Prior Coronary Artery Disease Research Articles

107 The long term prognostic value of dipyridamole stress myocardial contrast echocardiography in comparison with single photon emission tomography in patients with known or suspected coronary artery disease

BackgroundSingle photon emission computed tomography (SPECT) is a well-established method to evaluate patients with coronary artery disease (CAD). Myocardial contrast echocardiography (MCE) is an imaging technique that allows assessment of...

Characteristics, management and response to alteplase in China versus non-China participants of the ENCHANTED trial

BackgroundThe characteristics of patients with acute ischaemic stroke (AIS) and their management vary across regions, which may influence outcomes. We examined for differential patterns of outcome between China and non-China...

Abstract 125: Association Between Abo Blood Group, Von Willebrand Factor and Factor VIII in Patients Undergoing Vascular Surgery

Background: ABO blood groups have been associated with functional effects on factor VIII (FVIII), von Willebrand factor (vWF) and incident atherothrombosis. This study sought to examine the association between ABO blood type, FVIII and vWF in patients undergoing vascular surgery. Method: This is a retrospective analysis of data from a cohort of 181 patients undergoing elective vascular surgery. ABO blood type, FVIII and vWF was measured before surgery. The primary end point was the occurrence of MACE (defined as myocardial necrosis, myocardial infarction, stroke or death) within 30-days after surgery. Multivariable logistic regression modeling was used to estimate odds of MACE. Results: The mean age was 71.6 ± 9.8 and 29% were female. Non-O blood type was present in 105 patients (70 A, 27 B, 8 AB) and type O in 76 patients. Non-O had higher FVIII (128.2 ± 44.7 vs 112.4 ± 42.4, P<0.001) and vWF (176.0 ± 54.0 vs 133.2 ± 41.0, P<0.001) than type O. Thirty day MACE occurred in 38 (21.0%) patients; 25% in non-O and 15.8% in type O (P=0.13). After adjustment for age, sex, race, prior coronary artery disease and heart failure, patients with non-O blood type (vs. O) had a higher incidence of 30-day MACE (odds ratio 2.1, 95% CI 0.9 to 5.1, P=0.08) although statistical significance was not reached. There was no significant association between FVIII and vWF and 30-day MACE. Conclusions: Non-O blood type was associated with higher levels of FVIII and vWF and a trend towards increased 30-day MACE in patients undergoing vascular surgery. Larger studies across of ABO blood groups and perioperative events in different types of surgeries are warranted.

Asymptomatic hyperuricemia is independently associated with coronary artery calcification in the absence of overt coronary artery disease: A single-center cross-sectional study.

Recently, the pathogenic role of uric acid (UA) in both systemic metabolic and atherosclerotic diseases has been investigated. We sought to determine the independent correlation between serum UA levels and coronary artery calcification, as a marker of subclinical atherosclerosis. A total of 4188 individuals without prior coronary artery disease or urate-deposition disease were included. All of the participants underwent multidetector computed tomography (MDCT) for the evaluation of coronary artery calcification (CAC) during their health check-ups. The subjects were divided into thre groups according to CAC scores (group 1: 0; group 2: 1-299; group 3: ≥300). After controlling for other confounders, serum UA levels were found to be positively associated with increasing CAC scores (P = 0.001). Adjusted mean serum UA levels in each CAC group were estimated to be 5.2 ± 0.1 mg/dL, 5.3 ± 0.1 mg/dL, and 5.6 ± 0.2 mg/dL from groups 1, 2, and 3, respectively. Subsequent subgroup analyses revealed that this positive association was only significant in participants who were male, relatively older, less overweight, and did not have diabetes mellitus (DM), hypertension, smoking history, or renal dysfunction. In conclusion, serum uric acid levels were independently associated with CAC score severity and this finding is particularly relevant to the subjects who were male, relatively older, less overweight (body mass index < 25 kg/m), and without a history of DM, hypertension, smoking, or renal dysfunction.

Risk of acute myocardial infarction in patients with gastroesophageal reflux disease: A nationwide population-based study.

ObjectiveGastroesophageal reflux disease (GERD) is a common disease which can cause troublesome symptoms and affect quality of life. In addition to esophageal complications, GERD may also be a risk factor for extra-esophageal complications. Both GERD and coronary artery disease (CAD) can cause chest pain and frequently co-exist. However, the association between GERD and acute myocardial infarction (AMI) remain unclear. The purpose of the study was to compare the incidence of acute myocardial infarction in GERD patients with an age-, gender-, and comorbidity matched population free of GERD. We also examine the association of the risk of AMI and the use of acid suppressing agents in GERD patients.MethodsWe identified patients with GERD from the Taiwan National Health Insurance Research Database. The study cohort comprised 54,422 newly diagnosed GERD patients; 269,572 randomly selected age-, gender-, comorbidity-matched subjects comprised the comparison cohort. Patients with any prior CAD, AMI or peripheral arterial disease were excluded. Incidence of new AMI was studied in both groups.ResultsA total 1,236 (0.5%) of the patients from the control group and 371 (0.7%) patients from the GERD group experienced AMI during a mean follow-up period of 3.3 years. Based on Cox proportional-hazard model analysis, GERD was independently associated with increased risk of developing AMI (hazard ratio (HR) = 1.48; 95% confidence interval (CI): 1.31–1.66, P < 0.001). Within the GERD group, patients who were prescribed proton pump inhibitors (PPIs) for more than one year had slightly decreased the risk of developing AMI, compared with those without taking PPIs (HR = 0.57; 95% CI: 0.31–1.04, P = 0.066).ConclusionsThis large population-based study demonstrates an association between GERD and future development of AMI, however, PPIs use only achieved marginal significance in reducing the occurrence of AMI in GERD patients. Further prospective studies are needed to evaluate whether anti-reflux medication may reduce the occurrence of acute ischemic event in GERD patients.

Abstract P007: Sex-Specific Disparities in Risk Factor Control of Patients Undergoing Elective Percutaneous Coronary or Peripheral Intervention

Introduction: The American Heart Association (AHA) developed 7 health metrics to define “ideal cardiovascular health” in its 2020 Impact Goal. Sex-specific disparities in attainment of the 7 health metrics in patients undergoing elective percutaneous or peripheral interventions has not been well characterized. Methods: We interviewed 1,517 patients (1,127 males and 390 females) undergoing elective percutaneous coronary or peripheral intervention at a large tertiary care center between November 2010 and March 2015. Survey data was used to reconstruct the 7 health metrics (blood pressure, physical activity, cholesterol, diet, weight, smoking status, and metabolic control). Multivariable linear regression was performed to identify characteristics associated with ideal metric attainment in the overall cohort and when stratified by sex. Results: Overall, males were younger, less likely to be white, more likely to be married, and had higher levels of education and higher prevalence of prior coronary artery disease than females (p&lt;.05 for each). Males achieved fewer ideal health metrics than females (2.0 ± 1.2 vs 2.3 ± 1.1, p&lt;.01), including poorer attainment of the ideal smoking (p&lt;.01), physical activity (p&lt;.01), and diet health metrics (p&lt;.05). Females had poorer attainment of the ideal weight (p&lt;.05) and cholesterol health metrics (p=.01). After multivariable adjustment, males achieved fewer ideal health metrics than females (p&lt;.01; Table). Sex-specific differences are presented in the Table, which includes single marital status and depression as negative predictors of ideal metric attainment in males, and a reduced ejection fraction as a negative predictor in females. Conclusions: Attainment of the 7 AHA ideal health metrics is low in both males and females undergoing elective percutaneous coronary or peripheral intervention. Sex-specific disparities in risk factor control illustrate interesting areas for further exploration into the predictors of behavior that may guide future targeted interventions.

Use of CT angiography among patients with prior coronary artery bypass grafting surgery.

Given the inherent challenges in performing invasive coronary angiography (ICA) in patients who have coronary artery bypass grafts, there has been great interest in developing safe and accurate non-invasive techniques to assess graft patency. Clinically, such an evaluation is often required when patients present with symptoms suggestive of ischemia. However, while coronary computed tomography angiography (CTA) has been extensively studied in patients without known prior coronary artery disease (CAD), the role of CTA remains less clear for patients with prior coronary artery bypass grafting (CABG) surgery. Addressing the need for more data in this area, Drs. Barbero and colleagues published in The International Journal of Cardiology a comprehensive review on this topic: “64 slice-coronary computed tomography sensitivity and specificity in the evaluation of coronary artery bypass graft stenosis”.

Gender Differences in Knowledge, Attitudes and Practices towards Cardiovascular Disease and its Treatment among Asian Patients

Introduction: Knowledge, attitudes and practices (KAP) impact on cardiac disease outcomes, with noted cultural and gender differences. In this Asian cohort, we aimed to analyse the KAP of patients towards cardiac diseases and pertinent factors that influence such behaviour, focusing on gender differences. Materials and Methods: A cross-sectional survey was performed among consecutive outpatients from a cardiac clinic over 2 months in 2014. Results: Of 1406 patients approached, 1000 (71.1%) responded (mean age 57.0 ± 12.7 years, 713 [71.3%] males). There was significant correlation between knowledge and attitude scores (r = 0.224, P <0.001), and knowledge and practice scores (r = 0.114, P <0.001). There was no correlation between attitude and practice scores. Multivariate predictors of higher knowledge scores included female sex, higher education, higher attitude and practice scores and prior coronary artery disease. Multivariate predictors of higher attitude scores included higher education, higher knowledge scores and non-Indian ethnicity. Multivariate predictors of higher practice scores included male sex, Indian ethnicity, older age, higher knowledge score and hypertension. Males had lower knowledge scores (85.8 ± 8.0% vs 88.0 ± 8.2%, P <0.001), lower attitude scores (91.4 ± 9.4% vs 93.2 ± 8.3%, P = 0.005) and higher practice scores (58.4 ± 18.7% vs 55.1 ± 19.3%, P = 0.013) than females. Conclusion: In our Asian cohort, knowledge of cardiovascular health plays a significant role in influencing attitudes and practices. There exists significant gender differences in KAP. Adopting gender-specific strategies for future public health campaigns could address the above gender differences.

Oxidized Phospholipids on Apolipoprotein B-100 and Recurrent Ischemic Events Following Stroke or Transient Ischemic Attack

BackgroundBiomarkers to predict recurrent stroke and targets of therapy to prevent stroke are lacking. ObjectivesThis study evaluated whether patients with prior cerebrovascular events and elevated levels of oxidized phospholipids on apolipoprotein B-100 (OxPL-apoB), but without prior coronary artery disease (CAD), are at risk for recurrent stroke and CAD events following high-dose statin therapy. MethodsIn the SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) trial, OxPL-apoB levels were measured in 4,385 patients with stroke or transient ischemic attack at baseline and in 3,106 patients at 5 years following randomization to placebo or 80 mg atorvastatin. The primary endpoint was the time from randomization to a second nonfatal or fatal stroke. Secondary endpoints included first major coronary events and any cardiovascular event. ResultsPatients with recurrent stroke had higher baseline median OxPL-apoB levels than patients without (15.5 nmol/l vs. 11.6 nmol/l; p < 0.0001). After multivariable adjustment, elevated baseline OxPL-apoB predicted recurrent stroke (hazard ratio [HR]: 4.3; p < 0.0001), first major coronary events (HR: 4.0; p < 0.0001), and any cardiovascular event (HR: 4.4; p < 0.0001). These comparisons for any endpoint did not differ by treatment, shown as a nonsignificant interaction test. The net reclassification improvement, integrated discrimination improvement, and area under the receiver-operating characteristic curve (AUC) were all significantly improved by adding OxPL-apoB to the models, with ΔAUC +0.0505 (p < 0.0001) for recurrent stroke, ΔAUC +0.0409 (p < 0.0001) for first major coronary event, and ΔAUC +0.0791 (p < 0.0001) for any cardiovascular event. ConclusionsElevated OxPL-apoB levels predicted recurrent stroke and first major coronary events in patients with prior stroke or transient ischemic attack. The lack of statin–OxPL-apoB treatment interaction suggested that OxPLs might be statin-independent therapeutic targets to reduce risk of cardiovascular events. (Lipitor in the Prevention of Stroke, for Patients Who Have Had a Previous Stroke [SPARCL]; NCT00147602)

Long-term prognostic impact of CT-Leaman score in patients with non-obstructive CAD: Results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) study

BackgroundNon-obstructive coronary artery disease (CAD) identified by coronary computed tomography angiography (CCTA) demonstrated prognostic value. CT-adapted Leaman score (CT-LeSc) showed to improve the prognostic stratification. Aim of the study was to evaluate the capability of CT-LeSc to assess long-term prognosis of patients with non-obstructive (CAD). MethodsFrom 17 centers, we enrolled 2402 patients without prior CAD history who underwent CCTA that showed non-obstructive CAD and provided complete information on plaque composition. Patients were divided into a group without CAD and a group with non-obstructive CAD (<50% stenosis). Segment-involvement score (SIS) and CT-LeSc were calculated. Outcomes were non-fatal myocardial infarction (MI) and the combined end-point of MI and all-cause mortality. ResultsPatient mean age was 56±12years. At follow-up (mean 59.8±13.9months), 183 events occurred (53 MI, 99 all-cause deaths and 31 late revascularizations). CT-LeSc was the only multivariate predictor of MI (HRs 2.84 and 2.98 in two models with Framingham and risk factors, respectively) and of MI plus all-cause mortality (HR 2.48 and 1.94 in two models with Framingham and risk factors, respectively). This was confirmed by a net reclassification analysis confirming that the CT-LeSc was able to correctly reclassify a significant proportion of patients (cNRI 0.28 and 0.23 for MI and MI plus all-cause mortality, respectively) vs. baseline model, whereas SIS did not. ConclusionCT-LeSc is an independent predictor of major acute cardiac events, improving prognostic stratification of patients with non-obstructive CAD.

The Effect of FLT1 Variant on Long-Term Cardiovascular Outcomes: Validation of a Locus Identified in a Previous Genome-Wide Association Study.

BackgroundData on genetic variants that can predict follow-up cardiovascular events are highly limited, particularly for Asians. The aim of this study was to validate the effects of two variants in FLT1 and 9p21 on long-term cardiovascular outcomes in high-risk Korean patients.MethodsWe examined the prognostic values of the rs9508025 and rs1333049 variants that were found to be associated with coronary artery disease (CAD) risk in a previous Korean genome-wide association study. A total of 2693 patients (mean age: 55.2 years; male: 55.2%) with CAD or its risk factors at baseline were enrolled and followed for major adverse cardiac events (MACE).ResultsDuring the mean follow-up of 8.8 years, 15.4% of the patients experienced MACE. Kaplan-Meier curves showed that MACE-free survival was different according to the genotype of rs9508025 (log rank p = 0.02), whereas rs1333049 genotype did not correlate with the prognosis. Multivariate Cox proportional hazard analysis showed that C-allele of rs9508025 was significantly associated with a high rate of MACE, while rs1333049 was not. Further analyses demonstrated that the association of the rs9508025 variant with MACE was mainly due to its relation to coronary revascularization, which was also associated with the rs1333049 variant. In an additional analysis, rs9508025 was found to be an independent determinant of the outcome only in the subgroup with history of CAD.Conclusionsrs9508025 in FLT1 was significantly associated with long-term cardiovascular events, particularly in patients with prior CAD. The association of rs1333049 in 9p21 was not significant.

Prediction of 1-year clinical outcomes using the SYNTAX score in patients with prior heart failure undergoing percutaneous coronary intervention: sub-analysis of the SHINANO registry

Although coronary artery disease (CAD) is common in patients with heart failure (HF), little is known about the prognostic significance of coronary lesion complexity in patients with prior HF undergoing percutaneous coronary intervention (PCI). The aim of this study was to investigate whether the coronary Synergy between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery (SYNTAX) score could improve risk stratification in HF patients with CAD. Two hundred patients (mean age 73 ± 11 years, left ventricular ejection fraction 49 ± 15 %) with prior HF who underwent PCI were divided into two groups stratified by SYNTAX score (median value 12) and tracked prospectively for 1 year. The study endpoint was the composite of major adverse cardiovascular events (MACE), including all-cause death, myocardial infarction, stroke, and hospitalization for worsening HF. Adverse events were observed in 39 patients (19.5 %). Patients with high SYNTAX scores (n = 100) showed worse prognoses than those with low scores (n = 100) (26.0 vs. 13.0 %, respectively, P = 0.021). In multivariate Cox-regression analysis, SYNTAX score ≥12 was significantly associated with MACE (hazard ratio: 1.99, 95 % confidence interval: 1.02–3.97; P = 0.045). In patients with prior HF and CAD, high SYNTAX scores predicted a high incidence of MACE. These results suggest that the SYNTAX score might be a useful parameter for improving risk stratification in these patients.

The clinical efficacy and long-term prognostic value of stress echocardiography in octogenarians

IntroductionAlthough stress echocardiography (SE) is invaluable in younger populations, its prognostic value may be attenuated in the elderly due to shorter life expectancy and the frequent presence of severe comorbidities....

Feasibility and Safety of Evaluating Patients with Prior Coronary Artery Disease Using an Accelerated Diagnostic Algorithm in a Chest Pain Unit.

An accelerated diagnostic protocol for evaluating low-risk patients with acute chest pain in a cardiologist-based chest pain unit (CPU) is widely employed today. However, limited data exist regarding the feasibility of such an algorithm for patients with a history of prior coronary artery disease (CAD). The aim of the current study was to assess the feasibility and safety of evaluating patients with a history of prior CAD using an accelerated diagnostic protocol. We evaluated 1,220 consecutive patients presenting with acute chest pain and hospitalized in our CPU. Patients were stratified according to whether they had a history of prior CAD or not. The primary composite outcome was defined as a composite of readmission due to chest pain, acute coronary syndrome, coronary revascularization, or death during a 60-day follow-up period. Overall, 268 (22%) patients had a history of prior CAD. Non-invasive evaluation was performed in 1,112 (91%) patients. While patients with a history of prior CAD had more comorbidities, the two study groups were similar regarding hospitalization rates (9% vs. 13%, p = 0.08), coronary angiography (13% vs. 11%, p = 0.41), and revascularization (6.5% vs. 5.7%, p = 0.8) performed during CPU evaluation. At 60-days the primary endpoint was observed in 12 (1.6%) and 6 (3.2%) patients without and with a history of prior CAD, respectively (p = 0.836). No mortalities were recorded. To conclude, Patients with a history of prior CAD can be expeditiously and safely evaluated using an accelerated diagnostic protocol in a CPU with outcomes not differing from patients without such a history.

Combined aspirin and anticoagulant therapy in patients with atrial fibrillation.

The combined use of aspirin and oral anticoagulant therapy in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) has been questioned due to an increased risk of major bleeding with little to no benefit in preventing ischemic events. (1) To better understand patterns and indications for combined antiplatelet and anticoagulant therapy and identify patients who might reasonably be treated with oral anticoagulant (OAC) therapy alone. (2) To perform an updated literature review regarding the use of combined antiplatelet and OAC therapy in patients with AF and stable CAD. Retrospective review. Patients within the University of Cincinnati Health System with a diagnosis of non-valvular AF, excluding those with acute coronary syndrome or revascularization within the last 12months. Numbers and indications for combined antiplatelet and anticoagulant therapy and sequence of events leading to the initiation of each. Of 948 patients receiving OAC, 430 (45 %) were receiving concomitant OAC and aspirin. Among patients receiving combined antiplatelet and anticoagulant therapy, 49 and 42 % of patients respectively, had CAD or DM. In a more detailed analysis including chart review of 219 patients receiving combined OAC and aspirin, 27 % had a diagnosis of CAD and 14 % had a diagnosis of DM prior to the development of AF. These patients were initially treated with aspirin. Warfarin was added when they subsequently developed AF but aspirin wasn't discontinued. A surprisingly large proportion of patients (22.8 %) had no obvious indication for dual therapy. Prior myocardial infarction, CAD, vascular disease and DM (among others) increase the likelihood of receiving combined antiplatelet and anticoagulant therapy among patients with AF. A literature review suggests this may lead to increased major bleeding with little benefit in decreasing either AF-related stroke or cardiovascular events.

Incidence and predictors of sudden arrhythmic death or ventricular tachyarrhythmias after acute coronary syndrome: An asian perspective

Current data on the risk of sudden arrhythmic death (SAD) and ventricular tachyarrhythmias (VTs) after acute coronary syndrome (ACS) in the Asian population are limited. The purpose of this study was to investigate the incidence and predictors of SAD or VT after ACS in a contemporary cohort of Chinese patients in the era of early revascularization. Consecutive patients admitted to our unit for ACS from 2010 to 2015 were retrospectively reviewed. A total of 918 patients (74.8% male, mean age 65.9 ± 13.4 years) were included in the study. Of these patients, 864 (94.1%) survived to discharge. After a mean of 34.1 ± 21.8 months, 42 (4.9%) had SAD or VT. The event rate was 0.46% in month 1, 0.26% per month in the months 2 to 6, 0.15% per month in months 6 to 12, and 1.23% per year from the second year onward. In multivariate analysis, early VT (hazard ratio [HR] 5.78, 95% confidence interval [CI] 2.63-12.72, P < .01), left ventricular ejection fraction ≤35% (HR 1.96, 95% CI 1.03-3.73, P = .04), prior coronary artery disease (HR 2.50, 95% CI 1.29-4.82, P < .01), triple-vessel disease (HR 3.69, 95% CI 1.81-7.54, P < .01), and chronic kidney disease (HR 2.43, 95% CI 1.21-4.92, P = .01) independently predicted SAD or VT. This study reports the rate of SAD or VT among Asian patients after ACS in the era of early revascularization and optimal medical therapy. Aggressive preventive measures should be considered for patients with multiple risk factors for SAD or VT, especially in the initial period after ACS.

European Society of Cardiology-Recommended Coronary Artery Disease Consortium Pretest Probability Scores More Accurately Predict Obstructive Coronary Disease and Cardiovascular Events Than the Diamond and Forrester Score: The Partners Registry.

The most appropriate score for evaluating the pretest probability of obstructive coronary artery disease (CAD) is unknown. We sought to compare the Diamond-Forrester (DF) score with the 2 CAD consortium scores recently recommended by the European Society of Cardiology. We included 2274 consecutive patients (age, 56±13 years; 57% male) without prior CAD referred for coronary computed tomographic angiography. Computed tomographic angiography findings were used to determine the presence or absence of obstructive CAD (≥50% stenosis). We compared the DF score with the 2 CAD consortium scores with respect to their ability to predict obstructive CAD and the potential implications of these scores on the downstream use of testing for CAD, as recommended by current guidelines. The DF score did not satisfactorily fit the data and resulted in a significant overestimation of the prevalence of obstructive CAD (P<0.001); the CAD consortium basic score had no significant lack of fitness; and the CAD consortium clinical provided adequate goodness of fit (P=0.39). The DF score had a lower discrimination for obstructive CAD, with an area under the receiver-operating characteristics curve of 0.713 versus 0.752 and 0.791 for the CAD consortium models (P<0.001 for both). Consequently, the use of the DF score was associated with fewer individuals being categorized as requiring no additional testing (8.3%) compared with the CAD consortium models (24.6% and 30.0%; P<0.001). The proportion of individuals with a high pretest probability was 18% with the DF and only 1.1% with the CAD consortium scores (P<0.001) CONCLUSIONS: Among contemporary patients referred for noninvasive testing, the DF risk score overestimates the risk of obstructive CAD. On the other hand, the CAD consortium scores offered improved goodness of fit and discrimination; thus, their use could decrease the need for noninvasive or invasive testing while increasing the yield of such tests.

Incidence and predictors of 30-day cardiovascular complications in patients undergoing head and neck cancer surgery.

Incidence and predictors of peri-operative or post-operative cardiovascular complications in head and neck cancer surgery remain poorly elucidated. In this retrospective study, we investigated the rate and pre-operative risk factors for cardiovascular and cerebrovascular complications. This study included all patients (n=456) operated for head and neck cancer between 1999 and 2008. Patients' medical records were reviewed and the adjudication of endpoints was performed by adjudication committee. The 30-day incidence of cardiovascular and cerebrovascular complications was 7.2%. Cardiac mortality at 30days was 1.0%. Univariate predictors of MACCE (major adverse cardiac and cerebrovascular events) at the 30-day follow-up were history of myocardial infarction (OR 4.56, 95% CI 1.73-11.97, p=0.002); history of heart failure (OR 4.14, 95% CI 1.32-13.02, p=0.015); pre-existing coronary artery disease (OR 3.98, 95% CI 1.75-9.06, p=0.001); prior aspirin medication (OR 3.73, 95% CI 1.81-7.71, p<0.001); prior betablocker medication (OR 3.67, 95% CI 1.79-7.51, p<0.001); hypertension (OR 2.55, 95% CI 1.25-5.19, p=0.010); and increasing age (OR 1.08, 95% CI 1.05-1.12, p<0.001). In a multivariate model, independent predictors of MACCE were pre-existing coronary artery disease (OR 2.45, 95% CI 1.03-5.80, p=0.042) and increasing age (OR 1.08, 95% CI 1.04-1.11, p<0.001). Patients having surgery for head and neck cancer are at high (>5%) risk of developing vascular complications. Prior coronary artery disease and increasing age are independent risk factors for MACCE.

Components and determinants of therapeutic delay in patients with acute ST-elevation myocardial infarction: A tertiary care hospital-based study

BackgroundDelayed reperfusion is associated with worse outcomes in ST-segment elevation myocardial infarction (STEMI). This study was conducted to assess the components and determinants of therapeutic delay in STEMI patients of our state. MethodsThis study included consecutive patients of STEMI admitted to the coronary care units of two tertiary care hospitals in Srinagar, between 2012 and 2015. Various components of treatment delay including the patient’s decision to delay, referral delay, transportation delay, prehospital delay, and door-to-needle time were calculated. Factors associated with delayed treatment and clinico-demographic correlates of late presentation were identified. ResultsDuring a period of 3years, 523 patients (mean age, 57.6±10.5years) were enrolled in this study. Thrombolysis was administered to 60.2% patients, while 39.8% of patients could not be thrombolysed because of late presentation. The median treatment delay was 250minutes. Prehospital delay constituted about 83.8% of total treatment delay. Patient’s decision to delay, referral delay, and transport delay constituted 59%, 16%, and 25% of prehospital delay, respectively. Median door-to-needle time was 40minutes. Residence in rural areas [odds ratio (OR), 2.35; 95% confidence interval (CI), 1.60–3.46], absence of prior coronary artery disease (OR, 1.54; 95% CI, 1.00–2.39), and negative family history of coronary artery disease (OR; 2.76; 95% CI, 1.86–4.10), were identified as independent predictors of delayed presentation (p<0.001). Interestingly, 44.7% of the patients presented late due to misdiagnosis by local healthcare providers. ConclusionThe standard of STEMI management in our state is far from ideal, and calls for a lot of improvement. Major efforts to reduce prehospital and in-hospital treatment delays are urgently needed.

Temporal trends of single-photon emission computed tomography myocardial perfusion imaging in patients without prior coronary artery disease: A 22-year experience at a tertiary academic medical center

Between 1990 and 2006, there was a large national increase in utilization of single-photon emission computed tomography myocardial perfusion imaging (SPECT) for assessment of coronary artery disease (CAD). We aim to examine the trends of SPECT test results and patients' characteristics at Mayo Clinic Rochester. Using the Mayo Clinic nuclear cardiology database, we examined all SPECT tests performed between January 1, 1991, and December 31, 2012, in patients without prior CAD. The study cohort was divided into 5 time periods: 1991-1995, 1996-2000, 2001-2005, 2006-2010, and 2011-2012. There were 35,894 eligible SPECT tests (mean age 62.5 ± 12 years, 54% men). Annual utilization of SPECT increased significantly in 1992-2002 but then decreased without evidence of test substitution with stress echocardiography. There were modest changes in CAD risk factors over time. Testing of asymptomatic patients doubled (21.9% in 1991-1995 to 40% in 2006-2010) but later decreased to 33.6% in 2011-2012. Tests on patients with typical angina decreased dramatically (18.3% in 1991-1995 to 6.7% in 2011-2012). Summed stress score, summed difference score, and high-risk SPECT tests all decreased over time in both symptomatic and asymptomatic patients regardless of stress modality (exercise vs pharmacologic). In Mayo Clinic Rochester, annual SPECT utilization in patients without prior CAD increased in 1992-2002 but then decreased. Despite similar CAD risk factors and decreased utilization after 2003, more tests were low risk; summed stress score, summed difference score, and high-risk tests all decreased. Our findings confirm previous observations that SPECT was increasingly used in patients with a lower prevalence of CAD.