value of an exaggerated exercise systolic blood pressure response (EESBPR) remains controversial. Our aim was to assess whether an EESBPR is associated with the long-term outcome in patients with diabetes mellitus and known or suspected coronary artery disease (CAD). From an initial population of 22,262 patients with known or suspected CAD who underwent treadmill exercise electrocardiography or exercise echocardiography at our institution, 2,591 patients with a history of diabetes mellitus were selected for the present study. EESBPR was defined as systolic blood pressure >220 mm Hg during exercise. The end points were all-cause mortality and hard events (ie, death or myocardial infarction). A total of 236 patients (9.1%) developed an EESBPR during the tests. During a mean follow-up of 6.5 +/- 3.9 years, 484 patients died and 646 experienced hard events. The 10-year mortality rate was 16.6% in patients with an EESBPR compared to 30.9% in those without an EESBPR (p <0.001). The 10-year hard event rate was also lower in patients with an EESBPR (23.2% vs 38.9% in patients without an EESBPR; p <0.001). On multivariate analysis, an EESBPR remained independently associated with a lower risk of all-cause mortality (hazard ratio 0.53, 95% confidence interval 0.36 to 0.78, p = 0.001) and hard events (hazard ratio 0.57, 95% confidence interval 0.41 to 0.79; p <0.001). These results remained consistent in the subgroup of patients without a known history of CAD. In conclusion, an EESBPR was associated with improved survival and a lower rate of death or myocardial infarction in patients with diabetes mellitus and known or suspected CAD.

129 Dobutamine stress echocardiography and coronary artery spasm: a missed link

To assess whether abnormal dobutamine stress echocardiography (DSE) can be a consequence of dobutamine-induced coronary spasm in patients with angiographically documented vasospastic coronary arteries. Between January 2004 and April 2008, we prospectively evaluated all patients with known or suspected coronary artery disease (CAD) referred to the echocardiography laboratory for dobutamine stress tests (6061 examinations). Those with abnormal DSE underwent coronary angiogram with a systematic methylergometrine intracoronary injection in the case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients who had spontaneous occlusive coronary spasm or positive methylergometrine test, but no significant stenoses, were ultimately included in this study. About 581 patients had abnormal DSE, among them only 20 (3.4%) fulfilled the inclusion criteria. There were 15 males and 5 females, and mean age was 64.35 years (range 52-85); 8 patients had a known history of CAD and all of them had at least two established cardiovascular risk factors. The culprit vessel was the left anterior descending artery in 10 cases (50%), right coronary artery in 8 cases (40%), and left circumflex in 2 cases (10%). There was a systematic correspondence between the culprit arteries and dobutamine-induced wall motion abnormality territories. No complications occurred during examination or during the provocation test. All the patients were discharged with a calcium channel blocker and were doing well after 13 months of mean follow-up. Coronary artery spasm can be induced at DSE, but is a rare finding; it could, though, be clinically relevant as it may partly explain some erroneously labelled ‘false-positive’ examinations. Methylergometrine provocation test is a safe and advisable approach in such situations.

Coronary Artery Disease and Smoking Cessation Intervention by Primary Care Providers in a Rural Clinic

Among numerous risk factors for coronary artery disease (CAD), including family history, hypertension, diabetes mellitus and dyslipidemia, the single most modifiable risk factor is smoking. Smoking cessation for known CAD patients has recognized immediate and long term benefits, namely reduction in the chance of symptom recurrence and death. This article is a description of an evaluation of smoking cessation intervention by primary care providers for patients who smoke with a known history of CAD within 1 year of diagnosis. Nola J. Pender’s revised Health Promotion Model was the framework for this non-experimental, quality assurance study using descriptive retrospective chart review in a rural family practice clinic in the southern United States. Data were collected using a researcher-developed quality assurance tool with a final sample of 150 patient medical records. Results indicated that over two thirds (68.7%) of the patient sample received smoking cessation therapy prior to or within 1 year after diagnosis of CAD; however, 31.3% of the patient sample received no smoking cessation intervention. Although a large percentage of this sample received smoking cessation therapy, the American Heart Association and American College of Cardiology recommend smoking cessation therapy for all smokers with known history of CAD at each visit. It is recommended that this guideline be followed in all patients regardless of compliance with smoking cessation therapy, and that this therapy be consistently evaluated in its culturally relevant application to rural populations.

Coronary artery spasm and dobutamine stress echocardiography

The aim of this article was to assess whether abnormal dobutamine stress echocardiography (DSE) can be due to a dobutamine-induced coronary spasm in patients with angiographically documented vasospastic coronary arteries. Between January 2004 and April 2008, we prospectively evaluated all patients with known or suspected coronary artery disease (CAD) referred to the echocardiography laboratory for dobutamine stress tests (6061 examinations). Those with abnormal DSE underwent coronary angiogram with a systematic methylergometrine intracoronary injection in the case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients who had spontaneous occlusive coronary spasm or positive methylergometrine test, but no significant stenoses, were ultimately included in this study. About 581 patients had abnormal DSE, among them only 20 (3.4%) fulfilled the inclusion criteria. There were 15 males and 5 females, and mean age was 64.35 years (range 52-85); 8 patients had a known history of CAD and all of them had at least two established cardiovascular risk factors. The culprit vessel was the left anterior descending artery in 10 cases (50%), right coronary artery in 8 cases (40%), and left circumflex in 2 cases (10%). There was a systematic correspondence between the culprit arteries and dobutamine-induced wall motion abnormality territories. No complications occurred during examination or during the provocation test. All the patients were discharged with a calcium channel blocker and were doing well after 13 months of mean follow-up. Coronary artery spasm can be induced at DSE, but is a rare finding; it could, though, be clinically relevant as it may partly explain some erroneously labelled 'false-positive' examinations. Methylergometrine provocation test is a safe and advisable approach in such situations.

A Triglyceride/High‐Density Lipoprotein Ratio ≥3.5 Is Associated With an Increased Burden of Coronary Artery Disease on Cardiac Catheterization

An elevated triglyceride (TG)/high-density lipoprotein (HDL) ratio has been described as a predictor of insulin resistance and cardiovascular events. We evaluated whether a TG/HDL ratio > or = 3.5 was associated with the burden of coronary artery disease (CAD) on cardiac catheterization. A retrospective chart review of 156 consecutive adults presenting to the Montefiore Medical Center Emergency Department with symptoms of unstable angina and no known history of CAD who underwent cardiac catheterization as part of their index hospitalization was performed. TG and HDL data were available in 100 patients within 6 months prior to admission and no more than 24 hours after presentation. A priori, a burden of CAD score was developed. On multivariate analysis, a TG/HDL ratio > or = 3.5 was associated with the burden of CAD (odds ratio, 2.87; 95% confidence interval, 1.03-7.96; p = 0.04). Further study is warranted.

Relationship of socioeconomic markers to daily life ischemia and blood pressure reactivity in coronary artery disease patients

Socioeconomic status (SES) is an important predictor of clinical outcomes in patients with coronary artery disease (CAD). We hypothesized that a selected sample of low SES cardiac patients would display heightened cardiovascular stress responses in the laboratory and increased daily life ischemia compared to otherwise comparable higher SES patients. Eighty-two patients (M age=61.8+/-9.4 years; 71 men, 11 women) with a known history of CAD engaged in a stressful mental arithmetic task while blood pressure (BP) measures were collected. Myocardial ischemia was subsequently assessed via 48-hr ambulatory electrocardiographic monitoring in a subgroup of 51 patients. SES was defined by participants' residential block groups, which were linked to Census Bureau data about their neighborhood, including per capita income, percentage of the population below poverty, educational level, as well as self-report of number of years of education. Contrary to expectation, high SES participants in the study displayed higher diastolic BP (p<.01) and systolic BP (p<.001) responses to mental stress in the laboratory. Participants with daily life ischemia came from wealthier neighborhoods using indexes of poverty (p<.01), income (p<.02), and education (p<.04) compared to patients without ambulatory ischemia. This relationship was not accounted for by age, sex, race, body mass index, marital status, or measures of disease severity.

Pulmonary embolism and cardiac enzymes

Pulmonary embolism (PE) is often associated with chest pain, electrocardiographic changes, and right ventricular (RV) dysfunction on echocardiogram. There have been reports of elevated troponin levels with PE. RV dysfunction and elevated troponin levels have prognostic implications in acute PE. The purpose of this retrospective analysis was to determine whether PE was associated with elevated cardiac enzymes and whether there was any difference among patients who presented with or without chest pain. Records of 93 consecutive patients with high-probability ventilation/perfusion lung scan results for PE were analyzed for the presence or absence of chest pain on presentation, abnormalities in cardiac enzymes, and evidence of RV dysfunction on echocardiogram. A total of 56 of 93 patients had cardiac enzymes evaluated; 24 of these 56 patients had chest pains, and 32 did not. Only 1 patient of the 56 had abnormal cardiac enzymes. This patient had a known history of coronary artery disease (CAD) and had experienced an acute anterior myocardial infarction. Echocardiograms were performed in 36 of 93 patients. Evidence of RV dysfunction on echocardiograms was found in 22 of these patients. No significant relationship was found between RV dysfunction and chest pains (P > .10). We found no significant relationship between high-probability ventilation/perfusion scan results and abnormalities in cardiac enzymes irrespective of the presence or absence of chest pain. Patients with a history of CAD or RV dysfunction did not have a higher incidence of chest pain when compared with those with no known history of CAD or RV dysfunction.