Prior Coronary Artery Disease Research Articles

Relation of female sex to left atrial diameter and cardiovascular death in atrial fibrillation: The AFFIRM Trial

BackgroundFemale sex is associated with thromboembolism related to atrial fibrillation (AF). Left atrial (LA) diameter independently predicted incident cardiovascular (CV) major events in the general population. In AF patients, LA enlargement is associated to AF occurrence and recurrence. No data have previously been reported on the relationship between LA enlargement, sex and CV death in AF patients. Methods and resultsAll patients enrolled in the AFFIRM Trial with available data about LA dimension were included in this post-hoc analysis.Of the 2615 eligible for the present analysis, LA enlargement was recorded in 67.0%, more commonly in women than in men (p=0.032). Patients with LA enlargement had higher body mass index (BMI), and were more frequently hypertensive, diabetic, and diagnosed with a structural heart disease, prior coronary artery disease (CAD) and heart failure (HF). BMI, left ventricular mass, female sex and mitral valve insufficiency (p<0.001) were associated with LA enlargement.AF female patients with LA enlargement had a higher risk for CV death (p=0.011). LA diameter showed a significant association with CV death (p<0.001). Cox regression analysis demonstrated that LA diameter was an independent predictor of CV death in female AF patients (p=0.003). ConclusionsLA diameter enlargement is associated with female sex, and carries a higher risk for CV death, particularly in females. LA diameter was an independent predictor of CV death in female AF patients.

Aerobic Training Effect on Blood S-Klotho Levels in Coronary Artery Disease Patients

Rationale: Aerobic exercise and Klotho gene expression reduce the risk of cardiovascular events in patients with prior coronary artery disease (CAD) thus, aerobic exercise may create a decreased risk of mortality. Objective: The purpose of the present study was to compare the association between s-klotho serum levels and IGF-1 levels in 3 groups: 60 untrained coronary artery disease patients (CAD) age 52.6 ± 2 years, 60 active participants with CAD in supervised aerobic programs for at least 12 months (4-5 times•wk-1) age 53.0 ± 2 years, and 40 untrained healthy males, age 53.6 ± 1.5 years to assess association of aerobic training and s-klotho activity. Methods and results: Blood samples were drawn from a forearm vein after overnight fasting, s-Klotho levels in the serum were analyzed using an α-klotho Enzyme Linked Immunosorbent Assay ELISA kit, while, IGF-1 was measured by a chemiluminescent immunometric method. Significant (p>0.05) differences were noted between the aerobically trained CAD patients and both untrained groups: CAD patients and healthy subjects with regard to s- Klotho (491 ± 66, 386 ± 70 and 418 ± 81 pg•mL-1 respectively), IGF-1 (82 ± 12, 106 ± 21 and 98 ± 14 nmol•L-1 respectively) and maximal oxygen uptake (42.1 ± 4.5, 31.9 ± 3.9 and 35.8 ± 2.9 mL•kg-1•min-1 respectively). Conclusions: S-Klotho and aerobic exercise training are factors that may promote upgrading capacities of the CAD patients. Inflection of Klotho expression through aerobic training represents a relationship that may contribute to the explanation of the effects of aerobic activity on CAD patients. In addition, findings suggest that atenolol treatment does not influence s-Klotho and IGF-1 levels in CAD patients treated with atenolol.

Long term prognostic utility of coronary CT angiography in patients with no modifiable coronary artery disease risk factors: Results from the 5 year follow-up of the CONFIRM International Multicenter Registry

BackgroundCoronary computed tomography angiography (coronary CTA) can prognosticate outcomes in patients without modifiable risk factors over medium term follow-up. This ability was driven by major adverse cardiovascular events (MACE). ObjectiveDetermine if coronary CTA could discriminate risk of mortality with longer term follow-up. In addition we sought to determine the long-term relationship to MACE. MethodsFrom 12 centers, 1884 patients undergoing coronary CTA without prior coronary artery disease (CAD) or any modifiable CAD risk factors were identified. The presence of CAD was classified as none (0% stenosis), mild (1% to 49% stenosis) and obstructive (≥50% stenosis severity). The primary endpoint was all-cause mortality and the secondary endpoint was MACE. MACE was defined as the combination of death, nonfatal myocardial infarction, unstable angina, and late target vessel revascularization (>90 days). ResultsMean age was 55.6 ± 14.5 years. At mean 5.6 ± 1.3 years follow-up, 145(7.7%) deaths occurred. All-cause mortality demonstrated a dose-response relationship to the severity and number of coronary vessels exhibiting CAD. Increased mortality was observed for >1 segment non-obstructive CAD (hazard ratio [HR]:1.73; 95% confidence interval [CI]: 1.07–2.79; p = 0.025), obstructive 1&2 vessel CAD (HR: 1.70; 95% CI: 1.08–2.71; p = 0.023) and 3-vessel or left main CAD (HR: 2.87; 95% CI: 1.57–5.23; p = 0.001). Both obstructive CAD (HR: 6.63; 95% CI: 3.91–11.26; p < 0.001) and non-obstructive CAD (HR: 2.20; 95% CI: 1.31–3.67; p = 0.003) predicted MACE with increased hazard associated with increasing CAD severity; 5.60% in no CAD, 13.24% in non-obstructive and 36.28% in obstructive CAD, p < 0.001 for trend. ConclusionsIn individuals being assessed for CAD with no modifiable risk factors, all-cause mortality in the long term (>5 years) was predicted by the presence of more than 1 segment of non-obstructive plaque, obstructive 1- or 2-vessel CAD and 3 vessel/left main CAD. Any CAD, whether non-obstructive or obstructive, predicted MACE over the same time period.

Incidencia y mortalidad por infarto agudo de miocardio en la población mayor de 60 años del área de Tarragona

Population-based data available about the epidemiology of acute myocardial infarction is limited. This study investigated incidence and mortality from infarction among the general population over 60 years in Tarragona. Cohort study that included 27,204 individuals ≥60 years assigned to nine Primary Care Centers in the Tarragones county (Catalonia, Spain), who were prospectively followed between 01/12/2008 and 30/11/2011. During follow-up, all presumptive episodes of infarction were recruited among cohort members, but only confirmed cases (electrocardiogram and biomarkers confirmation) were included. There were an amount of 359 confirmed episodes of infarction, which means a global incidence rate of 475 episodes per 100,000 person-years (95% CI: 428-527). Incidence was 681 in men and 311in women (p<0.001). According to age, incidence was 277 in 60-69, 632 in 70-79 and 690 per 100,000 in ≥80 years (p<0.001). Incidence was 2,844 cases per 100,000 person-years among those persons whom had history of prior coronary artery disease. Overall 30-day mortality rate was 15.3%, in male 14.9% and in female 16.0% (p=0.776). Incidence was 2.2 times higher in men than in woman and increased considerable by age. It was greater among patients with prior history of coronary artery disease. Mortality was slightly lower in men than in women.

Incidence and risk conditions of ischemic stroke in older adults.

The objective of this study was to investigate incidence and mortality from ischemic stroke in older adults with specific underlying chronic conditions, evaluating the influence of these conditions in developing stroke. Population-based cohort study involving 27,204 individuals ≥60 years old in Southern Catalonia, Spain. All cases of hospitalization from ischemic stroke (confirmed by neuro-imaging) were collected from 01/12/2008 until 30/11/2011. Incidence rates and 30-day mortality were estimated according to age, sex, chronic illnesses, and underlying conditions. Multivariable Cox regression analysis was used to calculate Hazards Ratio (HR) and estimate the association between baseline conditions and risk of developing stroke. Mean incidence rate reached 453 cases per 100,000 person-years. Maximum rates appeared among individuals with history of prior stroke (2926 per 100,000), atrial fibrillation (1815 per 100,000), coronary artery disease (1104 per 100,000), nursing-home residence (1014 per 100,000), and advanced age ≥80 years (1006 per 100,000). Thirty-day mortality was 13% overall, reaching 21% among patients over 80 years. Age [HR: 1.06; 95% confidence interval (CI): 1.04-1.07], history of prior stroke (HR: 5.08; 95% CI: 3.96-6.51), history of coronary artery disease (HR: 1.65; 95% CI: 1.21-2.25), atrial fibrillation (HR: 2.96; 95% CI: 2.30-3.81), diabetes mellitus (HR: 1.55; 95% CI: 1.23-1.95), and smoking (HR: 1.64; 95% CI: 1.15-2.34) emerged independently associated with an increased risk of ischemic stroke. Incidence and mortality from ischemic stroke remains considerable. Apart from age and history of atherosclerosis (prior stroke or coronary artery disease), atrial fibrillation, diabetes, and smoking were the underlying conditions most strongly associated with an increased risk.

Temporal trends of stress myocardial perfusion imaging: Influence of diabetes, gender and coronary artery disease status

IntroductionTemporal trends of myocardial perfusion imaging (MPI) among diabetics and non-diabetics and the influence of gender and prior coronary artery disease (CAD) status has not been previously investigated. Materials and methodsConsecutive patients who underwent clinically indicated stress-MPI over a 17-year period (1996 through 2012) were studied. Data were collected prospectively as a part of the ongoing clinical databases. Study patients were divided into 4 temporal subgroups (1996 to 2000, 2001 to 2004, 2005 to 2008 and 2009 to 2012) to compare the trends of cardiac risk factors and the frequency of abnormal and ischemic MPI. ResultsOf 78,344 total stress MPI studies, 30.2% were in diabetics. The frequency of abnormal MPI studies, while substantially higher in diabetics, significantly declined over time both in diabetics (53.6% in 1996 to 39.8% in 2012) and non-diabetics (37% in 1996 to 27.4% in 2012), despite an increase in the cardiac risk factor profile. Furthermore, among patients with no known CAD, the temporal prevalence of abnormal MPI was highest in diabetic men (57.5% in 1996 to 31.9% in 2012), lowest in non-diabetic women (18.8% in 1996 to 11% in 2012), and both intermediate and comparable in non-diabetic men and diabetic women (36.4% and 35.7% in 1996 and 20.7% and 17.5% in 2012, respectively). ConclusionsDespite a temporal reduction in the prevalence of abnormal studies from 1996 through 2012, stress MPI continues to play an important clinical role, particularly in diabetics, men and patients with known-CAD.

Combined Quantitative Assessment of Myocardial Perfusion and Coronary Artery Calcium Score by Hybrid 82Rb PET/CT Improves Detection of Coronary Artery Disease.

Hybrid PET myocardial perfusion imaging (MPI) with CT allows the incorporation of coronary artery calcium (CAC) into the clinical protocol. We aimed to determine whether the combined analysis of MPI and CAC could improve the diagnostic accuracy of PET MPI in detection of obstructive coronary artery disease (CAD). Consecutive patients (n = 152; mean age ± SD, 69 ± 12 y) without prior CAD, referred to (82)Rb PET MPI followed by invasive coronary angiography performed within 14 days, were studied. Myocardial perfusion was quantified automatically for left anterior descending, left circumflex, and right coronary artery territories as an ischemic total perfusion deficit (ITPD) for 456 vessels. Global and per-vessel CAC Agatston scores were calculated. Obstructive CAD was defined as 50% or greater stenosis of the left main and 70% or greater stenosis in the left anterior descending, left circumflex, and right coronary arteries. Logistic regression and 10-fold cross validation were used to derive and validate the combined ITPD/logCAC (logarithm of coronary calcium) scores. In the prediction of per-vessel obstructive CAD, the receiver-operating-characteristic area under the curve for combined per-vessel ITPD/logCAC score was higher, 0.85 (95% confidence interval [CI], 0.81-0.89), than standalone ITPD area under the curve, 0.81 (95% CI: 0.76-0.85), and logCAC score, 0.73 (95% CI, 0.68-0.78; P < 0.05). The integrated discrimination improvement of combined per-vessel ITPD/logCAC analysis was 0.07 (95% CI, 0.04-0.09; P < 0.0001), as compared with ITPD alone. Combined automatically derived per-vessel ITPD and logCAC score improves accuracy of (82)Rb PET MPI for detection of obstructive CAD.

Incremental prognostic value of kidney function decline over coronary artery disease for cardiovascular event prediction after coronary computed tomography

It is unknown whether mild chronic kidney disease (CKD) is associated with adverse cardiovascular (CV) prognosis after accounting for coronary artery disease (CAD). Here we evaluated the interplay between CKD and CAD in predicting CV death or myocardial infarction (MI) and all-cause death. We included 1541 consecutive patients in the Partners registry (mean age 55 years, 43% female) over 18 years old with no known prior CAD who underwent coronary computed tomography angiography (CCTA). The results of CCTA were categorized as normal, nonobstructive (under half), or obstructive (half and over). Overall, 653 of the patients had no CAD, 583 had nonobstructive CAD, and 305 had obstructive CAD, while 1299 had eGFR over 60 ml/min per 1.73 m(2) and 242 had an eGFR under this value. The presence and severity of CAD was significantly associated with an increased rate of CV death or MI and all-cause death, even after adjustment for age, gender, symptoms, and risk factors. Similarly, reduced eGFR was significantly associated with CV death or MI and all-cause death after similar adjustment. The addition of reduced GFR to a model which included both clinical variables and CCTA findings resulted in significant improvement in the prediction of CV death or MI and all-cause death. Thus, among individuals referred for CCTA to evaluate CAD, renal dysfunction is associated with an increased rate of CV events, mainly driven by an increase in the rate of noncoronary CV events. In this group of patients, both eGFR and the presence and severity of CAD together improve the prediction of future CV events and death.

Left atrial enlargement increases the risk of major adverse cardiac events independent of coronary vasodilator capacity.

Longstanding uncontrolled atherogenic risk factors may contribute to left atrial (LA) hypertension, LA enlargement (LAE) and coronary vascular dysfunction. Together they may better identify risk of major adverse cardiac events (MACE). The aim of this study was to test the hypothesis that chronic LA hypertension as assessed by LAE modifies the relationship between coronary vascular function and MACE. In 508 unselected subjects with a normal clinical (82)Rb PET/CT, ejection fraction ≥40 %, no prior coronary artery disease, valve disease or atrial fibrillation, LAE was determined based on LA volumes estimated from the hybrid perfusion and CT transmission scan images and indexed to body surface area. Absolute myocardial blood flow and global coronary flow reserve (CFR) were calculated. Subjects were systematically followed-up for the primary end-point - MACE - a composite of all-cause death, myocardial infarction, hospitalization for heart failure, stroke, coronary artery disease progression or revascularization. During a median follow-up of 862 days, 65 of the subjects experienced a composite event. Compared with subjects with normal LA size, subjects with LAE showed significantly lower CFR (2.25 ± 0.83 vs. 1.95 ± 0.80, p = 0.01). LAE independently and incrementally predicted MACE even after accounting for clinical risk factors, medication use, stress left ventricular ejection fraction, stress left ventricular end-diastolic volume index and CFR (chi-squared statistic increased from 30.9 to 48.3; p = 0.001). Among subjects with normal CFR, those with LAE had significantly worse event-free survival (risk adjusted HR 5.4, 95 % CI 2.3 - 12.8, p < 0.0001). LAE and reduced CFR are related but distinct cardiovascular adaptations to atherogenic risk factors. LAE is a risk marker for MACE independent of clinical factors and left ventricular volumes; individuals with LAE may be at risk of MACE despite normal coronary vascular function.

Abstract 206: Aiming to Improve Stroke Care Continuity with Primary Care Follow-up Appointments Scheduled Prior to Hospital Discharge

Background: Follow-up care can facilitate patient recovery. To improve care continuity the Ohio Coverdell Stroke Program aimed to improve the proportion of hospitalized stroke patients for whom prior to discharge the hospital scheduled a follow-up appointment with primary care. This is not yet standard of care for stroke. Methods: Of 48 Ohio Coverdell Stroke Program participating hospitals, 37 had data entered into the registry for each quarter of the 12 month quality improvement initiative. Admitted stroke patients of any type planned for discharge home were included. Patients younger than 18 years of age, not admitted to the hospital from the emergency department, or admitted and only receiving comfort care were excluded. Patient-level and hospital-level data were examined to determine performance in a 6 month baseline period (quarters 1-2) and a 6 month active improvement phase (quarters 3 and 4). Patients discharged with and without an appointment scheduled were compared to identify targeted areas for continued improvement. Results: There were 4,558 stroke patients discharged home over 12 months from 37 geographically distributed hospitals (62.4% ischemic stroke, 29.0% TIA, 8.5% hemorrhagic stroke). At baseline, 13.4% of patients had an appointment scheduled with a primary care provider prior to discharge home. This increased to 18.7% in quarter 3 and 26.6% in quarter 4, representing a 98.5% improvement from baseline to quarter 4 in the proportion of patients with a primary care follow-up appointment scheduled. Median quarter 4 performance at a hospital level was 10.5% (distributed from 0-80.0% across 37 hospitals). Analysis of patient characteristics showed differences in the proportion of patients with an appointment by age (15.5% for ages&gt;65 years vs. 18.5% of younger patients, p=0.004); race (15.1% white race vs. 22.1% of African Americans, p&lt;0.001); history of prior stroke (19.0% with prior stroke vs. 16.3% with no prior stroke, p=0.031); comorbid diabetes (18.6% with diabetes vs. 16.1% without, p=0.021); dyslipidemia (18.2% with vs. 15.6% without, p=0.013); and obesity (14.4% were obese/overweight vs. 17.7% who were not overweight/obese, p=0.007). No significant patient level differences were found by patient sex, insurance, stroke type, stroke severity, prior myocardial infarction or coronary artery disease, prior TIA, family history of stroke, or comorbid atrial fibrillation, heart failure, or hypertension. Conclusions: Hospital performance with scheduling primary care follow-up appointments improved significantly; however, only 1 in 4 patients had an appointment scheduled prior to discharge. Case study analysis of missed opportunities may help identify barriers and facilitators associated with access, availability, and awareness that can be addressed in future improvement cycles.

All else being equal, men and women are still not the same: using risk models to understand gender disparities in care.

Despite growing awareness of the burden of cardiovascular disease (CVD) in women over the past 2 decades, reports of disparities in the delivery of health care for these diseases have persisted over time.1 Under-treatment of women as compared with men has been described for primary prevention, stable coronary artery disease (CAD) and suspected or diagnosed acute coronary syndromes in both observational studies and controlled experiments.2–6 However, because men and women are nonidentical in many ways that might be relevant for treatment decisions, a critical question for policy makers and clinicians is whether these gender-based variations in treatment correspond to lower quality care. A demonstration of clinical inequity (unequal treatment despite equal clinical need) rather than strict inequality (unequal treatment regardless of need or condition) has been proposed as a framework to identify inappropriate variations in healthcare utilization.7 Following this model, it is important to consider whether observed gender differences correspond to inequities or may reflect appropriate variations explained by differences in treatment indications and contraindications or patient preferences.7 In a well-known study published over a decade ago, investigators devised a clever experiment to address just this question of identifying inappropriate healthcare variations.8 Using actors posing as patients with chest pain, primary care physicians were less likely to refer women for cardiac catheterization than men. Because these patients were carefully designed to be identical in age, cardiac risk factors, and symptoms, followed a script standardizing patient communication, and only differed by gender (and race), it seemed obvious that biased decision-making must account for treatment differences. In this commentary, we illustrate why analyses that attempt to control for all known cardiac risk factors that affect treatment decisions might still yield misleading findings about the presence, magnitude, and causes of gender disparities. This residual bias occurs …

Ischemic Heart Disease in Women: a Nuclear Cardiology Latin America Perspective

Cardiovascular disease is the leading cause of death in Latin America. The increasing prevalence of diabetes mellitus (DM), coupled with modern lifestyle and population aging are contributing to increase ischemic heart disease (IHD)-related deaths in this region. Diagnosis of IHD in women can be challenging as they often present with no chest pain or atypical symptoms, delaying diagnosis and appropriate management. Women tend to have more advanced coronary artery disease (CAD), to be older, and have worse prognosis than men after myocardial infarction and bypass surgery. Life expectancy is usually higher for women but myocardial perfusion abnormalities, especially severe, predict increased mortality. This review will discuss IHD in Latin America women. Data from one of the largest nuclear cardiology registries in the world, involving 41,671 patients undergoing single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in a referral center in Brazil, will be shown to illustrate the role of nuclear cardiology to evaluate women in this region. DM was prevalent at 22 %. Women (n = 18,629), when compared to men (n = 23,043), were found (1) to be less likely to have a history of prior CAD (20.9 vs 35 %); (2) to have a high abnormality rate on SPECT-MPI, although lower than men (27 vs 35 %); and (3) to be less able to perform exercise stress, requiring more pharmacological stress than men (36.3 vs 24.2 %). Our data shows that 87 % of the 5027 women found to have abnormal SPECT-MPI had no typical symptoms, presenting either no chest pain (50 %) or atypical pain (37 %), some having high-risk perfusion findings.

Value of CACS Compared With ETT and Myocardial Perfusion Imaging for Predicting Long-Term Cardiac Outcome in Asymptomatic and Symptomatic Patients at Low Risk for Coronary Disease: Clinical Implications in a Multimodality Imaging World

ObjectivesThis prospective, observational study in 988 asymptomatic or symptomatic low-risk patients without prior coronary artery disease was conducted to define the relative value of coronary artery calcium score (CACS), exercise treadmill testing (ETT), and stress myocardial perfusion single-photon emission computed tomography (SPECT) variables in predicting long-term risk stratification. BackgroundCACS, ETT, and stress myocardial perfusion SPECT results predict patients' outcome. There are currently no data comparing their relative value in long-term risk stratification. MethodsPatients were stratified by Framingham risk score (FRS), with a median follow-up of 6.9 years. Cardiac events were defined as a composite of cardiac death, nonfatal myocardial infarction, and the need for coronary revascularization. Most patients (87%) were considered appropriate candidates for functional testing as defined by current appropriate use criteria. ResultsThe long-term cardiac event rate was 11.2% (1.6% per year). Multivariate risk predictors in all patients and in the appropriate use cohort were abnormal SPECT (hazard ratio [HR]: 1.83 and 1.99), ETT ischemia (HR: 1.70 and 1.76), decreasing exercise capacity (HR: 1.11 and 1.17), decreasing Duke treadmill score (HR: 1.07 for both), and CACS severity (HR: 1.29 for both), respectively. Throughout the 10-year follow-up, CACS improved risk prediction, with event rates ranging from 0.6% per year (CACS ≤10) to 3.7% per year (CACS >400) (p < 0.0001). CACS also improved risk prediction in all patients, in the appropriate use cohort and among those with low-risk ETT and SPECT results (all, p < 0.001). Area under the receiver-operating characteristic curve was increased when CACS variables (from 0.63 to 0.70; p = 0.01) but not ETT variables (from 0.63 to 0.65) were added to FRS. Moreover, net reclassification improvement was significantly increased when CACS was added to FRS + functional variables in all patients and in the appropriate use cohort (both, p < 0.0001). ConclusionsCACS significantly improved long-term risk stratification beyond FRS, ETT, and SPECT results across the spectrum of clinical risk and importantly even among those who are currently considered appropriate candidates for functional testing or have low-risk functional test results. Our findings support CACS as a first-line test over ETT or SPECT for accurately assessing long-term risk in such patients.

Abstract W MP106: Clinical Effectiveness of Anticoagulation with Warfarin among Ischemic Stroke Patients with Atrial Fibrillation: Findings from the Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study

Background: Oral anticoagulation is recommended for ischemic stroke patients with atrial fibrillation, based on clinical trials done in selected populations. However, little is known about whether the clinical benefit of warfarin is preserved outside the clinical trial setting, especially in older patients with ischemic stroke. Methods: PROSPER, a PCORI-funded research program designed by stroke survivors and stakeholders, used American Heart Association Get With The Guidelines (GWTG)-Stroke data linked to Medicare claims to evaluate the association between warfarin treatment at discharge and long-term outcomes among ischemic stroke survivors with atrial fibrillation (AF) and no contraindication to or prior anticoagulation therapy. The primary outcome prioritized by patients was home-time (defined as days spent alive and not in inpatient post-acute care facility) within 2-year follow-up after discharge. Results: Of 12,552 ischemic stroke patients with AF admitted from 2009-2011, 11,039 (88%) received warfarin treatment at discharge. Compared with those not receiving any anticoagulation, warfarin-treated patients were slightly younger (mean 80 vs. 83, p&lt;0.001), less likely to have a history of prior stroke or coronary artery disease, but had similar stroke severity as measured by NIHSS (median 5 [IQR 2-12] vs. 6 [2-13], p=0.09). After adjustment for all observed baseline characteristics using propensity score inverse probability weighting method, patients discharged on warfarin therapy had 45 more days of home-time during 2-year follow-up than those not receiving any oral anticoagulant (513 vs. 468 days, p&lt;0.001). Warfarin use was also associated with a lower risk of all-cause mortality, cardiovascular readmission or death, and ischemic stroke (Table). Conclusions: Among ischemic stroke patients with atrial fibrillation, warfarin therapy was associated with improved long-term outcomes.

0116: Metformin and contrast-induced nephropathy in diabetic patients treated with primary percutaneous coronary intervention for ST segment elevation myocardial infarction: a multicentre study

Contrast-induced nephropathy (CIN) is a frequent complication in patients undergoing percutaneous coronary intervention (PCI), associated with increased mortality. The impact of metformin, which has potential interactions with renal function, on CIN remains to be investigated. To analyze the association between chronic metformin treatment and the development of CIN after primary PCI for ST segment elevation myocardial infarction (STEMI). 372 patients with diabetes mellitus (DM) treated with PCI <24H in 2 coronary care units (Paris-Bichat and Dijon Hospital, France) were included. Serum creatinine (Cr) was measured before and 48H after PCI. CIN was defined as an increase in Cr of 44µmol/L (0.5 mg/dL) or 25% over baseline after PCI. Since PCI was urgent, metformin could not be withheld prior to PCI but was usually stopped after PCI. Mean age was 66±11 y, and 25% were women. 64% had hypertension, 56% had DM duration >5 year, and 26% had prior coronary artery disease. Metformin and sulfonylurea were the most frequently used antidiabetic chronic treatments (40% for both), and 27% were on insulin therapy. The other antidiabetic medications, including glinide, glitazone, and acarbose were rarely used (3%, 2%, and 5%, respectively). Mean baseline and post PCI Cr levels were 102±52 and 122±81µmol/L. Rate of CIN was similar in patients with or without metformin (21 vs 20%, respectively, p= 0.87). Logistic regression for the risk of CIN taking into account classical risk factors showed no impact of chronic metformin therapy, even in stratified analysis in patients with chronic kidney disease. Hospital mortality was similar between groups (7 vs 6%, respectively, p=0.69). Moreover, no case of lactic acidosis was reported during the hospital stay. In this multicentre study reflecting current clinical practice, metformin treatment prior to primary PCI had no significant impact on CIN. Larger studies are needed to confirm these findings.

Use of cardiac CT and calcium scoring for detecting coronary plaque: implications on prognosis and patient management.

Clinicians often use risk factor-based calculators to estimate an individual's risk of developing cardiovascular disease. Non-invasive cardiovascular imaging, particularly coronary artery calcium (CAC) scoring and coronary CT angiography (CTA), allows for direct visualization of coronary atherosclerosis. Among patients without prior coronary artery disease, studies examining CAC and coronary CTA have consistently shown that the presence, extent and severity of coronary atherosclerosis provide additional prognostic information for patients beyond risk factor-based scores alone. This review will highlight the basics of CAC scoring and coronary CTA and discuss their role in impacting patient prognosis and management.

Incidence of coronary artery disease before valvular surgery in isolated severe aortic stenosis

Background Angina pectoris has been recognized as one of the principal symptoms of aortic valve stenosis (AS), even in patients without significant coronary artery disease (CAD). However, the incidence of angina pectoris and related CAD in such patients is controversial. There is continuing debate as to whether coronary angiography is necessary before aortic valve replacement (AVR) in patients with severe AS. The purpose of this study was to evaluate the incidence and predictors of CAD in patients with severe AS in a Korean population. Methods Data from all consecutive patients with severe AS undergoing AVR at a major tertiary cardiac and vascular center in Korea were entered in a prospective registry beginning in 1995. Clinical and echocardiographic follow-up data were recorded into the database annually. Significant CAD was defined as one or more major coronary arteries having an estimated narrowing of ≥70% and left main coronary arteries having an estimated narrowing of ≥50% on coronary angiography. We excluded patients with multiple valve disease, significant aortic regurgitation, or prior CAD or valve surgery. Results Totally 574 patients with severe AS (mean age, (65.9±9.6) years) were enrolled in this study. Significant CAD was found in 61 patients (10.6%). Factors associated with increased likelihood of CAD were age, hypertension, diabetes mellitus, chronic renal failure, carotid disease, and aorta calcification. In Logistic regression analysis, the independent predictor of the presence of CAD was age (P=0.011). The incidence of CAD increased significantly at 69.2 years of age. Having two risk factors for cardiovascular disease was the most useful cutoff to predict whether a patient was going to have significant CAD. Conclusions There was a low incidence of significant CAD in a population of Korean patients with severe AS. Therefore, coronary angiography before AVR will be considered in patients with multiple risk factors for cardiovascular disease or in patients more than 69 years of age without risk factors for cardiovascular disease.

Association between psoriasis and coronary calcium score

Background: Emerging data suggests that chronic inflammatory disease, such as psoriasis, may be associated to coronary artery disease (CAD). Objective: Analyze the association between psoriasis and subclinical atherosclerosis using coronary calcium score (CAC). Methods: We investigated 221 participants with psoriasis and 718 age- and sex-matched controls without prior known CAD. All participants completed a questionnaire and underwent laboratory tests and a CAC exam. Logistic regression models adjusted for Framingham risk score (FRS) and C-reactive protein (hs-CRP) were built. CAC was included in the models as a binary variable with different cut off values. Results: Body-mass index, race, hypertension, HDL, LDL and hs-CRP were significantly associated with psoriasis presence and severity. Psoriasis severity was significantly associated with CAC (p = 0.04), particularly for very high CAC (>400) (p < 0.01). The OR for severe psoriasis and CAC >400 was 2.45 (95%CI: 1.26–4.75) in unadjusted models. In a model adjusted for the FRS, this association was no longer significant, but a trend was noted (p = 0.09). No significant changes in the association were noted after the inclusion of hs-CRP in the model. Conclusion: Psoriasis is associated with higher CAC values, mainly in individuals with severe psoriasis. The current findings also suggest the potential involvement of other mechanisms beyond classical cardiovascular risk factors and inflammation in this association.

Use of observation followed by outpatient stress testing in chest pain patients with prior coronary artery disease history: An evaluation of prognostic utility

ObjectiveTo determine the outcomes of patients with chest pain (CP) and prior history of coronary artery disease (CAD) managed with observation followed by outpatient stress myocardial perfusion imaging (MPI). MethodsRetrospective analysis of patients with CP managed with observation followed by outpatient stress MPI, comparing cardiovascular (CV) event rates stratified by CAD history. Results375 patients were included: 111 with and 264 without a CAD history. All patients underwent outpatient stress MPI within 72h of observation. MPI identified patients at risk for CV events. However, while patients with negative MPI and without a CAD history had very low rates of short- and long-term CAD events (0.8%, 0.8%, and 1.3% at 30days, 1year, and 3years, respectively), event rates of those with a negative test but a CAD history were significantly higher (2.6%, 5.3%, and 6.6% at 30days, 1year and 3years, respectively; p=0.044 and p=0.034 compared to CAD− patients at 1year and 3years, respectively). In a multivariable logistic regression model, a positive MPI proved to be an independent predictor of long-term CV events in patients with CP and prior CAD. ConclusionObservation followed by stress MPI can effectively risk stratify CP patients with prior CAD for CV risk. These patients are at increased risk of CV events even after a low-risk stress MPI study. Patients presenting with CP and managed with a strategy of observation followed by a negative stress MPI warrant close short- and long-term monitoring for recurrent events.

Abstract 212: Temporal Trends of SPECT Myocardial Perfusion Imaging in Patients with Coronary Heart Disease: A 22-Year Experience from a Tertiary Academic Medical Center

Background: Over the past 20 years, there has been an increasing decline in the prevalence of abnormal stress single-photon emission computed tomography myocardial perfusion imaging (SPECT) studies among patients with no history of coronary artery disease (CAD). The trend of SPECT studies among patients with known CAD has not been evaluated before. Methods: Using the Mayo Clinic nuclear cardiology database, we examined all stress SPECT tests performed between 1/1991-12/2012 in patients with prior history of CAD defined as having prior myocardial infarction, percutaneous coronary intervention, and/or coronary artery bypass grafting. Patients with left bundle branch block, paced rhythm, bicycle or rest-only tests, cardiomyopathy, valvular heart disease, and technically unsatisfactory studies were excluded. The study cohort was divided into 5 time periods: 1991-5, 1996-2000, 2001-5, 2006-10, and 2011-12. Results: There were 19373 eligible SPECT tests (mean age 66.2 ± 10.9y, 75.4% men). Annual utilization of SPECT studies in patients with history of CAD increased from an average of 495 tests per year between 1991-1995 to a peak of 1425 in 2003; and then decreased to 552 tests in 2012. Asymptomatic patients comprised 33% in 1991-1995, peaked at 48% in 2006, and then decreased back to 31% in 2012. Over time, patients with typical angina decreased while patients with dyspnea increased, P &lt;0.001 (Fig 1). The percentage of high risk SPECT tests significantly decreased, and the percentage of low-risk SPECT tests significantly increased despite the overall decline of SPECT utilization between 2003 and 2012. Almost 80% of all tests performed in 2012 had a low risk summed stress score compared to 29% in 1991, P &lt;0.001 (Fig 2). Conclusions: In Mayo Clinic Rochester, annual SPECT utilization in patients with prior CAD increased between 1992 and 2003, but then decreased significantly after 2003. Fewer patients had typical angina while patients with dyspnea increased over time. High risk SPECT tests declined while low risk tests increased dramatically. These data suggest that stress SPECT was being increasingly utilized in CAD patients without typical angina who are at low risk.