Predictor Of Long-term Cardiovascular Mortality Research Articles

GRACE and TIMI risk scores but not stress imaging predict long-term cardiovascular follow-up in patients with chest pain after a rule-out protocol

ObjectiveTo determine the long-term prognostic value of stress imaging and clinical risk scoring for cardiovascular mortality in chest pain patients after ruling out acute coronary syndrome (ACS).MethodsA standard rule-out protocol was performed in emergency room patients with a normal or non-diagnostic admission electrocardiogram (ECG) within 6 h of chest pain onset. ACS patients were identified by troponin T, recurrent angina and serial ECG. Dobutamine stress echocardiography (DSE) was performed after ACS was ruled out. Myocardial perfusion scintigraphy (MPS) was performed within 6 months in an outpatient setting according to the physician’s discretion.Results524 patients were included. GRACE and TIMI risk scores were 75 (57–96) and 1 (0–2) in the rule-out ACS group, and 89 (74–107) and 2 (1–3) in the ACS group, respectively (median, interquartile range). Follow-up (median 9.4 (8.9–10.0) years) was complete in 96%. 350 of 379 rule-out ACS patients had an interpretable DSE and 52 patients underwent an MPS. 21 of the rule-out ACS patients (6%) died of a cardiovascular cause compared with 24 (17%) ACS patients (p < 0.001). For rule-out ACS patients, C-statistics were 0.829 and 0.803 for the GRACE and TIMI scores. In these patients, DSE and MPS outcome did not predict long-term cardiovascular mortality. In multivariate analysis, known chronic heart failure, ACE inhibitor use, and GRACE score were independent predictors of cardiovascular mortality.ConclusionsTIMI and GRACE score but not DSE and MPS are accurate predictors of long-term cardiovascular mortality, even in chest pain patients with a normal or non-diagnostic electrocardiogram undergoing a rule-out protocol.

The Impact of Aspirin Resistance on the Long‐term Cardiovascular Mortality in Patients with Non‐ST Segment Elevation Acute Coronary Syndromes

Aspirin resistance has been associated with an adverse long-term outcome in patients with atherosclerotic coronary artery disease, but more studies are needed. The aim of this study was to investigate the impact of aspirin resistance, assessed by the Platelet Function Analyzer-100 (PFA-100) (Dade Behring Inc., Deerfield, Ill., USA) on the long-term prognosis in patients with non-ST segment elevation acute coronary syndromes (NSTE-ACS). A total of 496 consecutive patients were studied. The 1-y incidence of cardiovascular death was the prespecified study endpoint. The patients were divided, according to the values of PFA-100 collagen epinephrine closure time (CEPI-CT) upon presentation, into aspirin sensitives (those with a PFA-100 CEPI-CT>193 sec) and aspirin resistants (those with a PFA-100 CEPI-CT<or=193 sec). Aspirin resistants were younger (p-value = 0.04), and less frequently hypertensives (p-value=0.05) or diabetics (p-value=0.04) than aspirin sensitives. By 1 y, the incidence of cardiovascular deaths in the entire cohort was 12.9% (64/496), and aspirin resistants were at significantly higher risk of cardiovascular death (23.1% versus 9.6%; hazard ratio [HR]=2.6; 95% confidence interval [CI]=1.6-4.3; p-value<0.001), than aspirin sensitives. By multivariate Cox regression analysis, aspirin resistance (a PFA-100 CEPI-CT<or=193 sec) was among the most potent predictors of the 1-y incidence of cardiovascular death (HR=2.8; 95% CI=1.7-4.6; p-value<0.001). According to the present data, aspirin resistance, assessed by the PFA-100, is an independent predictor of long-term cardiovascular mortality in patients with NSTE-ACS.

Prognostic Value of Pulse-Wave Tissue Doppler Parameters in Patients With Systolic Heart Failure

The aim was to study the prognostic value of left ventricular (LV) function using pulse-wave tissue Doppler imaging (TDI) in an ordinary population with heart failure (HF). One hundred fifty-six patients hospitalized for HF and LV ejection fraction < or =40% were examined using conventional echocardiography and pulse-wave TDI for the assessment of longitudinal LV function. Mitral annular systolic and early diastolic (e') velocities were recorded from a mean of 4 annular sites from the apical 2- and 4-chamber views. Noninvasive LV filling pressure was calculated from the ratio between transmitral early inflow velocity (E) and e'. All patients were followed up for 2 years, and data from the National Registry of Deaths were collected. Mean LV ejection fraction was 24.7 +/- 7.2%. TDI recordings showed a mean mitral annular systolic velocity of 5.0 +/- 1.0 cm/s and e' velocity of 6.2 +/- 1.9 cm/s. E/e' ratio was 14.1 +/- 4.8. Thirty patients (19%) had atrial fibrillation. During follow-up, 27 patients (17%) died of a cardiovascular cause. Multivariate analysis showed that only E/e' ratio and age were predictors of cardiovascular mortality. A cut-off value for E/e' ratio >13 had sensitivity of 84% and specificity of 45% to identify patients who died within 2 years of cardiac reasons. In conclusion, in the acute stage of HF, E/e' ratio is a strong independent predictor of long-term cardiovascular mortality in an ordinary population with HF and systolic dysfunction. Systolic and diastolic velocities had no independent prognostic value.

The impact of circulating total homocysteine levels on long-term cardiovascular mortality in patients with acute coronary syndromes

Background To evaluate the possible independent impact of circulating total homocysteine (tHcy) levels on long-term cardiovascular mortality, in patients with either ST-segment elevation myocardial infarction (STEMI), or non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Methods A total of 458 STEMI and 476 NSTE-ACS patients who presented consecutively, within the first 12 and 24 h of index pain respectively were studied. Each cohort was divided according to tertiles of circulating tHcy levels upon presentation. Early (30 days) and late (31 days through 5 years) cardiovascular mortality was the predefined study endpoint. Results There was no difference in the risk of 30-day cardiovascular death among the tertiles of tHcy in patients with STEMI (7.2%, 8.5% and 12.4% for the first, second and third tertiles respectively; p trend = 0.3) or NSTE-ACS (3.1%, 3.8% and 5.7% for the first, second and third tertiles respectively; p trend = 0.5). Patients in the upper tHcy tertile were at significantly higher unadjusted risk of late (from 31 days trough 5 years) cardiovascular death than those in the other two tertiles in STEMI (23.4%, 27.9% and 41.8% for the first, second and third tertiles respectively; p trend < 0.001), and NSTE-ACS (24.7%, 28.1% and 45.6% for the first, second and third tertiles respectively; p trend < 0.001) cohorts. However, after adjustment for baseline differences, there was no significant difference in the risk of late cardiovascular death among tHcy tertiles in either cohort. When circulating tHcy levels were treated as a continuous variable, they were significantly associated with late cardiovascular death ( p < 0.001 for both cohorts) by univariate Cox regression analysis, but not by multivariate Cox regression analysis ( p = 0.8, and p = 1 for STEMI and NSTE-ACS cohorts, respectively). Conclusions Based on the present data circulating tHcy levels determined upon admission do not serve as an independent predictor of long-term cardiovascular mortality in patients with either STEMI or NSTE-ACS.

Comparison of usefulness of systolic, diastolic, and mean blood pressure and pulse pressure as predictors of cardiovascular death in patients ≥60 years of age (The Dubbo Study)

Blood pressure (BP) is an important predictor of future cardiovascular risk. Clinicians have traditionally recognized the importance of systolic BP, especially in older adults. 1 The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997; 157: 2413-2446 Crossref PubMed Google Scholar BP is also characterized by its pulsatile (estimated by pulse pressure [PP]) and steady (estimated by mean arterial pressure) components. 2 Darne B. Girerd X. Safar M. Cambien F. Guize L. Pulsatile versus steady component of blood pressure a cross-sectional analysis and a prospective analysis on cardiovascular mortality. Hypertension. 1989; 13: 392-400 Crossref PubMed Scopus (533) Google Scholar Two recent studies 3 Glynn R.J. Chae C.U. Guralnik J.M. Taylor J.O. Hennekens C.H. Pulse pressure and mortality in older people. Arch Intern Med. 2000; 160: 2765-2772 Crossref PubMed Scopus (196) Google Scholar , 4 Staessen J.A. Gasowski J. Wang J.G. Thijs L. Den Hond E. Boissel J.P. Coope J. Ekbom T. Gueyffier F. Liu L. et al. Risks of untreated and treated isolated systolic hypertension in the elderly meta-analysis of outcome trials. Lancet. 2000; 355: 865-872 Abstract Full Text Full Text PDF PubMed Scopus (1029) Google Scholar have emphasized the importance of PP, defined as systolic BP minus diastolic BP, as a predictor of cardiovascular events or mortality in the elderly. Another study 5 Domanski M.J. Davis B.R. Pfeffer M.A. Kastantin M. Mitchell G.F. Isolated systolic hypertension prognostic information provided by pulse pressure. Hypertension. 1999; 34: 375-380 Crossref PubMed Scopus (329) Google Scholar highlighted mean BP, defined as 1/3 systolic BP plus 2/3 diastolic BP, as a predictor of cardiovascular disease risk. Data from the Framingham Heart Study 6 Franklin S.S. Gustin W.T. Wong N.D. Larson M.G. Weber M.A. Kannel W.B. Levy D. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation. 1997; 96: 308-315 Crossref PubMed Scopus (1755) Google Scholar and other studies 7 Tate R.B. Manfreda J. Krahn A.D. Cuddy T.E. Tracking of blood pressure over a 40-year period in the University of Manitoba Follow-up Study, 1948–1988. Am J Epidemiol. 1995; 142: 946-954 PubMed Google Scholar indicate that systolic BP increases continuously with age, whereas diastolic BP increases until age 60 years and then begins to decrease steadily. As a result, PP may become a more important BP measurement associated with cardiovascular disease in older persons. 8 Franklin S.S. Khan S.A. Wong N.D. Larson M.G. Levy D. Is pulse pressure useful in predicting risk for coronary heart Disease? The Framingham Heart Study. Circulation. 1999; 100: 354-360 Crossref PubMed Scopus (1497) Google Scholar Darne et al 2 Darne B. Girerd X. Safar M. Cambien F. Guize L. Pulsatile versus steady component of blood pressure a cross-sectional analysis and a prospective analysis on cardiovascular mortality. Hypertension. 1989; 13: 392-400 Crossref PubMed Scopus (533) Google Scholar were among the first to report that PP, in addition to mean BP, was an independent cardiovascular risk factor. Mean BP has not been as extensively studied, with positive associations with cardiovascular disease in some 5 Domanski M.J. Davis B.R. Pfeffer M.A. Kastantin M. Mitchell G.F. Isolated systolic hypertension prognostic information provided by pulse pressure. Hypertension. 1999; 34: 375-380 Crossref PubMed Scopus (329) Google Scholar , 9 Benetos A. Safar M. Rudnichi A. Smulyan H. Richard J.L. Ducimetieere P. Guize L. Pulse pressure a predictor of long-term cardiovascular mortality in a French male population. Hypertension. 1997; 30: 1410-1415 Crossref PubMed Scopus (958) Google Scholar , 10 Dyer A.R. Stamler J. Shekelle R.B. Schoenberger J.A. Stamler R. Shekelle S. Collette P. Berkson D.M. Paul O. Lepper M.H. Lindberg H.A. Pulse pressure-III. Prognostic significance in four Chicago epidemiologic studies. J Chronic Dis. 1982; 35: 283-294 Abstract Full Text PDF PubMed Scopus (55) Google Scholar but not all 11 Franklin S.S. Sutton-Tyrrell K. Belle S.H. Weber M.A. Kuller L.H. The importance of pulsatile components of hypertension in predicting carotid stenosis in older adults. J Hypertens. 1997; 15: 1143-1150 Crossref PubMed Scopus (122) Google Scholar studies. It remains unclear which measures of BP, either alone or in combination, best predict the risk of cardiovascular disease mortality. Therefore, we studied the use of systolic BP, diastolic BP, PP, and mean BP in an elderly cohort of men and women aged ≥60 years at baseline with no history of cardiovascular disease. Using BP values at baseline, we compared the associations of each BP measure with the risk of cardiovascular disease mortality prospectively over 12 to 13 years of follow-up.

Mitral regurgitation following acute myocardial infarction.

Mitral valve regurgitation (MR) is a frequent Doppler echocardiographic finding in patients after acute myocardial infarction (AMI) and an independent predictor of long-term cardiovascular mortality. Reported risk factors include advanced age, prior myocardial infarction, infarct extension, and recurrent ischemia. During the early phase of AMI, transient ischemic MR is common and rarely causes hemodynamic compromise. However, when several chordae tendineae or a papillary muscle ruptures, acute left atrial and ventricular volume overload ensues, leading to abrupt hemodynamic deterioration with cardiogenic shock. Auscultation may be unrevealing due to decreased turbulence. Hence, the importance of a high index of suspicion for acute MR in any patient with acute pulmonary edema in the setting of AMI, especially if left ventricular systolic function is well preserved. Later, ventricular remodeling may lead to MR through annular dilatation or papillary muscle migration with malcoaptation of the leaflets. The widespread availability, ease of use and non-invasive nature of Doppler echocardiography have made it the standard diagnostic tool for detecting MR. Mechanical reperfusion of the infarct-related artery seems to be superior to fibrinolysis in decreasing its incidence acutely and in the long run. Nevertheless, when acute severe MR occurs, unless rapidly diagnosed and treated, this dreaded complication is associated with high morbidity and mortality. Prompt surgical intervention after hemodynamic stabilization is essential to ensure a good short-term and long-term prognosis. This review discusses the incidence, long-term prognosis, associated risk factors, complex pathophysiology, time of occurrence, clinical manifestations, diagnosis, and management of patients with MR after AMI.

Leukocyte Activation: Relation to Cardiovascular Mortality after Cerebrovascular Ischemia

Activated leukocytes are believed to be involved in the pathogenesis and progression of atherosclerotic vascular disease and its consequences. In a 4-year observational follow-up study, we investigated whether markers for systemic leukocyte activation (leukocyte-derived inflammatory mediators) were related to cardiovascular mortality after cerebrovascular ischemia. Using enzyme-linked immunosorbent assays, we measured the plasma levels of soluble tumor necrosis factor receptor protein-1 (sTNFR-1), neutrophil gelatinase-associated lipocalin (NGAL) and neutrophil protease-4 (NP4) in 144 patients (90 stroke, 54 transient ischemic attack) 1–3 days after cerebral ischemia. During the 4 years of follow-up, 42 (29%) of the 144 patients died; 38 of cardiovascular causes and 4 of other causes. Patients with evidence of higher leukocyte activation (n = 47) had a higher 4-year cardiovascular mortality rate than those without evidence of leukocyte activation (n = 97; p < 0.005). Logistic regression analysis with age, sex and other significant predictors as covariates showed higher plasma levels of sTNFR1 and NGAL both to be significant independent predictors of cardiovascular mortality, the respective odds ratio, 95% confidence intervals, and p values being 2.0, 1.2–3.4, p < 0.01, and 3.6, 1.2–10.5, p = 0.02, respectively. We concluded that in patients with acute cerebral ischemia, plasma markers of leukocyte activation were significant predictors of long-term cardiovascular mortality. This may indicate an important role of activated leukocytes in the progression of these diseases.