Predictor Of Nonfatal Myocardial Infarction Research Articles

Long-Term Follow-Up in Patients With Stable Angina and Unobstructed Coronary Arteries Undergoing Intracoronary Acetylcholine Testing

ObjectivesThe aim of this study was to investigate the prognosis of a large cohort of patients with stable angina and unobstructed coronaries undergoing acetylcholine spasm testing. BackgroundCoronary artery spasm can be found in up to 60% of patients with symptoms of myocardial ischemia despite unobstructed coronary arteries. MethodsConsecutive symptomatic patients with unobstructed coronary arteries undergoing acetylcholine testing to detect epicardial or microvascular coronary spasm were prospectively enrolled. After a median follow-up period of 7.2 years (6.5 to 7.9 years), data regarding mortality, nonfatal myocardial infarction, stroke, repeat coronary angiography, recurrent symptoms, and quality of life were obtained in 736 patients (57% women, mean age 62 ± 12 years). ResultsIn total, 55 deaths (7.5%), 8 nonfatal myocardial infarctions (1.4%), and 12 strokes (2.2%) occurred during the follow-up period. Recurrent symptoms were reported by 64% of patients, and repeat coronary angiography was performed in 12% of cases. Multivariate analysis revealed epicardial spasm as a predictor of nonfatal myocardial infarction (hazard ratio: 14.469; 95% confidence interval: 1.735 to 120.646) and repeat angiography (hazard ratio: 1.703; 95% confidence interval: 1.062 to 2.732), whereas patients with microvascular spasm more often had recurrent angina at follow-up (hazard ratio: 1.311; 95% confidence interval: 1.013 to 1.697). ConclusionsIn this long-term follow-up study, the overall prognosis of patients with coronary spasm was favorable. Patients with epicardial spasm were at increased risk for myocardial infarction and repeat angiography, while microvascular spasm was associated with recurrent angina. Acetylcholine testing may help identify patients at increased risk for adverse cardiac events among this overall low-risk population.

Prognostic value of visually detected coronary artery calcification on unenhanced non-gated thoracic computed tomography for prediction of non-fatal myocardial infarction and all-cause mortality

PurposeTo determine the prognostic value of visually detected coronary artery calcification (CAC) on unenhanced non-gated thoracic computed tomography (CT) for non-fatal myocardial infarction (MI) and all-cause mortality. MethodsThis retrospective single-centre cohort study comprised of 410 consecutive patients aged 40–80 years without any known cardiovascular disease at baseline. CT images without electrocardiogram-gating were acquired for a variety of respiratory medicine indications. CAC was examined by a single reader blinded to clinical data and outcome, using 1) the Agatston coronary calcium score (CCS), 2) visual CAC and 3) number of visually calcified coronary arteries. ResultsVisible CAC was identified in 201 (49.0%) of the 410 patients (60.5 ± 10.0 years old, 42.4% males). After a median follow up of 7.0 years, 39 patients (9.5%) experienced an event (death or non-fatal MI). After adjustment for cardiovascular risk factors, those with 1) higher CCS, 2) presence of visual CAC or 3) greater number of calcified coronary arteries by visual assessment, had an increased risk of adverse outcome (all p-value <0.05). There was no significant difference in c-statistics of the three methods of assessment (0.81, 0.80, 0.81 respectively), indicating that simple visual assessment of CAC may have a prognostic value similar to CCS. ConclusionAmong patients with no known cardiovascular disease who underwent unenhanced non-gated CT for a pulmonary-related indication, visually detected CAC was a strong independent predictor of non-fatal MI and all-cause mortality.

Abstract 313: Rates of All-cause Mortality, Myocardial Infarction and Coronary Revascularization Stratified by Appropriate Use Criteria in Coronary Artery Disease Patients Managed with Optimal Medical Therapy

Appropriate use criteria (AUC) have been developed for guiding clinical decision-making for coronary revascularization (revasc). We studied a prospective cohort of 693 pts initiated in 1992 and managed with optimal medical therapy (OMT). AUC scores could be calculated using noninvasive test results and coronary angiographic data in 230 pts, which constitute the study group. When non-invasive findings were discordant, patients were put in the higher risk stratum. Revasc status and myocardial infarction (MI) events were ascertained as of June 2005. Mortality status was ascertained as of December 31, 2008. Based on AUC scores, pts were classified as Appropriate (A), Inappropriate (I), or Uncertain (U) for revasc. Decisions to pursue invasive evaluation and revasc were based solely on stability of symptoms, LV function, and exercise duration. Survival analysis and stepwise Cox modeling was used to assess AUC class as a predictor of outcomes. Results: The majority of pts, 53% (121 of 230), were AUC Class A, with almost all the remainder in Class U, 34% (79 of 230). The mean age of the study group was 66.0 years. The annual incidence of all-cause mortality over a mean follow up period of 12.1 years was 3.6%. A total of 99 deaths occurred. There were no significant differences in the mortality curves of the 3 AUC classes. The annual incidence of non-fatal MI over a mean follow up of 6.45 years was 2.2%. AUC class A was not a predictor of non-fatal MI. The annual incidence of revasc over a mean follow up period of 5.38 years was 6.5%. Multivariate stepwise Cox models showed AUC class A was a significant predictor of revasc, along with diabetes mellitus. Beta-blocker therapy at entry was protective. Kaplan-Meier curves confirmed the findings for revasc and nonfatal MI. Conclusions: In an OMT cohort initiated in 1992, 53% of pts in whom AUC scores were calculable were deemed appropriate for revasc but were managed with OMT alone. Low annual incidence of mortality and rates of eventual revascularization were observed. Retrospective stratification showed no adverse mortality experience with OMT by AUC class. AUC Class A pts had a significantly higher rate of revasc during OMT, reflecting the goals of the AUC system, yet the annualized rates of death and MI in this class were comparable to the rates in the medical arms of recent RCT’s of OMT. These findings suggest that contemporary AUC classification may permit revasc in OMT pts without distinguishing that subset with a future mortality risk on OMT alone. AUC Classification of pts for revasc may require further refinement to enhance the selection of mortality benefit over OMT.

Prognostic value of coronary vessel dominance in relation to significant coronary artery disease determined with non-invasive computed tomography coronary angiography

Limited information is available regarding the relationship between coronary vessel dominance and prognosis. Therefore, the purpose of this study was to determine the prognostic value of coronary vessel dominance in relation to significant coronary artery disease (CAD) in patients referred for computed tomography coronary angiography (CTA). The study population consisted of 1425 patients (869 men, 57 ± 12 years) referred for CTA. To evaluate the impact of vessel dominance and significant CAD on CTA on outcome, patients were followed during a median period of 24 months for the occurrence of non-fatal myocardial infarction and all-cause mortality. The presence of a left dominant system was identified as a significant predictor for non-fatal myocardial infarction and all-cause mortality (HR: 3.20; 95% CI: 1.67-6.13, P < 0.001) and had incremental value over baseline risk factors and severity of CAD on CTA. In addition, in the subgroup of patients with significant CAD on CTA, patients with a left dominant system had a worse outcome compared with patients with a right dominant system (cumulative event rates: 9.5% and 35% at 3-year follow-up for a right and left dominant coronary artery system, respectively, log-rank P < 0.001). The presence of a left dominant system was identified as an independent predictor of non-fatal myocardial infarction and all-cause mortality, especially in patients with significant CAD on CTA. Therefore, the assessment of coronary vessel dominance on CTA may further enhance risk stratification beyond the assessment of significant CAD on CTA.

Assessment of the relation between IVUS measurements and clinical outcome in elderly patients after sirolimus-eluting stent implantation for de novo coronary lesions

This study aimed to evaluate the impact of vascular response assessed by intravascular ultrasound (IVUS) imaging on clinical outcomes in elderly patients (≥ 75 years) undergoing percutaneous coronary intervention (PCI) for de novo lesions with sirolimus-eluting stent (SES) implantation. Repeat coronary angiography with IVUS was performed 1 year after SES-based PCI for de novo lesions in 136 elderly patients (≥ 75 years) and 427 younger counterparts (< 75 years) (219 lesions and 635 lesions, respectively). Major adverse cardiac events (MACE) including cardiac death, non-fatal myocardial infarction, and target lesion revascularization (TLR) during 2-year follow-up were recorded. Despite similar angiographic in-stent restenosis and TLR and IVUS-detected incomplete stent apposition (ISA), absolute intimal hyperplasia and percentage of volumetric obstruction were lower in elderly than in younger patients. At 2-year follow-up, cumulative survival freedom from composite death and myocardial infarction or MACE was significantly reduced in elderly patients, but very late stent thrombosis was similar in the two groups. Cox proportional hazards model identified age, diabetes, left ventricular ejection fraction, lesion length,minimal stent cross-sectional area and plaque progression as independent predictors of non-fatal myocardial infarction or mortality. In elderly patients undergoing SES-based PCI, despite similar TLR, neointimal hyperplasia was significantly lower than in younger patients. IVUS measurements except for minimal stent cross-sectional area did not correlate with stent thrombosis and clinical outcomes at 2 years.

Impact of angiographic and intravascular ultrasound features on clinical outcome after sirolimus-eluting stent implantation for de-novo lesions in nondiabetic and type 2 diabetic patients

This study aimed to evaluate the impact of angiographic and intravascular ultrasound (IVUS) features on clinical outcome in nondiabetic and type 2 diabetic patients after percutaneous coronary intervention (PCI) with sirolimus-eluting stent (SES) implantation. Repeat coronary angiography with IVUS imaging was performed after SES-based PCI for de-novo lesions in 128 diabetic and 327 nondiabetic patients (189 lesions and 504 lesions, respectively). The rate of major adverse cardiac events including cardiac death, non fatal myocardial infarction (MI), and target lesion revascularization during clinical follow-up was recorded. In-stent and in-segment late loss, intimal hyperplasia volume, and percentage volumetric obstruction were similar, but stented external elastic membrane cross-sectional area and reference/stented segment ratio were lower in diabetic than in nondiabetic patients. Incomplete stent apposition (ISA) was less frequent, but occurrence of new coronary lesions was higher in diabetic than in nondiabetic patients. Despite similar target lesion revascularization, cumulative survival rates freedom from composite cardiac death and nonfatal MI or major adverse cardiac events were reduced in diabetic patients. Cox proportional hazards model identified diabetes, left ventricular ejection fraction, minimal stent CSA, maximal ISA area, atherosclerotic progression and lesion length as independent predictors of non fatal MI or mortality at follow-up. In diabetic patients, PCI with SES implantation neutralizes the excess risk of intimal hyperplasia and decreases occurrence of ISA, but could not modify the propensity of increased adverse clinical outcomes at follow-up.

A Predictive Instrument Using Contrast Echocardiography in Patients Presenting to the Emergency Department with Chest Pain and without ST-Segment Elevation

Risk stratification of patients presenting to the emergency department (ED) with suspected cardiac chest pain (CP) and an undifferentiated electrocardiogram (ECG) is difficult. We hypothesized that in these patients a risk score incorporating clinical, ECG, and myocardial contrast echocardiography (MCE) variables would accurately predict adverse events occurring within the next 48 hours. Patients with CP lasting for 30 minutes or more who did not have ST-segment elevation on the ECG, were enrolled. Regional function (RF) and myocardial perfusion (MP) were assessed by MCE. A risk model was developed in the initial 1166 patients (cohort 1) and validated in subsequent 720 patients (cohort 2). Any abnormality or ST changes on ECG (odds ratio [OR] 2.5; 95% confidence interval [CI], 1.4-4.5, P = .002, and OR 2.9, 95% CI, 1.7-4.8, P < .001, respectively), abnormal RF with normal MP (OR 3.5, 95% CI, 1.8-6.5, P < .001), and abnormal RF with abnormal MP (OR 9.6, 95% CI, 5.8-16.0, P < .001) were found to be significant multivariate predictors of nonfatal myocardial infarction or cardiac death. The estimate of the probability of concordance for the risk model was 0.82 for cohort 1 and 0.83 for cohort 2. The risk score in both cohorts stratified patients into 5 distinct risk groups with event rates ranging from 0.3% to 58%. A simple predictive instrument has been developed from clinical, ECG, and MCE findings obtained at the bedside that can accurately predict events occurring within 48 hours in patients presenting to the ED with suspected cardiac CP and an ECG that is not diagnostic for acute ischemic injury. Its application could enhance care of patients with CP in the ED. For instance, patients with a risk score of 0 could be discharged from the ED without further workup. However, this needs to be validated in a multicenter study.

Prognostic implications of vascular complications following PCI

To evaluate the effect of vascular complications (VC) on the adjusted risk of nonfatal myocardial infarction (MI) or death following percutaneous coronary intervention (PCI) at 1 year in a large contemporary cohort. Peri-procedural bleeding increases the risk of adverse clinical outcomes at 1 year. Whether access site VC's identify patients at high risk or independently alter the risk of adverse clinical outcomes at 1 year, however, is uncertain. 3,931 PCI procedures performed via a femoral access at a single site (WFUBMC) were evaluated. Access and nonaccess site post procedural bleeding were assessed. The adjusted risk of access site VC's association with 1-year clinical outcomes was evaluated by Cox proportional hazards modeling. Any VC occurred in 1.7%, and any TIMI bleeding in 6.7% after PCI. The hazard ratio (HR) adjusted for baseline and procedural covariates for any VC of nonfatal MI or all cause death at 1 year was 1.68 (1.00-2.81), P = 0.049 and 1.69 (0.92-3.09), P = 0.088 for all cause death alone. However, after adjusting for any TIMI bleeding, the HR for nonfatal MI or death was 0.84 (0.49-1.45), P = 0.527, and for death alone 0.75 (0.39-1.41), P = 0.369. The occurrence of VC following PCI was an independent predictor of nonfatal MI or death at 1 year, but only if accompanied by TIMI major or minor bleeding. A vascular complication without TIMI bleeding did not alter prognosis at 1 year.

A predictive model using myocardial contrast echocardiography for patients presenting to the emergency department with chest pain and a nondiagnostic electrocardiogram.

Risk stratification of patients presenting to an emergency department (ED) with suspected cardiac chest pain (CP) and an undifferentiated electrocardiogram (ECG) is difficult. We hypothesized that a risk score incorporating clinical, ECG, Rand contrast echocardiography variables [regional function (RF) and myocardial perfusion (MP)] obtained at the bedside would accurately predict adverse events in occurring within 48 h of ED presentation. A logistic risk model was developed in the initial 1166 patients (cohort 1), and validated in another 720 patients (cohort 2). Any abnormality or ST‐T changes on ECG (OR 2.5, 95% CI:1.4–4.5, p=0.002, and OR 2.9, 95% CI:1.7–4.8, p=0.001, respectively), abnormal RF with normal MP (OR 3.5, 95% CI:1.8–6.5, p=0.001), and abnormal RF with abnormal MP (OR 9.6, 95% CI:5.8–16.0, p=0.001) were found to be significant multivariate predictors of nonfatal myocardial infarction or cardiac death. The estimate of the probability of concordance for the risk model was 0.82 for cohort 1. Likewise, in cohort 2, the c‐index for the risk model was 0.83. In conclusion, a model based on variables obtained at the patient’s bedside can be used to accurately risk stratify patients presenting to the ED with suspected cardiac CP and a nondiagnostic ECG. Its application could enhance care of CP patients in the ED.

Prediction of Myocardial Infarction Versus Cardiac Death by Stress Echocardiography

The echocardiography literature to date has considered cardiac death and myocardial infarction (MI) as a combined end point. The purposes of the present study were to evaluate the differential prognosis of nonfatal MI versus cardiac death in patients undergoing stress echocardiography and to effectively risk stratify patients using the appropriate combination of functional, ischemic, and infarction data. The authors evaluated 3,259 patients (mean age, 59 +/- 13 years; 48% men) undergoing stress echocardiography. Follow-up (mean, 2.8 +/- 1.1 years) for confirmed nonfatal MI (n = 91) and cardiac death (n = 105) was obtained. Multivariate analysis showed that the strongest predictor of cardiac death was a low ejection fraction (chi(2) = 37.3, P < .0001), and the strongest predictor of nonfatal MI was the extent of ischemia (chi(2) = 12.3, P < .0001). The relationship between ejection fraction and cardiac death rate was an exponential curve (y = 16.91e(-0.50x); r = -0.99, P < .0001). Among patients with ejection fractions > 30% (the low-risk to intermediate-risk groups), peak wall motion score index (WMSI) was able to further risk stratify patients into a very low risk group (peak WMSI = 1.0; cardiac death rate, 0.26% per year) and a higher risk group (peak WMSI > 1.7; cardiac death rate, 2.56% per year). However, patients with ejection fractions < 30% had high cardiac death risk regardless of peak WMSI category. In patients referred for stress echocardiography, the integration of functional information (on the basis of ejection fraction) and ischemic and infarction data (on the basis of WMSI) effectively risk stratifies patients for the outcome-specific end points of cardiac death and nonfatal MI.

High prevalence of metabolic syndrome among young women with nonfatal myocardial infarction.

The aim of this study was to determine if the metabolic syndrome (MetS) or other risk factors might be common among young women with nonfatal myocardial infarction (MI). A matched case-control study using a structured interview and questionnaires, plus analysis of conventional and nonconventional risk factors for MI in serum or plasma was carried out at a teaching hospital. Subjects were 40 women with nonfatal MI at or before age 45 and an equal number of age-matched, ethnicity-matched, and smoking-matched female control subjects. Cases and control subjects were not significantly different with regard to serum or plasma levels of homocysteine, anticardiolipin antibodies, beta(2)-glycoprotein I, prothrombin, folate, vitamin B(12), high-sensitivity C-reactive protein (CPR), fibrinogen, amyloid A, plasminogen activator inhibitor type 1 (PAI-1), or tissue plasminogen activator (tPA) antigen levels. Compared with matched controls, cases had a higher rate of obesity (37% vs. 12%, p = 0.02), a higher proportion of fasting glucose >/=110 mg/dl (9% vs. 1%, p = 0.01), and higher overall insulin resistance (27% vs. 5%, p = 0.007). Type 2 diabetes tended to be more common in cases (17% vs. 5%, p = 0.10). Cases were also more likely to be hypertensive (35% vs. 12%, p = 0.04) and dyslipidemic (80% vs. 42%, p = <0.001) and to have higher triglyceride levels (110 +/- 13 mg/dl vs. 96 +/- 12, p = 0.02). Overall, after controlling for weight, cases were 4.7 times more likely to have three or more diagnostic criteria of the MetS than matched controls: chi-square = 7.2, OR = 4.7, 95% CI (1.3, 25.3), p = 0.008. Although this study may have been underpowered to recognize the contribution of other risk factors, we found that the dominant predictor of nonfatal MI in young women was the MetS. Screening young women with central obesity for other parameters of the MetS may help reduce the risk of MI at an early age.

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