Predictor Of Adverse Cardiac Events Research Articles

Prediction of adverse cardiac events in emergency department patients with chest pain using machine learning for variable selection.

BackgroundThe key aim of triage in chest pain patients is to identify those with high risk of adverse cardiac events as they require intensive monitoring and early intervention. In this study, we aim to discover the most relevant variables for risk prediction of major adverse cardiac events (MACE) using clinical signs and heart rate variability.MethodsA total of 702 chest pain patients at the Emergency Department (ED) of a tertiary hospital in Singapore were included in this study. The recruited patients were at least 30 years of age and who presented to the ED with a primary complaint of non-traumatic chest pain. The primary outcome was a composite of MACE such as death and cardiac arrest within 72 h of arrival at the ED. For each patient, eight clinical signs such as blood pressure and temperature were measured, and a 5-min ECG was recorded to derive heart rate variability parameters. A random forest-based novel method was developed to select the most relevant variables. A geometric distance-based machine learning scoring system was then implemented to derive a risk score from 0 to 100.ResultsOut of 702 patients, 29 (4.1%) met the primary outcome. We selected the 3 most relevant variables for predicting MACE, which were systolic blood pressure, the mean RR interval and the mean instantaneous heart rate. The scoring system with these 3 variables produced an area under the curve (AUC) of 0.812, and a cutoff score of 43 gave a sensitivity of 82.8% and specificity of 63.4%, while the scoring system with all the 23 variables had an AUC of 0.736, and a cutoff score of 49 gave a sensitivity of 72.4% and specificity of 63.0%. Conventional thrombolysis in myocardial infarction score and the modified early warning score achieved AUC values of 0.637 and 0.622, respectively.ConclusionsIt is observed that a few predictors outperformed the whole set of variables in predicting MACE within 72 h. We conclude that more predictors do not necessarily guarantee better prediction results. Furthermore, machine learning-based variable selection seems promising in discovering a few relevant and significant measures as predictors.

Agreement between manual and automated measurements of simple QRS/T angle

Abstract The spatial QRS/T angle (QRS/T) has been identified as a strong and independent predictor of adverse cardiac events. QRS/T can be determined from the electrocardiogram (ECG) by matrix transformation methods or formula which uses a combination of net QRS and T-wave amplitudes (QRS/Tsimple). Amplitudes can be measured automatically by using dedicated software (QRS/Tauto) or can be manually measured on a computer screen (QRS/Tmanual). This latter method allows analysis of QRS/T, when digital ECGs are not available. The aim of the study was to determine the agreement in the measurements between automatically derived QRS and T amplitudes and manually measured on the computer screen amplitudes. The relative error of the QRS/T between the two methods was estimated in 73 patients. In the case of QRS/Tmanual the inter-observer as well as intra-observer variability was estimated. The relative error between QRS/Tauto vs. QRS/Tmanual was 3.51%. Inter-observer and intra-observer variability of the QRS/Tmanual was 1.19% and 1.18% respectively. Manual measurement of the QRS/T is reliable, however, the predictive value of this parameter should be tested in clinical trials, before QRS/Tmanual can be considered a useful tool in clinical practice or retrospective studies.

Left atrial volume and adverse cardiovascular outcomes in unselected patients with and without CKD.

Patients with CKD have increased cardiovascular morbidity and mortality. This study investigated the prognostic value of common clinical echocardiographic parameters. There were 289 unselected consecutive patients who had a transthoracic echocardiogram between January and June 2003. Patients with stage 3 or 4 CKD (n=49) were compared with those with eGFR≥60 ml/min per 1.73 m(2), n=240). Left ventricular volume, ejection fraction and mass, left atrial volume, and function parameters were measured. The primary endpoint, determined a priori, was a composite of cardiac death, myocardial infarction, and congestive cardiac failure. Patients were followed for a median 5.6 years. The incidence of the primary endpoint was higher in patients with CKD (29% versus 12%, P=0.001), who were older and had a higher prevalence of hypertension and ischemic heart disease. Indexed left ventricular mass (LVMI) and left atrial volume (LAVI) were higher in patients with CKD. Furthermore, patients with LAVI>32 ml/m(2) had significantly lower event-free survival than patients with normal (<28 ml/m(2)) or mildly dilated LAVI (28-32 ml/m(2)) (P<0.001). Multivariate analysis showed that age (odds ratio [OR], 1.19; 95% confidence interval [95% CI], 1.08 to 1.31; P=0.001) and LVMI (OR, 3.66; 95% CI, 2.47 to 5.41; P<0.001) were independently associated with LAVI>32 ml/m(2). Multivariate Cox regression analysis demonstrated that CKD (hazard ratio [HR], 1.13; 95% CI, 1.01 to 1.26; P=0.04), hypertension (HR, 2.18; 95% CI, 1.05 to 4.54; P=0.04), and a larger LAVI (HR, 1.35; 95% CI, 1.02 to 1.77; P=0.04) were independent predictors of the primary endpoint. Patients with CKD were at higher risk for cardiovascular events. LAVI was significantly larger in the CKD group and was a predictor of adverse cardiac events.

The Ratio of Early Mitral Inflow Velocity to Global Diastolic Strain Rate as a Useful Predictor of Cardiac Outcomes in Patients with Atrial Fibrillation

Although the ratio of early mitral inflow velocity (E) to global diastolic strain rate (E'sr) has been correlated with left ventricular filling pressure, its relationship with cardiac outcomes in patients with atrial fibrillation (AF) has never been evaluated. The aim of this study was to examine the ability of E/E'sr ratio in predicting cardiac outcomes in patients with AF. In 190 patients with persistent AF, comprehensive echocardiography was performed, with assessment of E'sr from three standard apical views using the index beat method. Cardiac events were defined as death and hospitalization for heart failure. There were 50 cardiac events, including 22 deaths and 28 hospitalizations for heart failure, during an average follow-up period of 20 months (interquartile range, 14-32 months). Multivariate analysis showed old age, chronic heart failure, and increased E/E'sr ratio (per 10-cm E/E'sr increase; hazard ratio, 1.258; 95% confidence interval, 1.132-1.398, P < .001) were associated with increased cardiac events. In direct comparison, E/E'sr ratio outperformed the ratio of E to early diastolic mitral annular velocity (E') in predicting adverse cardiac events in both univariate and multivariate models (P ≤ .046). Additionally, the addition of E/E'sr ratio to a clinical model including age, chronic heart failure, diabetes, hypertension, left atrial volume index, left ventricular ejection fraction, and E/E' still provided an extra benefit in the prediction of adverse cardiac events (P = .010). E/E'sr ratio is a useful parameter and is stronger than E/E' ratio in predicting adverse cardiac events, and it may offer additional prognostic benefit over conventional clinical and echocardiographic parameters in patients with AF.

Myocardial perfusion scintigraphy: interpretation of a normal scan

Myocardial perfusion scintigraphy: interpretation of a normal scan

What is the clinical benefit of neutrophil-lymphocyte ratio in cardiovascular patients?

Dear Editor, Neutrophil-lymphocyte ratio (NLR) has gained a significant interest in the recent years, especially in cardiovascular research area. NLR is an easy to use parameter with not requiring an extreme effort to obtain. It can be obtained easily from the complete blood count (CBC) test, which is the most performed test in hospitals. NLR is used to predict cognitive dysfunction after carotid endarterectomy1, peripheral arterial disease prognostication2, presence, severity and extent of coronary artery disease3,4, and calcific aortic stenosis5. NLR has also been used for prediction of coronary heart disease mortality6, left atrial trombus7, impaired myocardial perfusion8, outcomes of cryoballoon-based atrial fibrillation ablation9, and prognostication of ST-elevation myocardial infarction (STEMI).10 In almost all of these studies, higher NLR was associated with worse clinical outcomes in patients with coronary artery disease, STEMI, peripheral arterial disease, calcific aortic stenosis and atrial fibrillation. However, there is no a universally accepted cut-off value of NLR that dictates a negative outcome as normal or abnormal. All of the above-mentioned studies have used different cutt-off values as normal or acceptable. Arbel et al. state >3 as an abnormally high value, other authors vary between <1.4 and <6 being normal.1-10 In a recent study, Ghaffari et al.11 evaluated the predictive value of peripheral neutrophil count and NLR in determining the prognosis of MI and the risk of major post-MI adverse events. In view of previous studies, it was not surprising to find an association between NLR and the frequency of heart failure and development of ventricular arrhythmias within the first day. The NLR was not associated with mortality but higher neutrophil count was the best predictive value for both mortality and heart failure. In STEMI, peripheral leukocyte count usually increases within 2 hours after the onset of chest pain, that peaks 2 to 4 days after infarction, returning to normal in one week.12 Ghaffari et al.11 measured CBC within 12-24 hours of onset of sypmtoms. The shorter lifespan with a rapid turn-over of neutrophils may have also affected the results of the study. Thus, serial neutrophil count may potentially be advantageous over its single measurement at the time of admission. This could easily be examined from the blood samples that are routinely obtained for monitoring cardiac enzymes. Also the measurement of NLR can be potentially affected by conditions such as metabolic syndrome, valvular heart disease, abnormal thyroid function tests, renal or hepatic dysfunction, local or systemic infection and ingestion of anti-inflammatory drugs.13 Park et al.10 evaluated the prognostic value of leukocyte profiles (neutrophil, lymphocyte, and monocyte absolute counts) in patients with STEMI treated with primary percutaneous intervention (PCI) and found that patients with 24-hour NLRs ≥5.44 were at increased risk for mortality and not admission leukocyte profile but the leukocyte profile at 24 hours after admission was associated with clinical outcomes (all-cause death). Indeed, Chia et al. showed that total leukocyte and neutrophil counts at 24 hours after primary PCI was an independent predictor of adverse cardiac events in patients with STEMI, but not the baseline hematologic indexes.14 After bare metal stent implantation hypersensitivity-mediated inflammation by eosinophilic cationic protein may be responsible for major cardiac events.15 Furthermore, hypersensitivity reactions against the drug eluting stent polymer material or the eluted drug have been associated with thrombotic complications probably mediated by persistent inflammation and incomplete apposed stent struts.16 Ghaffari et al. did not give any information about their revascularisation strategies. Therefore, it is not clear what type of stents were generally used and how long was their door to needle time. Also there was no any information about the patients’ medication. In conclusion, should the presence of a higher NLR without a universally accepted cutt-off value alert the physician to a higher hospital mortality? If so, how can we manipulate the NLR to improve the outcome? The NLR may be useful when combined with standardized clinical mortality risk prediction scores and other inflammatory markers. More importantly, further epidemiological studies will be required to consider NLR as a useful marker in these clinical settings.

Relationships of Elevated Systemic Pentraxin-3 Levels With High-Risk Coronary Plaque Components and Impaired Myocardial Perfusion After Percutaneous Coronary Intervention in Patients With ST-Elevation Acute Myocardial Infarction

We aimed to assess the relationships of pentraxin-3 (PTX3) with coronary plaque components and myocardial perfusion after percutaneous coronary intervention (PCI) in order to clarify the mechanisms underlying the prognostic function of PTX3 in ST-elevation acute myocardial infarction (STEMI) patients. We enrolled 75 STEMI patients who underwent pre-PCI virtual histology (VH)-intravascular ultrasound. Relationships of the systemic pre-PCI PTX3 level with coronary plaque components and post-PCI myocardial blush grade (MBG) were evaluated. Lesions with elevated pre-PCI PTX3 (median ≥3.79ng/ml) had higher frequencies of VH-derived thin-cap fibroatheroma (65.8% vs. 24.3%, P<0.0001), plaque rupture (63.2% vs. 24.3%, P=0.001), and post-PCI MBG (0-1) (65.8% vs. 40.5%, P=0.03) than those with PTX3 <3.79ng/ml. In multivariate analysis, pre-PCI PTX3 level was independently related to post-PCI MBG (0-1) (odds ratio, 11.385; 95% confidence interval (CI), 1.346-96.289; P=0.026). At 9-month follow-up, cardiac event-free survival was poorer for patients with post-PCI MBG (0-1) (log-rank test χ(2)=8.6; P=0.003). Cox proportional-hazards analysis showed post-PCI MBG (0-1) (hazard ratio, 4.109; 95% CI, 1.372-12.309; P=0.012) and Killip class >2 on admission (hazard ratio, 5.356; 95% CI, 1.409-20.359; P=0.014) as independent predictors of adverse cardiac events during follow-up. Systemic pre-PCI PTX3 was associated with high-risk plaque components and impaired post-PCI myocardial perfusion. Thus, PTX3 may be a reliable predictor of outcome in STEMI patients.

What evidence is there for intraoperative predictors of perioperative cardiac outcomes? A systematic review

BackgroundPatients undergo cardiac preoperative evaluation to identify those at risk of adverse perioperative cardiac events. The Revised Cardiac Risk index is commonly used for this task, although it is unable to accurately risk stratify in all patients. This may be partly a result of intraoperative events which significantly modify preoperative risk.MethodsWe conducted a systematic review to identify independent intraoperative predictors of adverse cardiac events in patients undergoing non-cardiac surgery. Four databases (Ovid Healthstar 1966 to Jan 2012, Ovid Medline 1946 to 6 March 2012, EMBASE 1974 to March 05 2012 and The Cochrane Library to March 06 2012) were searched.ResultsFourteen eligible studies were identified. The need for intraoperative blood transfusion (odds ratio (OR), 2.3; 95% confidence interval (CI), 1.4-3.3), vascular surgery (OR, 2.3; 95% CI, 1.2-3.4) and emergent/urgent surgery (OR, 2.3; 95% CI, 1.1-3.5) were the only independent intraoperative risk predictors identified in more than study. Other independent intraoperative factors identified included a >20 mmHg fall in mean arterial blood pressure for > 60 min (OR, 3.0; 95% CI, 1.8-4.9), >30% increase in baseline systolic pressure (OR, 8.0; 95% CI, 1.3-50), tachycardia in the recovery room (>30 beats per min (bpm) from baseline for >5 min) (OR, 7; 95% CI, 1.9-26), new onset atrial fibrillation (OR, 6.6; 95% CI, 2.5-20), hypothermia (OR, 2.2; 95% CI, 1.1-5) and remote ischemic preconditioning (OR, 0.22; 95% CI, 0.07-0.67). Other markers of surgical complexity were not independently associated with postoperative adverse cardiac outcomes. None of these studies controlled for blood transfusion.ConclusionsIntraoperative events significantly increase the risk for postoperative cardiac complications, although only intraoperative blood transfusion has strong evidence supporting this finding. It is possible that modification of these intraoperative risk factors by anesthetists and surgeons may reduce postoperative cardiac events and improve outcome. The Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study will add important information to understanding intraoperative risk factors for adverse cardiac events.

The Prognostic Value of Normal Stress Cardiac Magnetic Resonance in Patients With Known or Suspected Coronary Artery Disease

Background— Ischemia detection with stress cardiac magnetic resonance (CMR) is typically based on induction of either myocardial perfusion defect or wall motion abnormality. Single-center studies have shown the high value of stress CMR for risk stratification. The aim of this study was to define the prognostic value of stress CMR for prediction of adverse cardiac events in patients with known or suspected coronary artery disease. Methods and Results— Studies published between January 1985 and April 2012 were identified by database search. We included studies using stress CMR to evaluate subjects with known or suspected coronary artery disease and providing primary data on clinical outcomes of nonfatal myocardial infarction or cardiac death with a follow-up time ≥3 months. Total of 14 studies were finally included, recruiting 12 178 patients. The negative predictive value for nonfatal myocardial infarction and cardiac death of normal CMR was 98.12% (95% confidence interval, 97.26–98.83) during a weighted mean follow-up of 25.3 months, resulting in estimated event rate after a negative test equal to 1.88% (95% confidence interval, 1.17–2.74). The corresponding annualized event rate after a negative test was 1.03%. Comparable negative predictive values for major coronary events were obtained in studies considering the absence of inducible perfusion defect compared with those evaluating the absence of inducible wall motion abnormality (98.39% versus 97.31%, respectively; P =0.227 by meta-regression analysis). Conclusions— Stress CMR has a high negative predictive value for adverse cardiac events, and the absence of inducible perfusion defect or wall motion abnormality shows a similar ability to identify low-risk patients with known or suspected coronary artery disease.

Evaluation of atrial volume and function with magnetic resonance imaging in hypoplastic left heart

Background Increased left atrial volume and reduced atrial emptying are predictors of adverse cardiac events in adults. The atrium in single ventricle hearts contributes to ventricular filling to a greater degree than in normal hearts. Standardized methods of determining atrial function in single ventricles are lacking. We aimed to assess the feasibility and reproducibility of quantifying atrial volumes and function in hypoplastic left heart (HLH) prior to the Glenn operation.

Preoperative B-type natriuretic peptide risk stratification: do postoperative indices add value?

AbstractObjectives: It is unclear if there is value in measuring postoperative B-type natriuretic peptide (BNP) in patients risk-stratified using preoperative BNP.Design: Prospective observational study.Setting and subjects: Patients undergoing vascular surgery at Inkosi Albert Luthuli Hospital, Durban.Data on intraoperative risk predictors, i.e. the nature of the surgery, number of transfused red blood cell units and the duration of surgery, were collected. Preoperative and postoperative BNP, electrocardiographic and troponin I monitoring were performed. Multivariable analysis was conducted to identify independent predictors of adverse cardiac events and then tested using reclassification statistics.Outcome measures: The composite of troponin elevation within the first three postoperative days and all-cause mortality within 30 days of surgery.Results: In 149 eligible patients, the study outcome occurred in 27 patients and was independently predicted by red blood cell (RBC) transfusion [odds ratio (OR) 1....

Changing Risk of Perioperative Myocardial Infarction

Years ago, patients with recent myocardial infarction (MI) were reported to be at high risk of reinfarction (27%) and death after surgery. Therapy has changed in the 3 decades since those reports, so we reexamined that risk as well as other cardiac comorbidities and surgical work values in predicting adverse outcome. We used the National Surgical Quality Improvement Program Participant Use Data File for 2005 to 2009. We included all patients of all included specialties, for outpatient and inpatient surgery. Cardiac comorbidities included history of congestive heart failure (30 days) or MI (6 months), percutaneous coronary intervention, previous cardiac surgery, and history of angina (30 days). Other predictors included a frailty index and American Society of Anesthesiologists (ASA) class. Adverse cardiac events included cardiac arrest requiring cardiopulmonary resuscitation, MI, and death. Cases were stratified according to surgical work units. Univariate χ(2) analysis and multivariate logistic regression established simple relationships and interactions, with p < 0.05 significant. Of patients who had recent MI, 2.1% had reinfarction perioperatively and 26% of those died. The odds ratio for infarction with vs without recent MI in inpatients age 40 years and older was 4.6. Frailty and ASA class were stronger predictors of perioperative MI and cardiac arrest than was history of MI, and risk increased as surgical work increased. The risk caused by preoperative MI has improved by an order of magnitude in the last 30 years. The ASA class and especially frailty are better predictors of adverse cardiac events.

Stent thrombosis in patients with chronic kidney disease

Chronic kidney disease is a strong predictor of adverse cardiac events, including death, myocardial infarction and stent thrombosis (ST), after percutaneous coronary intervention. In the past few years, the development of new therapeutic strategies (including both drugs and devices) and a more complete understanding of the pathophysiology and predictive factors of thrombosis have led to a significant reduction of this complication. Despite this, ST still remains a dramatic event due to its morbidity and mortality. Further efforts should be pursued to identify patients at high risk of ST in order to adopt a more effective preventive strategy. This review sought to examine the total weight of evidence regarding ST with the use of drug-eluting stents in patients with chronic kidney disease.

New index for assessing the chronotropic response in patients with end-stage liver disease who are undergoing dobutamine stress echocardiography

The inability to achieve 85% of the maximum predicted heart rate (MPHR) on dobutamine stress echocardiography (DSE) is defined as chronotropic incompetence and is a predictor of major cardiac events after orthotopic liver transplantation (OLT). The majority of patients with end-stage liver disease (ESLD) receive beta-blockers for the prevention of variceal bleeding. In these patients, it is impossible to determine whether chronotropic incompetence is secondary to cirrhosis-related autonomic dysfunction or is merely a beta-blocker effect. We evaluated the usefulness of the maximum achieved heart rate (MAHR) and the heart rate reserve (HRR) in the detection of chronotropic incompetence in ESLD patients on beta-blocker therapy before DSE. We also evaluated the usefulness of a new index, the modified heart rate reserve (MHRR), in diagnosing chronotropic incompetence and predicting major cardiovascular adverse events after OLT. The study population consisted of 284 ESLD patients. The mean values of MAHR (expressed as a percentage of 85% of MPHR) and HRR were significantly lower for patients on beta-blockers versus patients off beta-blockers [97.1% versus 101.6% (t = 5.01, P < 0.001) and 71.7% versus 77.3% (t = 4.03, P < 0.001), respectively], whereas the values of MHRR were similar in patients on beta-blockers and patients off beta-blockers [102.3% versus 102.1% (t = 0.04, P = 0.97)]. A regression analysis showed a significant association of MAHR (P < 0.001) and HRR (P < 0.001) with beta-blockers, whereas MHRR was not associated with beta-blocker treatment (P = 0.92). MAHR and HRR were found to have no value for diagnosing chronotropic incompetence in ESLD patients. MHRR was not affected by beta-blocker therapy. Patients who developed heart failure (HF) and myocardial infarction (MI) after OLT had significantly lower MHRR values according to pretransplant DSE. MHRR was significantly associated with the subsequent development of HF (P = 0.01) and MI (P = 0.01) after OLT. MHRR may be useful for the determination of the target heart rate for stress testing, the diagnosis of chronotropic incompetence, and the prediction of adverse cardiac events after OLT.

Prognostic Significance of Unrecognized Myocardial Infarction Detected with MR Imaging in Patients with Impaired Fasting Glucose Compared with Those with Diabetes

To investigate whether the presence of myocardial infarction (MI) detected with late gadolinium-enhanced magnetic resonance (MR) imaging is an independent predictor of major adverse cardiac events (MACEs) in patients with impaired fasting glucose (IFG) and those with overt diabetes mellitus (DM). Institutional review board approval was obtained for this study, and all subjects provided written informed consent. Late gadolinium-enhanced and cine MR imaging were performed in 190 patients with IFG and 160 patients with DM without known previous MI to evaluate the presence and extent of late gadolinium enhancement as well as global and regional left ventricular function. MACEs were defined as cardiac death, MI, unstable angina, heart failure, and ventricular arrhythmia. The Cox proportional hazards model was used to investigate the relationship between clinical and MR imaging variables and MACEs. Follow-up information was obtained in 181 of the 190 patients with IFG (95%) and 151 of the 160 patients with DM (94%). MACEs were observed in 15 of the 181 patients with IFG (8.3%) and 24 of the 151 with DM (15.9%). Late gadolinium enhancement was an independent predictor for MACE in both the IFG group (adjusted hazard ratio, 5.186; P = .003) and DM group (adjusted hazard ratio, 3.229; P = .015). MACE-free survival was significantly higher in patients with IFG than in those with DM (P = .019, log-rank test). However, the MACE-free survival curve for patients with IFG and late gadolinium enhancement was similar to that for patients with DM and late gadolinium enhancement (P = .735). The presence of MI detected with late gadolinium-enhanced MR imaging is the strongest multivariable predictor of adverse cardiac events in patients with IFG. Late gadolinium-enhanced MR imaging may help identify a subpopulation of subjects in the prediabetic stage who may benefit from more intensive treatments.

Cardiac risk assessment by gated single-photon emission computed tomography in asymptomatic end-stage renal disease patients at the start of dialysis

ObjectivesThis study assessed the impact of cardiac risk assessment using gated single-photon emission computed tomography (SPECT) on cardiac events in end-stage renal disease (ESRD) patients. MethodsWe evaluated 215 asymptomatic patients who began dialysis between January 2005 and April 2009. Baseline electrocardiography and echocardiography were performed in all the patients. The subjects were stratified into low- and high-risk groups according to the baseline cardiac status, and gated SPECT was additionally recommended for the high-risk patients. ResultsThe study population consisted of 50 low- and 165 high-risk patients undergoing SPECT. Among the high-risk patients, 75 (45.5%) showed perfusion defects on SPECT and their overall cardiac-event rate per person-year of follow-up was 15.0%, significantly higher than 4.5% in high-risk group without perfusion defect and 1.2% in low-risk group. The presence of perfusion defect was a significant independent predictor of adverse cardiac events [hazard ratio (HR) 2.11; 95% confidence interval (CI) 1.05-4.24; P = .035]. When gated SPECT was added to the clinical and the echocardiographic variables, the prognostic stratification significantly improved (P < .001). However, coronary revascularization was not associated with improved cardiac event-free survival (HR 0.62; 95% CI 0.26-1.52; P = .296). ConclusionsGated SPECT may provide additional prognostic information for cardiac risk stratification, particularly among high-risk patients starting dialysis.

Abstract 9264: Predicting Acute Coronary Heart Disease Events in Women

Background: Coronary heart disease (CHD) is treatable if detected early yet few instruments measure women's prodromal symptoms (PS) of CHD. The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) identifies women's PS but prospective cohort data regarding the MAPMISS' predictability is limited. Purpose: To conduct a longitudinal observational cohort study designed to assess the ability of the MAPMISS' PS score to predict CHD events requiring clinical intervention in women, and to identify the most predictive components of the MAPMISS' PS score. Methods: Women referred for initial cardiac evaluation to clinics in Arkansas and Kentucky were eligible to participate; those with previous cardiac events and cognitive impairment were excluded. A total of 1114 women participated. The MAPMISS questionnaire was administered at time of enrollment and subsequently every 3 months for two years. The MAPMISS contains 33 PS. Each PS is weighted by its reported severity (0-3, 3=most severe) and frequency (less than monthly to daily, 0.125-7, 7=daily), and summed across symptoms (range 0-693). Cox proportional-hazards models adjusted by age and race were used to estimate hazard ratios (HR) and corresponding 95% confidence intervals (CI) for CHD events. Prodromal symptoms were entered in the Cox model as time dependent covariates. Results: Of the 1114 women, 1097 (98.5%) completed the study. Of these, 77 (7%) reported having an adverse cardiac event during the two-year follow-up. The total PS score was a significant predictor of adverse cardiac events (p&lt;0.001). Back pain, between/under shoulder blades, was the strongest predictor of adverse cardiac events (HR=3.17, 95%CI = 1.28- 7.85), followed by change in thinking or remembering (HR=2.90, 95%CI = 1.20- 7.04), and non-specific, generalized chest pain (HR=2.97, 95%CI = 1.04- 8.50). Women reporting one or more of these three symptoms were over 5 times as likely to have an adverse cardiac event as women with none of these symptoms (HR=5.25, 95%CI = 2.37- 11.64). Conclusion: The total PS score from the MAPMISS could be useful in screening women at risk of an adverse cardiac event.

Preoperative Brain Natriuretic Peptide (BNP) Is a Better Predictor of Adverse Cardiac Events Compared to Preoperative Scoring System in Patients Who Underwent Abdominal Surgery

Cardiovascular disease is the leading cause of perioperative death in surgical patients. A variety of clinical scoring systems have been developed to predict adverse cardiovascular events. B-type natriuretic peptide (BNP) is a sensitive and specific predictor of left ventricular systolic dysfunction and predicts first cardiovascular event and death in the general population. We present a prospective, single-center, observational cohort study of patients undergoing major abdominal surgery and evaluate the role of BNP in predicting adverse cardiac events. A total of 205 patients were included in the study. All patients were assessed by a cardiological clinical evaluation, a 12-lead ECG report, and a preoperative and postoperative blood sample for plasmatic BNP assessment. The primary end point was the predictive power of preoperative BNP levels for adverse cardiac events until 30 days after discharge. Thirty-one of 205 (15%) patients had adverse cardiac events in the postoperative period up to 30 days after discharge. Five patients (2.4%) of these died of cardiac events. Preoperative BNP values were significantly increased in the 31 patients compared to the other patients in the postoperative period [mean = 112.93 pg/ml (range = 5-2,080) vs. 178.99 pg/ml (range = 5-3,980); median = 117 vs. 23 pg/ml; 95% CI = 49-181; p < 0.0001]. At logistic regression, a preoperative BNP value of >36 pg/ml was the only effective predictor of adverse cardiac events. We have demonstrated that elevated preoperative BNP levels are independent predictors of adverse cardiac events in a cohort of patients undergoing major abdominal surgery in a general surgery department, and this is the first study about this specific cohort of patients.

TCT-248: Predictors Of Adverse Cardiac Events after PCI With GENOUS EPC-Coated Stents Compared To Drug Eluting Stents

TCT-248: Predictors Of Adverse Cardiac Events after PCI With GENOUS EPC-Coated Stents Compared To Drug Eluting Stents

Usefulness of Tissue Doppler Imaging‐Myocardial Performance Index in the Evaluation of Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction

In heart failure with preserved ejection fraction (HFPEF), physiological abnormalities are not solely restricted to diastolic function. Because the tissue Doppler imaging (TDI)-derived myocardial performance index (MPI) offers the advantage of recording systolic and diastolic tissue velocity simultaneously in the same cardiac cycle, this study aimed to determine whether TDI-MPI is an informative index for assessing HFPEF, compared with conventional echo parameters. In patients with HFPEF, TDI-MPI would be an independent predictor for adverse cardiac events. Among 408 patients who had diastolic dysfunction without heart failure (HF) or HFPEF, cardiac function was evaluated by mitral flow (MF) or TDI-MPI. During the median follow-up of 32 months, clinical outcomes, which were defined as the composite of cardiovascular death and admission for HF, were assessed. Mean MF and TDI-MPI were significantly greater in the HFPEF group. TDI-MPI rather than MF had a significant correlation with N-terminal pro-brain natriuretic peptide level. The area under the receiver operating characteristic curve of TDI-MPI for the detection of HFPEF was 0.86. With regard to clinical outcomes, 31 events were identified during follow-up periods. On a multivariate analysis, TDI-MPI >0.66 was the best prognostic predictor of events and provided incremental predictive value. Compared to MF-MPI, TDI-MPI may be a more useful parameter for the evaluation of patients with HFPEF.