New-onset Angina Research Articles

Prognostic Value of Coronary CT Angiography-derived Fractional Flow Reserve on 3-year Outcomes in Patients with Stable Angina.

Background The prognostic value of coronary CT angiography (CTA)-derived fractional flow reserve (FFR) beyond 1-year outcomes and in patients with high levels of coronary artery calcium (CAC) is uncertain. Purpose To assess the prognostic value of coronary CTA-derived FFR test results on 3-year clinical outcomes in patients with coronary stenosis and among a subgroup of patients with high levels of CAC. Materials and Methods This study represents a 3-year follow-up of patients with new-onset stable angina pectoris who were consecutively enrolled in the Assessing Diagnostic Value of Noninvasive CT-FFR in Coronary Care, known as ADVANCE (ClinicalTrials.gov: NCT02499679) registry, between December 2015 and October 2017 at three Danish sites. A high CAC was defined as an Agatston score of at least 400. A lesion-specific coronary CTA-derived FFR value of 2 cm with distal-to-stenosis value at or below 0.80 represented an abnormal test result. The primary end point was a composite of all-cause death and nonfatal spontaneous myocardial infarction. Event rates were estimated using the one-sample binomial model, and relative risk was compared between participants stratified by results of coronary CTA-derived FFR. Results This study included 900 participants: 523 participants with normal results (mean age, 64 years ± 9.6 [SD]; 318 male participants) and 377 with abnormal results from coronary CTA-derived FFR (mean age, 65 years ± 9.6; 264 male participants). The primary end point occurred in 11 of 523 (2.1%) and 25 of 377 (6.6%) participants with normal and abnormal coronary CTA-derived FFR results, respectively (relative risk, 3.1; 95% CI: 1.6, 6.3; P < .001). In participants with high CAC, the primary end point occurred in four of 182 (2.2%) and 19 of 212 (9.0%) participants with normal and abnormal coronary CTA-derived FFR results, respectively (relative risk, 4.1; 95% CI: 1.4, 11.8; P = .001). Conclusion In individuals with stable angina, a normal coronary CTA-derived FFR test result identified participants with a low 3-year risk of all-cause death or nonfatal spontaneous myocardial infarction, both in the overall cohort and in participants with high CAC scores. Clinical trial registration no. NCT02499679 Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Sinitsyn in this issue.

A patient with pulseless ST elevation myocardial infarction caused by a very late stent thrombosis

Background: Persistent contrast staining is highly associated with stent thrombosis. Case summary: A 75-year-old woman presented with new-onset effort angina. A coronary angiogram revealed a 90% blockage of the distal left main trunk (LMT) and a 99% blockage of the ostial left anterior descending coronary artery (LAD). A 3.0 × 18-mm CYPHER™ the stent had previously been implanted into the dominant proximal circumflex artery (LCx) in 2009 because of unstable angina. The patient developed pulseless ST elevation myocardial infarction after the withdrawal of antiplatelet therapy before a scheduled CABG. The patient recovered with VA-ECMO and PCI using aspiration thrombectomy and urgent CABG. Discussion: This case highlighted that a preoperative patient may develop thrombosis at a previous stent site with peri-stent contrast staining and withdrawal of an antiplatelet regimen in certain settings poses an imminent risk for preoperative deterioration. A bridging strategy using intravenous PY12 inhibitor before CABG should be considered in this setting. The revascularization strategy should be selected based on coronary anatomy, hemodynamic status and baseline risk for CABG. A hybrid revascularization approach should be considered in this patient population.

Smoking cessation for secondary prevention of cardiovascular disease.

Smoking is a leading cause of cardiovascular disease (CVD), particularly coronary heart disease (CHD). However, quitting smoking may prevent secondary CVD events in people already diagnosed with CHD. OBJECTIVES: To examine the impact of smoking cessation on death from CVD and major adverse cardiovascular events (MACE), in people with incident CHD. We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and the trials registries clinicaltrials.gov and the International Clinical Trials Registry Platform. We ran all searches from database inception to 15 April 2021. SELECTION CRITERIA: We included cohort studies, and both cluster- and individually randomised controlled trials of at least six months' duration. We treated all included studies as cohort studies and analysed them by smoking status at follow-up. Eligible studies had to recruit adults (> 18 years) with diagnosed CHD and who smoked tobacco at diagnosis, and assess whether they quit or continued smoking during the study. Studies had to measure at least one of our included outcomes with at least six months' follow-up. Our primary outcomes were death from CVD and MACE. Secondary outcomes included all-cause mortality, non-fatal myocardial infarction, non-fatal stroke, new-onset angina and change in quality of life. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods for screening and data extraction. We assessed the risk of bias for the primary outcomes using the ROBINS-I tool. We compared the incidence of death from CVD and of MACE (primary outcomes) between participants who quit smoking versus those who continued to smoke for each included study that reported these outcomes. We also assessed differences in all-cause mortality, incidence of non-fatal myocardial infarction, incidence of non-fatal stroke and new onset angina. We calculated hazard ratios (HRs) and 95% confidence intervals (95% CI). For our outcome, change in quality of life, we calculated the pooled standardised mean difference (SMD) and 95% CI for the difference in change in quality of life from baseline to follow-up between those who had quit smoking and those who had continued to smoke. For all meta-analyses we used a generic inverse variance random-effects model and quantified statistical heterogeneity using the I²statistic. We assessed the certainty of evidence for our primary outcomes using the eight GRADE considerations relevant to non-randomised studies. We included 68 studies, consisting of 80,702 participants. For both primary outcomes, smoking cessation was associated with a decreased risk compared with continuous smoking: CVD death (HR 0.61, 95% CI 0.49 to 0.75; I² = 62%; 18 studies, 17,982 participants; moderate-certainty evidence) and MACE (HR 0.57, 95% CI 0.45 to 0.71; I² = 84%; 15 studies, 20,290 participants; low-certainty evidence). These findings were robust to our planned sensitivity analyses. Through subgroup analysis, for example comparing adjusted versus non-adjusted estimates, we found no evidence of differences in the effect size. While there was substantial heterogeneity, this was primarily in magnitude rather than the direction of the effect estimates. Overall, we judged 11 (16%) studies to be at moderate risk of bias and 18 (26%) at serious risk, primarily due to possible confounding. There was also some evidence of funnel plot asymmetry for MACE outcomes. For these reasons, we rated our certainty in the estimates for CVD death as moderate and MACE as low. For our secondary outcomes, smoking cessation was associated with a decreased risk in all-cause mortality (HR 0.60, 95% CI 0.55 to 0.66; I² = 58%; 48 studies, 59,354 participants), non-fatal myocardial infarction (HR 0.64, 95% CI 0.58 to 0.72; I² = 2%; 24 studies, 23,264 participants) and non-fatal stroke (HR 0.70, 95% CI 0.53 to 0.90; I² = 0%; 9 studies, 11,352 participants). As only one study reported new onset of angina, we did not conduct meta-analysis, but this study reported a lower risk in people who stopped smoking. Quitting smoking was not associated with a worsening of quality of life and suggested improvement in quality of life, with the lower bound of the CI also consistent with no difference (SMD 0.12, 95% CI 0.01 to 0.24; I² = 48%; 8 studies, 3182 participants). AUTHORS' CONCLUSIONS: There is moderate-certainty evidence that smoking cessation is associated with a reduction of approximately one-third in the risk of recurrent cardiovascular disease in people who stop smoking at diagnosis. This association may be causal, based on the link between smoking cessation and restoration of endothelial and platelet function, where dysfunction of both can result in increased likelihood of CVD events. Our results provide evidence that there is a decreased risk of secondary CVD events in those who quit smoking compared with those who continue, and that there is a suggested improvement in quality of life as a result of quitting smoking. Additional studies that account for confounding, such as use of secondary CVD prevention medication, would strengthen the evidence in this area.

Development and Validation of a Prediction Model for Cardiovascular Events in Exercise Assessment of Coronary Heart Disease Patients After Percutaneous Coronary Intervention.

ObjectiveThis study aimed to develop a model for predicting cardiovascular events in the exercise assessment of patients with coronary heart disease after percutaneous coronary intervention (PCI) based on multidimensional clinical information.MethodsA total of 2,455 post-PCI patients who underwent cardiopulmonary exercise testing (CPET) at the Peking University Third Hospital from January 2016 to September 2019 were retrospectively included in this study; 1,449 post-PCI patients from January 2018 to September 2019 were assigned as the development cohort; and 1,006 post-PCI patients from January 2016 to December 2017 were assigned as the validation cohort. Clinical data of patients before testing and various indicators in the exercise assessment were collected. CPET-related cardiovascular events were also collected, including new-onset angina pectoris, frequent premature ventricular contractions, ventricular tachycardia, atrial tachycardia, and bundle branch block during the examination. A nomogram model for predicting CPET-related cardiovascular events was further developed and validated.ResultsIn the development cohort, the mean age of 1,449 post-PCI patients was 60.7 ± 10.1 years. CPET-related cardiovascular events occurred in 43 cases (2.9%) without fatal events. CPET-related cardiovascular events were independently associated with age, glycosylated hemoglobin, systolic velocity of mitral annulus, ΔVO2/ΔWR slope inflection, and VE/VCO2 slope > 30. The C-index of the nomogram model for predicting CPET-related cardiovascular events was 0.830, and the area under the ROC curve was 0.830 (95% CI: 0.764–0.896). For the validation cohort of 1,006 patients, the area under the ROC curve was 0.807 (95% CI: 0.737–0.877).ConclusionPost-PCI patients with older age, unsatisfactory blood glucose control, impaired left ventricular systolic function, oxygen uptake parameter trajectory inflection, and poor ventilation efficiency have a higher risk of cardiovascular events in exercise assessment. The nomogram prediction model performs well in predicting cardiovascular events in the exercise assessment of post-PCI patients and can provide an individualized plan for exercise risk prediction.

Coronary computed tomographic angiography as gatekeeper for new-onset stable angina.

Patients with new-onset stable angina constitute a substantial part of the population seen by cardiologists. Currently, the diagnostic workup of these patients depends on the pre-test probability of having obstructive coronary artery disease. It consists of either functional testing for myocardial ischaemia or anatomical testing by using coronary computed tomographic angiography (CCTA) or invasive coronary angiography. In case the pre-test probability is > 5%, the current guidelines for the management of chronic coronary syndromes do not state a clear preference for one of the noninvasive techniques. However, based on the recently published cost-effectiveness analysis of the PROMISE trial and considering the diagnostic yield in patients with angina and nonobstructive coronary artery disease, we argue a more prominent role for CCTA as a gatekeeper for patients with new-onset stable angina.

Novel Insights Into the Interaction Between the Autonomic Nervous System and Inflammation on Coronary Physiology: A Quantitative Flow Ratio Study.

Background: Heart rate variability (HRV) was proposed as a noninvasive biomarker to stratify the risk of cardiovascular disease. However, it remains to be determined if HRV can be used as a surrogate for coronary artery physiology as analyzed by quantitative flow ratio (QFR) in patients with new-onset unstable angina pectoris (UAP).Methods: A total of 129 consecutive patients with new-onset UAP who underwent 24-h long-range 12-channel electrocardiography from June 2020 to December 2020 were included in this study. HRV, coronary angiography, and QFR information was retrieved from patient medical records, the severity of coronary lesions was evaluated using the Gensini score (GS), and total atherosclerotic burden was assessed using the three-vessel contrast QFR (3V-cQFR) calculated as the sum of cQFR in three vessels.Results: Multivariate logistic analysis showed that low-frequency power (LF) and high-sensitivity C-reactive protein (hs-CRP) were directly correlated with functional ischemia of target vessel, which were inversely correlated with total atherosclerotic burden as assessed by 3V-cQFR. Moreover, incorporation of the increase in LF into the existing model that uses clinical risk factors, GS, and hs-CRP significantly increased the discriminatory ability for evaluating coronary artery physiology of target vessel.Conclusions: LF and hs-CRP are independently associated with functional ischemia in patients with new-onset UAP. The relative increase of LF and hs-CRP could add value to the use of classical cardiovascular risk factors to predict the functional severity of coronary artery stenosis. Our results suggest a potential association between the autonomic nervous system, inflammation, and coronary artery physiology.

Association of Posttraumatic Stress Disorder and Incident Ischemic Heart Disease in Women Veterans

Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD) in predominantly male populations or limited community samples. Women veterans represent a growing, yet understudied, population with high levels of trauma exposure and unique cardiovascular risks, but research on PTSD and IHD in this group is lacking. To determine whether PTSD is associated with incident IHD in women veterans. In this retrospective, longitudinal cohort study of the national Veterans Health Administration (VHA) electronic medical records, the a priori hypothesis that PTSD would be associated with greater risk of IHD onset was tested. Women veterans 18 years or older with and without PTSD who were patients in the VHA from January 1, 2000, to December 31, 2017, were assessed for study eligibility. Exclusion criteria consisted of no VHA clinical encounters after the index visit, IHD diagnosis at or before the index visit, and IHD diagnosis within 90 days of the index visit. Propensity score matching on age at index visit, number of prior visits, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted to identify women veterans ever diagnosed with PTSD, who were matched in a 1:2 ratio to those never diagnosed with PTSD. Data were analyzed from October 1, 2018, to October 30, 2020. PTSD, defined by International Classification of Diseases, Ninth Revision (ICD-9), or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), diagnosis codes from inpatient or outpatient encounters. Incident IHD, defined as new-onset coronary artery disease, angina, or myocardial infarction, based on ICD-9 and ICD-10 diagnosis codes from inpatient or outpatient encounters, and/or coronary interventions based on Current Procedural Terminology codes. A total of 398 769 women veterans, 132 923 with PTSD and 265 846 never diagnosed with PTSD, were included in the analysis. Baseline mean (SD) age was 40.1 (12.2) years. During median follow-up of 4.9 (interquartile range, 2.1-9.2) years, 4381 women with PTSD (3.3%) and 5559 control individuals (2.1%) developed incident IHD. In a Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (hazard ratio [HR], 1.44; 95% CI, 1.38-1.50). Secondary stratified analyses indicated that younger age identified women veterans with PTSD who were at greater risk of incident IHD. Effect sizes were largest for those younger than 40 years at baseline (HR, 1.72; 95% CI, 1.55-1.93) and decreased monotonically with increasing age (HR for ≥60 years, 1.24; 95% CI, 1.12-1.38). This cohort study found that PTSD was associated with increased risk of IHD in women veterans and may have implications for IHD risk assessment in vulnerable individuals.

Some fibrinolytic parameters in coronary artery disease patients: focus on unstable angina subgroups

Unstable angina is classified into new-onset, progressive, and angina at rest. Though hemostasis plays a crucial role in the pathogenesis of coronary artery disease, including unstable angina, limited data exist regarding peculiarities of fibrinolytic parameters in the above-mentioned types of unstable angina. Our study aims to investigate if there is a difference in the fibrinolytic state between the groups of patients with new-onset, progressive unstable angina in comparison with stable angina patients depending on medical history data, electrocardiographic and hemodynamic features. In our cross-sectional study, we recruited 93 coronary artery disease patients (mean age 62.32 (6.94) years, 41 males (44.1%)). They were divided into 3 groups: stable angina patients (n=22) (control), new-onset unstable angina patients (n=21), and progressive unstable angina patients (n=50). The groups were comparable by baseline characteristics. Blood samples were obtained before treatment onset. The concentrations of tissue plasminogen activator and inhibitor of plasminogen activator (type 1) were measured by the ELISA method. We registered 14 points at the admission department, particularly age, sex, body mass index, smoking, presence of the family history of cardiovascular disorders, ST-segment depression, T-wave variability, arrhythmias, left bundle branch blockage, heart rate, systolic and diastolic blood pressure, Sokolov-Lyon voltage criteria, and unstable angina type (new-onset or progressive). After comparison of fibrinolytic parameters’ concentrations among groups under investigation, we defined the main independent predictors among observed 14 parameters to create optimal regression models for assessment of fibrinolytic parameters concentrations. The groups under investigation differ significantly in concentration of tissue plasminogen activator (P&lt;0.001) and inhibitor of plasminogen activator (type 1) (P&lt;0.001). The tissue plasminogen activator concentration correlated significantly with ST depression (r=0.344, P=0.001), T wave variability (r=-0.233, P=0.02), systolic blood pressure (r=-0.675, P&lt;0.001), diastolic blood pressure (r=-0.655, P&lt;0.001), heart rate (r=-0.568, P&lt;0.001) and clinical unstable angina subgroups (r=-0.706, P&lt;0.001) as well as plasminogen activator inhibitor (type 1) concentration associated with age (r=-0.560, P&lt;0.001), body mass index (r=-0.249, P=0.049), ST-segment depression (r=0.542, P&lt;0.001), arrhythmia (r=0.210, P=0.03), systolic blood pressure (r=0.310, P=0.04), and clinical unstable angina subgroups (r=-0.406, P&lt;0.001). An optimal regression models for tissue plasminogen activator and its inhibitor assessment included systolic blood pressure, heart rate, unstable angina subgroup (R2adj. = 65.0%, P&lt;0.001) and systolic blood pressure, unstable angina subgroup (R2adj. = 42.7%, P&lt;0.001), respectively. Thus, fibrinolytic state among unstable angina clinical types differs significantly independently on observed baseline clinical, electrocardiographic and hemodynamic parameters. This finding confirms the utility of Braunwald unstable angina classification.

Abstract 12702: Association of Posttraumatic Stress Disorder With Incident Ischemic Heart Disease in Women Veterans

Introduction: Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD). Women veterans represent a growing, yet understudied, population with high trauma exposure and a unique cardiovascular risk profile, but research on the PTSD-IHD relation in this group is lacking. Hypothesis: PTSD is associated with incident IHD in women veterans. Methods: Veterans Administration (VA) electronic medical records (EMR) was used to identify women veterans who received care from any VA from 1/1/2000-12/31/2017. Exclusion criteria included: no VA follow-up(s) after index visit; IHD diagnosis at or before index visit; IHD diagnosis within 90 days of index visit. Propensity score matching on age at index visit, year of index visit, number of visits before index visit, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted in a 1:2 ratio to identify 129,510 women veterans with PTSD and 259,020 women veterans without PTSD. PTSD was defined by International Classification of Disease (ICD)-9/ICD-10 diagnosis codes and inpatient or outpatient encounters. Incident IHD was defined as new-onset coronary artery disease, angina, or myocardial infarction diagnoses based on ICD-9/ICD-10 diagnosis codes and inpatient or outpatient encounters. Results: The analytic sample was relatively young (mean age=40.3 ( SD =12.5)). Median length of follow-up was 1,921 days (interquartile range=884-3,547 days). In a propensity score-adjusted Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (HR=1.15, 95% CI 1.10-1.19; P &lt;.001). Secondary stratified analyses indicated that women veterans with PTSD who were of younger age (particularly those aged &lt;40 years), Black race, and Hispanic/Latino ethnicity, plus those exposed to military sexual trauma, exhibited some of the greatest elevations in incident IHD risk. Conclusions: Findings demonstrate that PTSD is an independent predictor of incident IHD in women veterans, especially in younger women and racial and ethnic minorities. Results may have implications for IHD risk assessment in these vulnerable populations.

Sex-based impact of carotid plaque in patients with chest pain undergoing stress echocardiography

ObjectiveWomen with suspected angina without history of coronary artery disease (CAD) less frequently have flow-limiting stenosis (FL-CAD) and more often have microvascular disease, affecting predictive accuracy of stress echocardiography (SE)...

Comparison between radial versus femoral percutaneous coronary intervention access in Indonesian hospitals, 2017–2018: A prospective observational study of a national registry

BackgroundCoronary heart disease is a leading cause of death in Indonesia and percutaneous coronary intervention (PCI) is a routinely performed procedure. The aim of this study is to provide real-world insight on the demographics of coronary artery disease and comparison between radial compared to femoral PCI in Indonesia, which performed radial access whenever possible. MethodsThis is a prospective cohort study involving 5420 patients with coronary artery disease who underwent PCI at 9 participating centers in the period of January 2017–December 2018. ResultsRadial access rate was performed in 4038 (74.5%) patients. Patients receiving femoral access has a higher rate of comorbidities and complex lesions compared to radial access. The incidence of in-hospital mortality, cardiogenic shock, major arrhythmia, and tamponade were higher in femoral group. The incidence of in-hospital mortality was 114 (2.1%). New-onset angina (OR 3.412), chronic renal failure (OR 3.47), RBBB (OR 4.26), LBBB (OR 6.26), left main stenosis PCI (OR 3.58), cardiogenic shock (OR 4.9), and arrhythmia (OR 15.59) were found to be independent predictors of in-hospital mortality. Radial access did not independently affect in-hospital mortality. In propensity-matched cohort, radial access was not associated with lower in-hospital mortality in both bivariable and multivariable model. However, radial access was associated with reduced in-hospital mortality in STEMI subgroup (OR 0.31). ConclusionHigher rate of adverse events was noted on the femoral access group. However, it might stem from the fact that patients with more comorbidities and complex lesions are more likely to be assigned to femoral access-group. Neither radial or femoral access is superior in terms of in-hospital mortality upon propensity-score matching/multivariable analysis.

Incidence of Cardiovascular Events After Renal Transplantation.

Renal transplant recipients may present with transplant-specific risk factors related to end-stage renal disease. Although cardiovascular disease-related deaths may be reduced in renal transplant recipients, this disease is still the leading cause of death in patients with a functioning allograft. In this study, our aim was to determine the incidence of cardiovascular events after renal transplant. This observational retrospective cohort study analyzed renal transplant recipients seen at Başkent University Hospital from 2014 to 2017. Posttransplant cardiovascular events were defined as presence of myocardial infarction, percutaneous coronary interventions, new-onset angina, and death. Patient characteristics, traditionals cardiovascular risk factors, routine biochemistry, and other comorbidities were included in our analyses. In total, 56 renal transplant recipients older than 18 years were included (mean age of 48.4 ± 11.3 years; 21.4% were female patients). In the patient group, 14.2% had coronary artery disease pre-transplant, and 1 patient had an acute myocardial infarction. Mean time from transplant to incidence of cardiovascular events (as shown by coronary angiography) was 9.34 ± 5.2 years. Thirty-six recipients (64.2%) had a cardiovascular event during this posttransplant period, and 6 patients who developed cardiovascular events were women. Five patients (8.9%) required bypass surgery after coronary angiography. Stent implantations were needed in 14 patients. The remaining patients received medical treatment decisions. Twenty-one patients had no acute or chronic cardiovascular events. One patient died because of noncardiac reasons (pulmonary aspergillosis). Two patients died after cardiac surgery, and 1 patient died because of decompensated heart failure. The presence of symptoms of cardiovascular disease is an important prognostic marker that requires cardiac evaluation. As with the general population, modifiable risk factors can reduce the incidence of cardiovascular events in renal transplant recipients.

Association of Optimism With Cardiovascular Events and All-Cause Mortality

Optimism and pessimism can be easily measured and are potentially modifiable mindsets that may be associated with cardiovascular risk and all-cause mortality. To conduct a meta-analysis and systematic review of the association between optimism and risk for future cardiovascular events and all-cause mortality. PubMed, Scopus, and PsycINFO electronic databases were systematically searched from inception through July 2, 2019, to identify all cohort studies investigating the association between optimism and pessimism and cardiovascular events and/or all-cause mortality by using the following Medical Subject Heading terms: optimism, optimistic explanatory style, pessimism, outcomes, endpoint, mortality, death, cardiovascular events, stroke, coronary artery disease, coronary heart disease, ischemic heart disease, and cardiovascular disease. Data were screened and extracted independently by 2 investigators (A.R. and C.B.). Adjusted effect estimates were used, and pooled analysis was performed using the Hartung-Knapp-Sidik-Jonkman random-effects model. Sensitivity and subgroup analyses were performed to assess the robustness of the findings. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline was followed. Cardiovascular events included a composite of fatal cardiovascular mortality, nonfatal myocardial infarction, stroke, and/or new-onset angina. All-cause mortality was assessed as a separate outcome. The search yielded 15 studies comprising 229 391 participants of which 10 studies reported data on cardiovascular events and 9 studies reported data on all-cause mortality. The mean follow-up period was 13.8 years (range, 2-40 years). On pooled analysis, optimism was significantly associated with a decreased risk of cardiovascular events (relative risk, 0.65; 95% CI, 0.51-0.78; P < .001), with high heterogeneity in the analysis (I2 = 87.4%). Similarly, optimism was significantly associated with a lower risk of all-cause mortality (relative risk, 0.86; 95% CI, 0.80-0.92; P < .001), with moderate heterogeneity (I2 = 73.2%). Subgroup analyses by methods for assessment, follow-up duration, sex, and adjustment for depression and other potential confounders yielded similar results. The findings suggest that optimism is associated with a lower risk of cardiovascular events and all-cause mortality. Future studies should seek to better define the biobehavioral mechanisms underlying this association and evaluate the potential benefit of interventions designed to promote optimism or reduce pessimism.

The prognostic value of exercise stress echocardiography – Validation of a newly implemented method in our center

AimThe aim of this study was to assess the validity and prognostic value of exercise stress echocardiography, as a newly introduced method at our workplace, over the medium-term time horizon. Methods and resultsBetween February 2014 and May 2017, 204 patients (63% males, 60±11 years) underwent exercise stress echocardiography (ESE) due to stable symptoms including chest pain or exertional dyspnea, with a known or suspected ischemic heart disease (IHD). A pre-test probability of IHD was 45±17%. The contrast agent was used in 25 (12%) patients. Positive test: new appearance of wall motion abnormalities in at least two adjacent left ventricular segments. The test complication rate was 0%.ESE was positive in 13 (6%) patients, 10 of them (77%) had a significant coronary artery stenosis. ESE was nondiagnostic (patients failed to achieve 85% of maximum predicted heart rate) in 27 (13%) patients.During the follow-up (median 17, IQR 8–29 months) 195 patients (96%) were successfully contacted. 2 (1%) patients died of malignancy, 68 (33%) were referred to coronary angiography, 2 (1%) had unstable angina pectoris (UAP), 2 (1%) had myocardial infarction (MI), 12 (6%) underwent percutaneous coronary intervention (PCI) or surgical revascularization. Patients with positive test result: n=13 (6%): 9 (69%) underwent revascularization due to significant coronary artery stenosis, 2 (15%) had MI. Patients with non-diagnostic test n=27 (14%): 2 (7%) died of malignancy, 1 patient underwent PCI. Patients with negative diagnostic test n=164 (80%), 2 cases of new-onset angina pectoris within 12 months following the testing (PCI was performed).The negative predictive value (death, MI, UAP, revascularization) of negative diagnostic test was 98.8%. ConclusionExercise stress echocardiography in hands of an experienced operator is a safe and valuable method. Negative result of a diagnostic exercise stress echocardiography has, based on our experience, an excellent negative predictive value concerning cardiovascular morbidity and mortality within the 17 month-time median.

Correlation between epicardial fat thickness and aortic valve sclerosis.

Background Epicardial fat is a true visceral fat deposit with adverse effects through the secretion of numerous proinflammatory and proatherogenic cytokines. Previous studies showed an association between aortic valve sclerosis and coronary artery disease. The aim of this study was to determine the correlation between epicardial fat thickness and aortic valve sclerosis. Method The study involved 225 patients who were admitted for coronary angiography due to new-onset angina. They underwent transthoracic echocardiography and epicardial fat thickness was determined. The sclerosis scoring of each aortic cusp, average aortic valve sclerosis score index, and left ventricular ejection fraction were determined. The variables of left ventricular diastolic function obtained included the early diastolic velocity determined by transmitral pulsed Doppler, and early mitral annular velocity measured by tissue Doppler. Results Patients with an epicardial fat thickness ≥7 mm were older ( p = 0.006), with more hypertension ( p = 0.045) and hyperlipidemia ( p < 0.001). Their average aortic valve sclerosis score index was higher (1.4 ± 1.02 vs. 0.86 ± 0.85, p = 0.001), and left ventricular ejection fraction and early mitral annular velocity were lower ( p < 0.001 and 0.03, respectively). They also exhibited more left ventricular hypertrophy ( p = 0.026) and a trend towards more significant coronary artery disease and 3-vessel disease ( p = 0.086 and 0.073, respectively). Conclusion Our findings confirm that epicardial fat as a marker of visceral adipose tissue may have an important role in promoting inflammatory and atherosclerotic changes in the aortic valve.

Prognostic value of tissue Doppler E/e' ratio in hypertension patients with preserved left ventricular ejection fraction

ABSTRACTObjectives: This study aims to investigate the association of tissue Doppler E/e' with cardiac events in hypertension patients, independent of and incremental to clinical and left ventricular geometric patterns. Methods: We retrospectively enrolled 222 asymptomatic nonischemic patients with hypertension who had echocardiogram in 2012 to evaluate tissue Doppler E/e'. Patients were followed up for cardiac events (cardiac events were defined as myocardial infarction, coronary revascularization procedures, new-onset angina (stable or unstable), heart failure). A cox regression was used to assess the association of the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/e') with cardiac events. Results: A total of 222 patients were included in analysis. There were 10 primary cardiac events during 3.2 ± 0.4 years follow-up. The E/e' ratio was the strongest predictor of cardiac events in Cox-proportional hazards models. Following adjustment for covariates, a unit rise in the E/e' ratio was associated with a 26% increment in risk of a cardiac event (HR 1.26, CI 1.06–1.50, p = 0.008). When E/e' ＞14 the hazard ratio of cardiac event was significantly increased compared with E/e' ≤ 14 in Kaplan–Meier analysis (log-rank ratio, 16.26; p ＜ 0.001). Conclusions: E/e', a non-invasive estimate of left ventricular filling pressure, predicts cardiac events in hypertensive population with preserved left ventricular ejection fraction, independent of and incremental to clinical and left ventricular geometric patterns. E/e' represents an early, effective tool for cardiovascular risk stratification in hypertension population.

The importance of subclinical left ventricular dysfunction and blood pressure pattern in asymptomatic type-2 diabetic patients: the diagnostic and prognostic significance of Tissue Doppler parameters, left ventricular global longitudinal strain, and nighttime blood pressure during sleep

The primary aims of this study have been to explore the diagnostic and prognostic significance of Tissue Doppler parameters (TDI), global longitudinal strain (GLS), and blood pressure (BP) pattern in normotensive diabetic patients. MethodsThe study consisted of 121 diabetic patients and 41 healthy subjects. Conventional and TDI echocardiography were performed on all patients, including E/Em (ratio of diastolic velocities). GLS was derived from two-dimensional speckle-tracking. Ambulatory BP monitoring (ABPM) was obtained over 24h.Over the three year follow up, the end points were cardiac events (myocardial infarction, coronary revascularization procedures, new-onset angina, heart failure). ResultsGLS was found to be significantly lower (‐17.5±2.1vs-24.4±2.4; p<0.001), while E/Em was significantly higher (10.3±2.24vs7.4±1.8; p<0.001) in diabetic patients.A non-dipping pattern of BP was observed in 38 diabetic patients (31.4%); 14 diabetic patients had an increase in their nocturnal BP.Significant predictors of an adverse cardiac event: a reduction of GLS value (‐17%,p=0.05) increase in E/Em (>15, p=0.002) and systolic BP during nocturnal sleep (>119mmHg,p=0.020). ConclusionEarly detection of nocturnal hypertension and subclinical LV dysfunction by TDI and 2D spackle tracking are of significant clinical and prognostic importance.

Incidence of cardiovascular events and associated risk factors in kidney transplant patients: a competing risks survival analysis

BackgroundThe high prevalence of cardiovascular risk factors among the renal transplant population accounts for increased mortality. The aim of this study is to determine the incidence of cardiovascular events and factors associated with cardiovascular events in these patients.MethodsAn observational ambispective follow-up study of renal transplant recipients (n = 2029) in the health district of A Coruña (Spain) during the period 1981–2011 was completed. Competing risk survival analysis methods were applied to estimate the cumulative incidence of developing cardiovascular events over time and to identify which characteristics were associated with the risk of these events.Post-transplant cardiovascular events are defined as the presence of myocardial infarction, invasive coronary artery therapy, cerebral vascular events, new-onset angina, congestive heart failure, rhythm disturbances, peripheral vascular disease and cardiovascular disease and death. The cause of death was identified through the medical history and death certificate using ICD9 (390–459, except: 427.5, 435, 446, 459.0).ResultsThe mean age of patients at the time of transplantation was 47.0 ± 14.2 years; 62% were male. 16.5% had suffered some cardiovascular disease prior to transplantation and 9.7% had suffered a cardiovascular event. The mean follow-up period for the patients with cardiovascular event was 3.5 ± 4.3 years. Applying competing risk methodology, it was observed that the accumulated incidence of the event was 5.0% one year after transplantation, 8.1% after five years, and 11.9% after ten years. After applying multivariate models, the variables with an independent effect for predicting cardiovascular events are: male sex, age of recipient, previous cardiovascular disorders, pre-transplant smoking and post-transplant diabetes.ConclusionsThis study makes it possible to determine in kidney transplant patients, taking into account competitive events, the incidence of post-transplant cardiovascular events and the risk factors of these events. Modifiable risk factors are identified, owing to which, changes in said factors would have a bearing of the incidence of events.

Cardio-Ankle Vascular Index is Independently Associated with Future Cardiovascular Events in Outpatients with Metabolic Disorders.

We investigated whether cardio-ankle vascular index (CAVI), an arterial stiffness marker, independently predicts future cardiovascular events in subjects with metabolic disorders. 1562 outpatients underwent CAVI between April 2004 and March 2006 at Toho University, Sakura Medical Center in Chiba, Japan. Patients who already had cardiovascular events at baseline, patients with low ankle brachial index (＜0.9), and patients with atrial fibrillation were excluded. After exclusion, 1080 subjects with metabolic disorders including diabetes mellitus, hypertension and dyslipidemia were screened and followed prospectively. Eventually, 1003 subjects (92.9% of 1,080 subjects) followed until March 2012 (follow-up duration 6.7±1.6 years) were analyzed. During the observation period, 90 subjects had new-onset myocardial infarction or angina pectoris confirmed by angiography. All subjects were stratified into quartiles by baseline CAVI (Q1: CAVI ≤8.27, Q2: CAVI 8.28-9.19, Q3: CAVI 9.20-10.08, Q4: CAVI ≥10.09). Age, male ratio and future cardiovascular events increased as CAVI quartile became higher. In Cox proportional hazards regression analysis, the factors independently associated with higher risk of future cardiovascular events were every 1.0 increment of CAVI [hazard ratio (HR) 1.126, p= 0.039], male gender (HR 2.276, p=0.001), smoking (HR 1.846, p=0.007), diabetes mellitus (HR 1.702,p=0.020), and hypertension (HR 1.682, p=0.023). In individuals with metabolic disorders, CAVI was a predictor of future cardiovascular events, independent of traditional coronary risk factors. CAVI is a potentially valuable tool to identify persons likely to benefit from more intensive therapeutic approaches.

Dietary fat composition and cardiac events in patients with type 2 diabetes

ObjectiveTo evaluate associations of dietary fat composition with the development of cardiac events in patients with type 2 diabetes, without ischemic heart disease who were followed for at least 12 months. MethodsIn this prospective cohort study the usual diet of patients was retrospectively assessed by a 3-day weighed diet record (WDR). Compliance with the WDR technique was assessed by comparing protein intake estimated from 3-day WDR and 24-h urinary nitrogen output. The following were considered cardiac events: myocardial infarction, myocardial revascularization procedures, congestive heart failure, new-onset angina pectoris, and sudden death. ResultsA total of 227 patients with type 2 diabetes (aged 59 ± 10 years; 46.0% male), were followed during 4.6 years. In a multivariate Cox regression analysis, the intake of polyunsaturated fatty acids had a protective effect for cardiac events (HR = 0.31, 95% CI: 0.11–0.89; P = 0.03) adjusted for age, gender, duration of diabetes, smoking, compliance with WDR, using hypolipidemic agents, and the presence of hypertension and diabetic nephropathy. When the fat intake was divided into quartiles, the highest intake of α-linolenic acid (>1.25% of energy) was negatively associated with cardiac events (HR = 0.58, 95% CI: 0.39–0.85; P = 0.006), adjusted for the same covariates.. ConclusionIn patients with type 2 diabetes without ischemic heart disease, a high intake of polyunsaturated fatty acids, especially alpha linolenic acid, was protective for the development of cardiac events..