Prevalence Of Angiographic Coronary Artery Disease Research Articles

Effect of Metabolic Syndrome Score, Metabolic Syndrome, and Its Individual Components on the Prevalence and Severity of Angiographic Coronary Artery Disease.

Background:The clinical significance of metabolic syndrome (MS) score, MS, and its individual components with respect to risk prediction of coronary artery disease (CAD) remains unclear. The objective of this study was to investigate whether and to what extent MS score, MS, and its individual components were related to the risk of CAD.Methods:Among 1191 participants who underwent coronary angiography for the confirmation of suspected myocardial ischemia, 858 were included in this study according to the inclusion criteria from September 2010 to June 2013. MS was diagnosed with the 2005 National Cholesterol Education Program Adult Treatment Panel III criteria. The severity of coronary atherosclerosis was assessed by Gensini score.Results:The results showed that the age- and sex-adjusted odds ratios (ORs) for CAD were as follows: MS score, 1.327; MS, 2.013; elevated waist circumference, 1.447; reduced high-density lipoprotein cholesterol, 1.654; and elevated fasting glucose, 1.782; all P < 0.05; whereas for elevated triglycerides, 1.324, and elevated blood pressure, 1.342, both P > 0.05. After multivariate adjustment, results showed that only MS and elevated fasting glucose were significantly associated with CAD (OR, 1.628, 95% confidence interval [CI], 1.151–2.305, P = 0.006 for elevated fasting glucose, and OR, 1.631, 95% CI, 1.208–2.203, P = 0.001 for MS). The study showed that only MS score and elevated fasting glucose were significantly associated with Gensini score (standardized coefficient, 0.101, P = 0.031 for elevated fasting glucose and standardized coefficient, 0.103, P = 0.009 for MS score).Conclusions:The present study demonstrated that MS score, MS, and its individual components might have different contributions to CAD prevalence and severity. MS and elevated fasting glucose were independent risk factors for the prevalence of angiographic CAD whereas MS score and elevated fasting glucose were significantly associated with the severity of CAD.

Stress thallium-201/rest technetium-99m sequential dual-isotope high-speed myocardial perfusion imaging validation versus invasive coronary angiography

BackgroundRecent advances in nuclear myocardial perfusion imaging (MPI) have made it possible to develop a dual-isotope protocol for high-speed acquisition with image quality and radiation delivery comparable to that obtained with conventional single isotope protocols. So far, no study has compared dual-isotope high-speed MPI to invasive coronary angiography (ICA) in a large cohort using a Cadmium-zinc-telluride SPECT system. MethodsOver a 1-year period (May 2011 to April 2012), 1366 patients underwent dual-isotope high-speed MPI. Patients with ICA within 3 months after dual-isotope high-speed MPI were included together with patients with a low likelihood of coronary artery disease (CAD) in order to assess normalcy rate. Global summed stress score (SSS) and summed rest score (SRS) were calculated, and ICA results were analyzed independently. The main end point was a patient-based assessment of the diagnostic performance of dual-isotope high-speed MPI in detecting or ruling out significant CAD (>70% reduction in lumen diameter). ResultsInclusion criteria were fulfilled for 214 patients (143 men; age 60 ± 14 years; ICA, n = 104; low likelihood for CAD, n = 110). An exercise stress test was performed in 62% of patients and a pharmacological stress test was performed with either dipyridamole (32%) or dobutamine (6%). Average examination duration was 22.4 ± 4.5 minutes. Mean SSS, SRS, and SDS were 8.0 ± 4.9, 3.1 ± 4.3, and 5.0 ± 3.2, respectively. Prevalence of angiographic CAD was 75%. ICA detected stenosis in the left main trunk, left anterior descending artery, left circumflex artery, and right coronary artery in 4, 33, 31, and 42 patients, respectively. Sensitivity of dual-isotope high-speed MPI was 94%, normalcy rate was 92%, and accuracy was 83% for detecting CAD. ConclusionDual-isotope high-speed MPI is reliable at detecting or ruling out CAD. NCT01785589

Validation and Quantification of Genetic Determinants of Lipoprotein-a Levels and Predictive Value for Angiographic Coronary Artery Disease

Lipoprotein(a) (Lp[a]) has gained attention as a heritable coronary artery disease (CAD) risk factor and therapeutic target. Two genetic variants in the LPA gene have been reported to influence Lp(a) levels and increase CAD risk. The aim of this study was to prospectively test these variants for their associations with Lp(a) and CAD risk. Participants (n = 1,400) in the Intermountain Heart Collaborative Study Registry who had Lp(a) cholesterol levels determined at coronary angiography were genotyped for rs3798220 and rs1045587 in LPA. Variants were detected by Taqman polymerase chain reaction. Chi-square and linear and logistic regression tests were used as appropriate among genotypes for Lp(a) and angiographic CAD. Age averaged 63 years; 65% were men; and severe CAD was present in 57%, mild CAD in 12%, and no CAD in 31%. Minor allele frequencies were 0.023 for rs3798220 and 0.090 for rs10455872. In multivariate modeling, only rs10455872 (odds ratio [OR] 2.33, 95% confidence interval [CI] 1.67 to 3.33, p = 1.75 × 10⁻⁹) and rs3798220 (OR 1.99, 95% CI 0.99 to 4.00, p = 0.065) contributed to the prediction of elevated Lp(a) cholesterol. Lp(a) cholesterol was weakly associated with CAD (OR 1.17, 95% CI 1.00 to 1.37, p = 0.055). Rs10455872 strongly predicted prevalent CAD (per allele OR 1.43, 95% CI 1.07 to 1.91, p = 0.0172); the effect size for the rare rs3798220 variant was similar (dominant OR 1.47, 95% CI 0.81 to 2.67, p = 0.20), but power was limited to demonstrate significance. The combined genotype explained only a small percentage (≤4%) of variability in Lp(a) cholesterol and prevalence of angiographic CAD. In conclusion, heritable contributions of LPA rs10455872 and rs3798220 to Lp(a) cholesterol levels and to angiographic CAD were prospectively assessed in this study. The percentage of intersubject variability in Lp(a) cholesterol and the percentage of prevalent CAD explained were small.

Paradoxical protective effect of central obesity in patients with suspected stable coronary artery disease

Increased body mass index (BMI) has been paradoxically inversely associated with the presence of angiographic coronary artery disease (CAD). Central obesity measures, considered to be more appropriate for assessing obesity-related cardiovascular risk, have been little studied in relation to the presence of CAD. The aim was to investigate the association of central obesity with the presence of angiographic CAD as well as the prognostic significance of obesity measures in CAD prediction when added to other cardiovascular risk factors. Patients with suspected stable CAD (n = 403, age 61 ± 10 years, 302 males) referred for diagnostic coronary angiography with documented anthropometric data were enrolled. Significant angiographic CAD was found in 51% of patients. Both BMI (OR = 0.64 per 1 SD increase, P = 0.001) and waist circumference (WC) (OR = 0.54 per 1 SD increase, P < 0.001) were inversely associated with the presence of CAD even after adjustment for cardiovascular risk factors. In subgroup analysis, BMI and WC were significantly inversely associated with the presence of CAD in males, non diabetics, patients >60 years old and patients with Framingham risk score (FRS) >20% (P < 0.01 for all). The addition of BMI or WC in FRS-based regression models improved prediction of CAD (P = 0.03 and P < 0.001 for BMI and WC respectively) without a significant difference between the two models (P = 0.08). Central and overall obesity were independently associated with a reduced prevalence of angiographic CAD, lending further credence to the existence of the 'obesity paradox'. Obesity measures may further improve risk discrimination for the presence of CAD when added in an established risk score such as FRS.

Association of fasting plasma glucose with the prevalence and severity of angiographic coronary artery disease in population with no history of diabetes

A total of 906 subjects with no history of diabetes who had undergone coronary angiography were included in this study and categorized into four groups according to the level of fasting plasma glucose (FPG):≤5.5 mmoL/L,5.6-6.0 mmol/L,6.1-6.9 mmoL/L,and ≥ 7.0 mmol/L.Significant coronary artery disease (CAD) was defined as ≥ 50％ reduction of lumen diameter at least in one major coronary artery.The severity of coronary atherosclerosis was defined by the Gensini score.The clinical data,laboratory indexes,and coronary angiography results were compared among various groups.The risk factors for the prevalence and severity of angiographic CAD were analyzed.The results showed that the prevalence of angiographic CAD,the number of diseased vessels,and the Gensini score were increasing with increasing FPG levels among four groups (P＜0.05 or P＜0.01).The FPG level was significantly correlated with angiographic CAD (P =0.004) and the Gensini score (P =0.010),suggesting that FPG was an independent risk factor for the prevalence and severity of angiographic CAD. Key words: Fasting plasma glucose; Coronary artery disease; Coronary angiography

Fasting plasma glucose correlates with angiographic coronary artery disease prevalence and severity in Chinese patients without known diabetes

Type 2 diabetes mellitus is a risk factor for coronary artery disease (CAD). While there is a clear association of fasting plasma glucose (FPG) with microvascular complications, the risk for CAD conferred by FPG is relatively less clear. Therefore, we investigate the association between different FPG and the prevalence and severity of angiographic CAD in high-risk Chinese patients without known diabetes. Among 1,419 subjects who were to undergo coronary angiography for the confirmation of suspected myocardial ischemia, 906 subjects without known diabetes were included in this study and categorized into four groups according to the level of FPG: group 1, ≤5.5 mmol/l; group 2, 5.6-6.0 mmol/l; group 3, 6.1-6.9 mmol/l; and group 4, ≥7.0 mmol/l. Significant angiographic CAD was defined as ≥50 % lumen diameter reduction in at least one major coronary artery in a given subject. The severity and extent of coronary atherosclerosis were defined as the number of diseased vessels, the proportion of totally occluded vessel and the Gensini score. Associations between FPG and the prevalence and severity of CAD were assessed by logistic and linear stepwise regression analyses. The angiographic CAD prevalence, the number of diseased vessels, the totally occluded vessel, and the Gensini score increased corresponding to increasing FPG levels from ≤5.5 mmol/l to 5.6-6.0 mmol/l to 6.1-6.9 mmol/l to ≥7.0 mmol/l (P < 0.05). The FPG had significant association with angiographic CAD (adjusted OR, 1.53; 95 % CI, 1.19-1.98; P = 0.001) and the Gensini score (standardized regression coefficient = 0.172, P = 0.011). Compared with group 1, group 2, 3 and 4 demonstrated significantly higher CAD prevalence after adjustment (adjusted OR, 1.61 [1.16-2.19]; P = 0.015 for group 2; 1.49 [1.11-2.59]; P = 0.027 for group 3; and 4.19 [2.85-6.16]; P = 0.024 for group 4, respectively). FPG group was also significantly associated with the Gensini score (Standardized coefficients, 0.185; P = 0.007, respectively). FPG was an independent risk factor for the prevalence and severity of significant angiographic CAD in our study population. The severity of angiographic CAD increased along with the increasing FPG levels even in prediabetic state.

Nuclear myocardial perfusion imaging with a novel cadmium-zinc-telluride detector SPECT/CT device: first validation versus invasive coronary angiography

We evaluated the diagnostic accuracy of attenuation corrected nuclear myocardial perfusion imaging (MPI) with a novel hybrid single photon emission computed tomography (SPECT)/CT device consisting of an ultrafast dedicated cardiac gamma camera with cadmium-zinc-telluride (CZT) solid-state semiconductor detectors integrated onto a multislice CT scanner to detect coronary artery disease (CAD). Invasive coronary angiography served as the standard of reference. The study population included 66 patients (79% men; mean age 63 ± 11 years) who underwent 1-day (99m)Tc-tetrofosmin pharmacological stress/rest examination and angiography within 3 months. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) as well as accuracy of the CT X-ray based attenuation corrected CZT MPI for detection of CAD (≥ 50% luminal narrowing) was calculated on a per-patient basis. The prevalence of angiographic CAD in the study population was 82%. Sensitivity, specificity, PPV, NPV and accuracy were 87, 67, 92, 53 and 83%, respectively. In this first report on CZT SPECT/CT MPI comparison versus angiography we confirm a high accuracy for detection of angiographically documented CAD.

Apolipoprotein E genotypes, circulating C-reactive protein and angiographic coronary artery disease: The Ludwigshafen Risk and Cardiovascular Health Study

C-reactive protein (CRP) has been implicated in the development of atherosclerosis. The genetic polymorphism of apolipoprotein (apo) E is associated with the concentration of CRP. We analyzed the association between the apo E genotype, CRP and angiographic coronary artery disease (CAD). The concentration of CRP was similar in patients with stable CAD and in controls, but increased in patients presenting with acute coronary syndromes. In models adjusting for the main confounding variables, the alleles ɛ4 and ɛ2 were associated with decreased and increased concentrations of CRP, respectively, compared to the wild-type allele ɛ3. In spite of this, the ɛ2 allele was associated with a lower prevalence of angiographic CAD, while the slight over-representation of the ɛ4 allele was statistically not significant. We conclude that the apo E genotype is associated with circulating CRP. A causal role of CRP in the development of CAD would be supported if genotypes that raise CRP in the long-term were themselves associated with CAD. As we found the opposite, we suggest that the association between CRP and cardiovascular events reflects confounding and reverse causation.

Lipoprotein(a) levels and long-term cardiovascular risk in the contemporary era of statin therapy

Lipoprotein(a) [Lp(a)] has enhanced atherothrombotic properties. The ability of Lp(a) levels to predict adverse cardiovascular outcomes in patients undergoing coronary angiography has not been examined. The relationship between serum Lp(a) levels and both the extent of angiographic disease and 3-year incidence of major adverse cardiovascular events (MACE: death, myocardial infarction, stroke, and coronary revascularization) was investigated in 2,769 patients who underwent coronary angiography [median Lp(a) 16.4 mg/dl, elevated levels (≥30 mg/dl) in 38%]. An elevated Lp(a) was associated with a 2.3-fold [95% confidence interval (CI), 1.7-3.2, P < 0.001] greater likelihood of having a significant angiographic stenosis and 1.5-fold (95 CI, 1.3-1.7, P < 0.001) greater chance of three-vessel disease. Lp(a)≥30 mg/dl was associated with a greater rate of MACE (41.8 vs. 35.8%, P = 0.005), primarily due to a greater need for coronary revascularization (30.9 vs. 26.0%, P = 0.02). A relationship between Lp(a) levels and cardiovascular outcome was observed in patients with an LDL cholesterol (LDL-C) ≥70-100 mg/dl (P = 0.049) and >100 mg/dl (P = 0.02), but not <70 mg/dl (P = 0.77). Polymorphisms of Lp(a) were also associated with both plasma Lp(a) levels and coronary stenosis, but not a greater rate of MACE. Lp(a) levels correlate with the extent of obstructive disease and predict the need for coronary revascularization in subjects with suboptimal LDL-C control. This supports the need to intensify lipid management in patients with elevated Lp(a) levels.

Non-diabetic hyperglycaemia correlates with angiographic coronary artery disease prevalence and severity

Aim The role of glycaemia as a coronary artery disease (CAD) risk factor is controversial, and the optimal glucose level is still a matter of debate. For this reason, we assessed the prevalence and severity of angiographic CAD across hyperglycaemia categories and in relation to haemoglobin A 1c (HbA 1c) levels. Methods We studied 273 consecutive patients without prior revascularization undergoing coronary angiography for suspected ischaemic pain. CAD severity was assessed using three angiographic scores: the Gensini's score; extent score; and arbitrary index. Patients were grouped, according to 2003 American Diabetes Association criteria, into those with normal fasting glucose (NFG), impaired fasting glucose (IFG) and diabetes mellitus (DM). Results CAD prevalence was 2.5-fold higher in both the IFG and DM groups compared with the NFG group. Deterioration of glycaemic profile was a multivariate predictor of angiographic CAD severity (extent score: P = 0.027; arbitrary index: P = 0.007). HbA 1c levels were significantly higher among CAD patients ( P = 0.016) and in those with two or more diseased vessels ( P = 0.023) compared with the non-CAD group. HbA 1c levels remained predictive of CAD prevalence even after adjusting for conventional risk factors, including DM (adjusted OR: 1.853; 95% CI: 1.269–2.704). Conclusion Non-diabetic hyperglycaemia, assessed either categorically by fasting glucose categories or continuously by HbA 1c levels, correlates with the poorest angiographic outcomes.

Metabolic Syndrome and Angiographic Coronary Artery Disease Prevalence in Association with the Framingham Risk Score

The association of metabolic syndrome with coronary artery disease (CAD) has been studied extensively. However, little is known about the effect of Framingham risk score (FRS) and metabolic syndrome components on the association of metabolic syndrome with angiographically significant CAD. Our aim was to investigate whether that relationship is influenced by individual's 10-year CAD risk profile as assessed by FRS. Furthermore, we sought to elucidate whether metabolic syndrome is associated with angiographically significant CAD independently of its individual components. We studied a consecutive sample of 150 patients undergoing coronary angiography for the evaluation of chest pain. Metabolic syndrome was defined according to the revised National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria, and the 10-year CAD risk was estimated by the FRS. Metabolic syndrome patients had a 2-fold higher CAD prevalence compared to those without metabolic syndrome [odds ratio (OR), 2.004; 95% confidence interval (CI), 1.029-3.905] but this finding was attenuated after adjustment for FRS (OR, 1.770; 95% CI, 0.872-3.594). Stratification of patients into three groups according to FRS revealed that metabolic syndrome predictive ability was confined in those being at <10% 10-year CAD risk. Including metabolic syndrome and its individual components into the same logistic regression model, only the glucose criterion was an independent predictor of angiographically significant CAD (OR, 4.137; 95% CI, 1.477-11.583). Metabolic syndrome is an independent determinant of angiographically significant CAD only among those individuals at low 10-year risk for future coronary events. Individual components of the syndrome, such as impaired fasting glucose, have a stronger association with CAD than the syndrome as a whole.

Left anterior descending artery length and coronary atherosclerosis in apical ballooning syndrome (Takotsubo/stress induced cardiomyopathy)

A proposed etiology of apical ballooning syndrome (ABS) is a spontaneously aborted anterior myocardial infarction (MI) in patients with a long "wrap around" left anterior descending artery (LAD) rather than it being a unique cardiomyopathy. The aim of this study was to evaluate whether patients with ABS have a higher frequency of "wrap around" LAD. A retrospective analysis of the coronary anatomy and presence of coronary artery disease (CAD) by angiography was performed among 97 ABS patients, and compared to a matched control group with anterior ST-elevation MI. LAD length was graded: type 1--does not supply the left ventricular (LV) apex, type 2--the LAD and right coronary both supply the apex, type 3--supplies the entire apex, and type 4--supplies the apex and >25% of the inferior wall (wrap around). ABS patients had lower ejection fractions at presentation (41% ± 14% vs 47% ± 13%, p=0.001). There was no difference in the frequency of the 4 types of LAD between ABS (7%, 11%, 55%, 27%) and controls (3%, 13%, 51%, 33%), p=0.45. In ABS, there was no difference in the mean LV ejection fraction (32.7%, 38.8%, 42.9%, 41.1%, respectively, p=0.39), or wall motion score index at presentation in the 4 LAD groups. The prevalence of angiographic CAD in ABS was 84%. ABS patients do not have a higher frequency of "wrap around" LAD. This fact, together with a greater magnitude of LV dysfunction at presentation, supports that cardiomyopathy is not due to spontaneously aborted anterior MI.

Genetic variation at the 9p21 locus predicts angiographic coronary artery disease prevalence but not extent and has clinical utility

Variants at the 9p21 locus have been associated with coronary heart disease, but their precise disease phenotype and utility for clinical risk assessment are uncertain. Consenting patients with early-onset angiographic coronary artery disease (CAD) (n = 1,011) were compared with matched subjects (n = 545) free of angiographic disease and with a random population sample (n = 565). Cases and controls were genotyped for 4 variants, and ORs for angio-CAD were determined. Findings were validated in a separate set of cases and controls (n = 1,452). Alleles were highly correlated (r(2) > or = 0.9), and all predicted angio-CAD compared with both control groups. Genotype at rs2383206 (minor allele frequency 45.9%), the most predictive (P < .0001), was associated with an adjusted odds ratio for angio-CAD of 1.39 (95% CI, 1.05-1.85) for heterozygote and 1.73 (1.26-2.37) for homozygote risk-allele carriers and explained 21% of population attributable risk and was independent of traditional risk factors and myocardial infarction. For the comparison of combined cases versus combined control samples (N = 3,573), CAD was predicted by high-risk allele homozygosity at P = 9 x 10(-8). Despite this, extent of disease was not increased. Applied to patients with intermediate Framingham risk scores, 9p21 genotyping modified risk classification in 24%. Variants at the 9p21 locus robustly predict angiographic CAD prevalence, independent of standard risk factors, but not CAD extent or myocardial infarction; provide pathophysiological insights; and may be clinically useful in refining coronary heart disease risk classification.

Sex Differences in Congenital Heart Disease

Sex differences in the clinical presentation, diagnosis, and treatment outcomes of cardiac disease have long been recognized. Since the mid-1980s, the total number of deaths from cardiovascular disease has been higher for women than for men. A greater proportion of women (52%) than men (42%) with myocardial infarction die of sudden cardiac death before reaching the hospital, perhaps in part because women tend to have nonspecific prodromal symptoms rather than chest pain and these symptoms are not recognized as being cardiac in origin.1 Even after acute myocardial infarction, women are 46% less likely to undergo coronary angiography than men, despite accounting for confounders.2 Two-thirds of women who suffer a myocardial infarction never completely recover,3,4 and those who do survive have a 2-fold recurrence of myocardial infarction and mortality during the first year compared with their male counterparts.5 Article p 26 Women with stable angina have higher in-hospital mortality rates6 and worse outcomes after coronary interventions, both percutaneous and surgical. Following percutaneous coronary interventions women have higher rates of short- and long-term mortality, cardiac events, and the need for emergency coronary artery bypass grafting. This may relate to the comparatively smaller coronary artery size of women,7 although this is unproven.8 Higher mortality and complication rates of coronary artery bypass grafting also occur, with women obtaining less functional relief, more frequent hospital readmissions, and lower functional gains than their male counterparts.9 Whether some of these sex disparities relate to an autoimmune precursor for atherosclerotic disease remains speculative. Sex-specific differences in C-reactive protein, as an inflammatory marker, are consistent with the 10-fold increased frequency of inflammatory-mediated autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and thyroiditis in women compared with men.4,10 Recent studies report atherosclerotic plaque in both the carotid and coronary arteries …

C-reactive protein genotypes associated with circulating C-reactive protein but not with angiographic coronary artery disease: the LURIC study

Circulating C-reactive protein is associated with future cardiovascular events. The causal role of C-reactive protein in the development of atherosclerosis remains controversial. We analysed the association between three genetic polymorphisms (PM) (-717C>T, rs2794521; +1059G>C, rs1800947; +1444C>T, rs1130864) at the C-reactive protein locus and related haplotypes with both circulating C-reactive protein and angiographic coronary artery disease (CAD). The concentration of C-reactive protein was similar in patients with stable CAD and in controls, but increased in patients presenting with acute coronary syndromes. In models adjusting for the main confounding variables, the minor alleles of the +1059G>C (rs1800947) and the +1444C>T PM (rs1130864) were associated with decreased and increased concentrations of C-reactive protein, respectively. Haplotypes 1 and 4 decreased, and haplotype 2 increased C-reactive protein, whereas haplotype 3 had no appreciable effect. None of the genetic variants affecting circulating C-reactive protein was consistently associated with the prevalence of angiographic CAD. A causal role of C-reactive protein in the development of CAD would require that genetic PM resulting in long-term modulation of the concentration of C-reactive protein be themselves associated with CAD. We were not able to detect such a relationship, which can be attributed to either a very small genetic effect size or the relationship between C-reactive protein and cardiovascular events may reflect confounding and reverse causation.

Impact of Ethnicity and Gender Differences on Angiographic Coronary Artery Disease Prevalence and In-Hospital Mortality in the American College of Cardiology–National Cardiovascular Data Registry

Although populations referred for coronary angiography are increasingly diverse, there is limited information on coronary artery disease (CAD) prevalence and in-hospital mortality other than for predominately white male patients. We examined gender and ethnic differences in CAD prevalence and in-hospital mortality in a prospective cohort of patients referred for angiographic evaluation of stable angina (n=375,886) or acute coronary syndromes (ACS; unstable angina or myocardial infarction, n=450,329) at 388 US hospitals participating in the American College of Cardiology-National Cardiovascular Data Registry, an angiographic registry. Univariable and multivariable (with covariates that included risk factors, symptoms, and comorbidities) logistic regression models were used to estimate significant CAD, defined as > or = 70% stenosis, and in-hospital mortality. Within stable angina and ACS cohorts, 7% of patients were black, 2% were Hispanic, 0.3% were Native American, 1% were Asian, and 90% were white, respectively. In stable angina, the risk-adjusted OR for significant CAD was 0.34 for women compared with men (P<0.0001), with black women having the lowest risk-adjusted odds (P<0.0001) compared with other females. Among ACS patients, the risk-adjusted OR of significant CAD was 0.47 for women compared with men (P<0.0001); similarly, black women had the lowest risk-adjusted odds (P<0.0001) compared with other females. Higher in-hospital mortality was reported for white women presenting with stable angina (P<0.00001). White women had a 1.34-fold (95% CI 1.21 to 1.48) higher risk-adjusted odds ratio for mortality than white men with stable angina (P<0.0001), with higher rates noted for white women who were older or had significant CAD (both P<0.0001). Lower utilization of elective coronary revascularization, aspirin, and glycoprotein IIb/IIIa inhibitors (all P<0.0001) may have contributed to higher in-hospital mortality for white women. In ACS, higher in-hospital mortality was reported for Hispanic (P=0.015) and white (P<0.0001) women; however, neither white (P=0.51) or Hispanic (P=0.13) women had higher in-hospital risk-adjusted mortality. The likelihood for significant CAD at coronary angiography and for in-hospital mortality varied significantly by ethnicity and gender. Future clinical practice guidelines should be tailored to gender subsets of the population, in particular for black women, to improve the efficient use of angiographic laboratories and to target at-risk populations of women and men.

Impaired fasting glucose and the prevalence and severity of angiographic coronary artery disease in high-risk Chinese patients

We assessed the relation between different fasting plasma glucose (FPG) levels of 5.6 to 6.9 mmol/L and the prevalence and severity of angiographic coronary artery disease (CAD) in high-risk Chinese patients. Among 512 subjects who were to undergo coronary angiography for the confirmation of suspected myocardial ischemia, 409 subjects were enrolled and categorized into 3 groups based on FPG levels: (1) ≤5.5 mmol/L, (2) 5.6 to 6.0 mmol/L, and (3) 6.1 to 6.9 mmol/L. Each of these groups was further divided into subgroups by sex; the second and third groups were combined as an additional group according to the 2003 definition of impaired fasting glucose (FPG at 5.6-6.9 mmol/L). We analyzed the coronary artery stenosis score, the prevalence of angiographic CAD, and the percentage of stenosis in the 3 main arteries among the groups and examined the risk factors for angiographic CAD prevalence by logistic regression analysis. A higher correlation was observed between angiographic CAD prevalence and FPG levels of 6.1 to 6.9 mmol/L as compared with FPG levels ≤5.5 mmol/L (adjusted odds ratio [OR], 2.67; 95% confidence interval [CI], 1.72-4.10; P = .011). The FPG levels of 5.6 to 6.9 mmol/L (adjusted OR, 2.57; 95% CI, 1.65-4.02; P < .001) and 5.6 to 6.0 mmol/L (adjusted OR, 2.33; 95% CI, 1.58-3.49; P = .008) were modestly correlated with angiographic CAD prevalence. The angiographic CAD prevalence, coronary artery stenosis score, and the percentage of stenosis in the left anterior descending branch increased corresponding to increasing FPG levels from ≤5.5 mmol/L to 5.6 to 6.0 mmol/L to 6.1 to 6.9 mmol/L. We concluded that FPG levels of 5.6 to 6.9 mmol/L as well as of 6.1 to 6.9 mmol/L may be an independent risk factor for angiographic CAD; furthermore, there was a progressive and graded relation between FPG levels of 5.6 to 6.9 mmol/L and angiographic CAD prevalence and severity in high-risk Chinese patients.

Angiographic, Pathologic, and Clinical Relationships in Coronary Artery Disease in Cardiac Allografts

To date, the etiologic factors involved in the development of allograft coronary disease remain speculative and the treatment uncertain. The purpose of this study was to review the relationship of clinical, angiographic, and pathologic features of cardiac allograft vascular disease in a large population of heart transplant recipients followed for up to 15 years. From 1981 to 1996, 789 angiograms from 255 cardiac allografts were reviewed to determine the prevalence and severity of coronary artery disease. Demographic, clinical, and laboratory variables were analyzed to identify factors associated with the presence of angiographic coronary artery disease. In addition, pathologic examination was performed on many of the lost grafts. Unsuspected severe donor coronary artery disease may be responsible for up to 10% of early graft failures. Angiographic coronary artery disease prevalence increased by approximately 10% with every 2-year interval after transplantation. Angiographic coronary artery disease consisted most often of minor luminal irregularities. Severe disease occurred in 12% of patients. At 1 year, the most significant factors associated with the presence of coronary artery disease were older donor age and the number of rejection episodes. Immunologic factors as well as traditional coronary risk factors such as hypercholesterolemia and hyperglycemia may play an important role in the genesis and progression of later-developing abnormalities. Cardiac allograft coronary artery disease is a major limiting factor to the long-term success of cardiac transplantation. Immune processes, as well as traditional coronary artery disease risk factors, appear to play a role in the development of this disease.

Validation of the accuracy of pretest and exercise test scores in women with a low prevalence of coronary disease: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study

Background Recently revised American College of Cardiology/American Heart Association guidelines have suggested that exercise test scores be used in decisions concerning patients with suspected coronary artery disease (CAD). Pretest and exercise test scores derived for use in women without known CAD have not been tested in women with a low prevalence of CAD. Methods Within the Women's Ischemia Syndrome Evaluation (WISE) study, we evaluated 563 women undergoing coronary angiography for suspected myocardial ischemia. The prevalence of angiographic CAD was 26%. Overall, 189 women underwent treadmill exercise testing. Prognostic end points included death, myocardial infarction, stroke, and revascularization. Results Each score stratified women into 3 probability groups ( P <.001) according to the prevalence of coronary disease: Pretest: low 20/164 (12%), intermediate 53/245 (22%), high 75/154 (49%); Exercise test: low 11/83 (13%), intermediate 22/74 (30%), high 17/32 (53%). However, the Duke score did not stratify as well: low 7/46 (15%), intermediate 36/126 (29%), high 6/17 (35%); P = .44. When pretest and exercise scores were considered together, the best stratification with the exercise test score was in the intermediate pretest group ( P < .03). The Duke score did not stratify this group at all ( P = .98). Pretest and exercise test scores also stratified women according to prognostic end points: pretest—low 7/164 (4.3%), intermediate 28/245 (11.4%), high 27/154 (17.5%), P < .01; exercise test—low 4/83 (4.8%) and intermediate-high 17/106 (16%), P = .014. Conclusion Both pretest and exercise test scores performed better than the Duke score in stratifying women with a low prevalence of angiographic CAD. The exercise test score appears useful in women with an intermediate pretest score, consistent with American College of Cardiology/American Heart Association guidelines.

Clinical Utility of the Exercise ECG in Patients With Diabetes and Chest Pain

The purpose of this study was to determine the characteristics of exercise treadmill testing in diabetic patients presenting with chest pain. The diagnosis of coronary artery disease (CAD) in diabetic patients is confounded by different manifestations of coronary disease than are seen in the general population. Because of the association of diabetes with accelerated CAD, it is critical to assess the diagnostic utility of the standard exercise test in diabetic patients with chest pain. This study was a retrospective analysis of standard exercise test results in 1,282 male patients without prior myocardial infarction who had undergone coronary angiography and were being evaluated for possible CAD at two Veterans' Administration institutions. In patients with diabetes, 38% had an abnormal exercise test result, and the prevalence of angiographic CAD was 69%; the sensitivity of the exercise test was 47% (95% confidence interval [CI], 41 to 58), and specificity was 81% (95% CI, 68 to 89). In patients without diabetes, 38% had an abnormal exercise test result, and the prevalence of angiographic CAD was 58%; the sensitivity of the exercise test was 52% (95% CI, 48 to 56), and specificity was 80% (95% CI, 76 to 83). The receiver operating characteristic curves were also similar in both diabetic and nondiabetic patients (0.67 and 0.68, respectively). These data demonstrate that the standard exercise test has similar diagnostic characteristics in diabetic as in nondiabetic patients.