Traditional Risk Stratification Research Articles

Sudden cardiac death risk stratification.

Arrhythmic sudden cardiac death (SCD) may be caused by ventricular tachycardia/fibrillation or pulseless electric activity/asystole. Effective risk stratification to identify patients at risk of arrhythmic SCD is essential for targeting our healthcare and research resources to tackle this important public health issue. Although our understanding of SCD because of pulseless electric activity/asystole is growing, the overwhelming majority of research in risk stratification has focused on SCD-ventricular tachycardia/ventricular fibrillation. This review focuses on existing and novel risk stratification tools for SCD-ventricular tachycardia/ventricular fibrillation. For patients with left ventricular dysfunction or myocardial infarction, advances in imaging, measures of cardiac autonomic function, and measures of repolarization have shown considerable promise in refining risk. Yet the majority of SCD-ventricular tachycardia/ventricular fibrillation occurs in patients without known cardiac disease. Biomarkers and novel imaging techniques may provide further risk stratification in the general population beyond traditional risk stratification for coronary artery disease alone. Despite these advances, significant challenges in risk stratification remain that must be overcome before a meaningful impact on SCD can be realized.

White coat effect and masked uncontrolled hypertension in treated hypertensive-diabetic patients: Prevalence and target organ damage.

The association between hypertensive phenotypes of controlled hypertension (CH), white-coat effect (WCE), masked uncontrolled hypertension (MUH) and sustained hypertension (SH) with target organ damage have not been clearly established in diabetic hypertensive treated patients. The present study aims to evaluate the prevalence of the four phenotypes considering the current cut-off points for office and 24 h-ambulatory blood pressure monitoring (ABPM) and the association with left ventricle hypertrophy (LVH), diastolic function and nephropathy. Cross-sectional study with 304 patients on anti-hypertensive treatment aged 57.6 ± 6.1 years, who were submitted to ABPM and echocardiography. They were classified into CH (normal office BP and ABPM), WCE (high office BP and normal ABPM), MUH (normal office BP and high ABPM), and SH (high office BP and ABPM). Median HbA1c and diabetes duration were 7.9% (6.8-9.2), and 10 years (5-16), respectively. Prevalences of CH, WCE, MUH and SH were 27.3%, 17.1%, 18.8%, and 36.8%. MUH prevalence was higher than previously described. There was a significant increasing trend across the four groups in variables related to LVH (P < 0.001 for trend). There was not a clear "dose-response" relationship of the four hypertensive phenotypes with nephropathy and diastolic function. The use of ABPM beyond the traditional cardiovascular risk stratification tools has limitations, but is still useful in high-risk patients. Longitudinal studies could better evaluate the role of the use of ABPM in this scenario. Cut-off points for normality of office and ABPM influence the prevalences of WCH and MUH.

Prognostic value of cardiovascular MRI in diabetics

Despite an increased cardiovascular risk in patients with diabetes mellitus they are a heterogeneous population with very different individual manifestation of diseases; therefore, a profound stratification is recommended. Clinical examinations and blood biomarkers are typically used in diabetic patients to determine the risk for developing cardio-cerebrovascular events. Cardiac as well as whole-body magnetic resonance imaging (MRI) including cardiovascular sequences are established methods for clinical diagnostics. Their significance in predicting the outcome and the corresponding risk stratification for patients with diabetes is becoming increasingly more important based on recent study results. Late gadolinium enhancement (LGE) in cardiac MRI detects silent myocardial ischemia in up to 30% of diabetic patients, which is associated with a hazard ratio of 3-6 for cardiovascular events. Regional left ventricular wall motion abnormalities and decreased ejection fraction also have a prognostic value in diabetics. Based on whole-body MRI, the vessel score as well as carotid artery stenosis have been evaluated as additional predictors for cardio-cerebrovascular events. The MRI-based predictors have independent and incremental prognostic value beyond traditional risk stratification for cardio-cerebrovascular events; however, only the comprehensive assessment of whole-body MRI including angiography allows the identification of patients who remain free of cardio-cerebrovascular events over a period of 6 years. Cardiac MRI, particularly the detection of LGE, can be recommended for risk stratification of patients with diabetes mellitus. The clinical relevance of the added prognostic value of whole-body MRI needs to be clarified in further studies.

Incremental Benefit of Coronary Artery Calcium Score Above Traditional Risk Factors for All-Cause Mortality in Asymptomatic Korean Adults

Coronary artery calcium score (CACS) is a well-recognized marker for subclinical coronary atherosclerosis, particularly in asymptomatic populations. To date, however, the added prognostic benefit of CACS compared with traditional risk factors in an Asian population remains unknown. This study therefore investigated the benefit of CACS over traditional risk factors for all-cause mortality in a large multicenter registry of asymptomatic Korean adults. A total of 34,386 individuals were retrospectively enrolled to participate in a general health examination. The Framingham 10-year risk score (FRS) was calculated according to the traditional risk stratification algorithm and CACS was calculated in log(CACS+1) for continuous data and categorized as 0, 1-100, 101-400 and >400. During a median follow-up of 4.9 years (IQR, 3.0-7.1), there were 303 all-cause deaths (0.9%). Following adjustment, CACS was independently associated with all-cause death (hazard ratio, 1.10; 95% confidence interval (CI): 1.05-1.17; P<0.001). Notably, CACS added further prognostic value above and beyond FRS (likelihood ratio, χ(2)=75.42, P<0.001; continuous net reclassification improvement=0.40, 95% CI: 0.29-0.51, P≤0.001; improving C-statistic from 0.64, 95% CI: 0.61-0.67 to 0.68, 95% CI: 0.64-0.71; ∆C=0.04, 95% CI: 0.01-0.06, P=0.002). In an asymptomatic Korean population, CACS improved prediction of all-cause mortality over and above that of a conventional risk tool.

Risk calculators and updated tools to select and plan a repeat biopsy for prostate cancer detection.

Millions of men each year are faced with a clinical suspicion of prostate cancer (PCa) but the prostate biopsy fails to detect the disease. For the urologists, how to select the appropriate candidate for repeat biopsy is a significant clinical dilemma. Traditional risk-stratification tools in this setting such as prostate-specific antigen (PSA) related markers and histopathology findings have met with limited correlation with cancer diagnosis or with significant disease. Thus, an individualized approach using predictive models such as an online risk calculator (RC) or updated biomarkers is more suitable in counseling men about their risk of harboring clinically significant prostate cancer. This review will focus on the available risk-stratification tools in the population of men with prior negative biopsies and persistent suspicion of PCa. The underlying methodology and platforms of the available tools are reviewed to better understand the development and validation of these models. The index patient is then assessed with different RCs to determine the range of heterogeneity among various RCs. This should allow the urologists to better incorporate these various risk-stratification tools into their clinical practice and improve patient counseling.

The Impact of Multiparametric Pelvic Magnetic Resonance Imaging on Risk Stratification in Patients With Localized Prostate Cancer

To determine the impact of multiparametric magnetic resonance imaging (MP-MRI) of the prostate on established risk stratification criteria in patients with clinically localized adenocarcinoma of the prostate (ACP). The cohort included 71 patients who underwent MP-MRI of the prostate at a tertiary care referral center as part of their initial workup for ACP. Tumor characteristics comprising traditional risk stratification criteria (prostate-specific antigen, clinical T stage, and biopsy Gleason score) were recorded, and the initial National Comprehensive Cancer Network risk group was calculated. The National Comprehensive Cancer Network risk group was then recalculated incorporating MRI findings. The impact of MRI findings on changes in risk group classification was evaluated using the Stuart-Maxwell test. For patients undergoing radical prostatectomy, MRI findings were correlated with pathologic findings. The cohort included 11 (15.5%), 39 (54.9%), and 21 patients (29.6%) with low-, intermediate-, and high-risk disease, respectively. MRI findings led to risk group upstaging in 12 cases (16.9%). The highest yield was demonstrated in patients with intermediate-risk disease, in whom MRI led to upstaging in 25.6% of patients. There was a significant difference between pre-MRI and post-MRI risk group classifications (P<.01) for the entire cohort. Compared with radical prostatectomy specimens, the specificity of MRI for T3 disease was 92.9%. In our cohort of patients undergoing MP-MRI for previously untreated, clinically localized ACP, MRI findings led to changes in risk stratification in a substantial proportion of patients. Our findings support the use of MP-MRI in the workup of patients with localized ACP.

The impact of pelvic magnetic resonance imaging on risk stratification in patients with localized prostate cancer.

130 Background: We aimed to determine the impact of multiparametric magnetic resonance imaging (MRI) of the prostate on established risk stratification criteria in patients with clinically localized adenocarcinoma of the prostate (ACP). Methods: We included patients who had undergone multiparametric prostate MRI at our institution as part of their initial workup for ACP. Traditional risk stratification criteria (prostate specific antigen, clinical T stage, biopsy Gleason score) were recorded, and the initial National Comprehensive Cancer Network (NCCN) risk group was calculated. The NCCN risk group was then recalculated incorporating MRI findings. The impact of MRI findings on changes in risk group classification was evaluated using the Stuart-Maxwell test for marginal homogeneity. Results: Of 71 patients analyzed, 11 (15.5%), 39 (54.9%), and 21 (29.6%) had low, intermediate, and high risk disease, respectively. MRI findings led to risk group upstaging in 12 cases (16.9%). The highest yield was demonstrated in patients with intermediate-risk disease, in whom MRI led to upstaging in 25.6% of patients. The Stuart-Maxwell test demonstrated a significant difference between pre-MRI and post-MRI risk group classifications (p &lt;0.01) for the entire cohort. Pre-MRI and post-MRI risk groups for all patients are shown in the table, with off-diagonal elements representing risk group changes. MRI findings resulted in clearly documented changes in the treatment strategy for 5 patients (7.0%), including addition of androgen deprivation therapy in 2 patients, elimination of definitive therapy in 2 patients determined to have metastatic disease, and elimination of a brachytherapy boost in one patient. Conclusions: In our cohort of patients with clinically localized ACP, MRI findings often led to significant changes in risk stratification and treatment. Our findings support the routine use of MRI in the workup of patients with clinically localized ACP, particularly those with intermediate risk disease . [Table: see text]

Current Roles and Future Applications of Cardiac CT: Risk Stratification of Coronary Artery Disease

Cardiac computed tomography (CT) has emerged as a noninvasive modality for the assessment of coronary artery disease (CAD), and has been rapidly integrated into clinical cares. CT has changed the traditional risk stratification based on clinical risk to image-based identification of patient risk. Cardiac CT, including coronary artery calcium score and coronary CT angiography, can provide prognostic information and is expected to improve risk stratification of CAD. Currently used conventional cardiac CT, provides accurate anatomic information but not functional significance of CAD, and it may not be sufficient to guide treatments such as revascularization. Recently, myocardial CT perfusion imaging, intracoronary luminal attenuation gradient, and CT-derived computed fractional flow reserve were developed to combine anatomical and functional data. Although at present, the diagnostic and prognostic value of these novel technologies needs to be evaluated further, it is expected that all-in-one cardiac CT can guide treatment and improve patient outcomes in the near future.

Rest myocardial perfusion imaging: a valuable tool in ED

BackgroundAcute chest pain is a frequent cause of emergency department (ED) visits. Rest myocardial perfusion imaging (RMPI) during or immediately after an episode of chest pain can provide diagnostic and prognostic information concerning acute coronary syndromes. AimOur purpose was to evaluate the RMPI score in risk stratification of chest pain suspected to be of cardiac ischemic origin and negative troponin assessment. MethodsNinety-six patients without an ongoing myocardial infarction or a history of coronary artery disease and in whom RMPI was performed in the ED because of chest pain suspected to be related with acute myocardial ischemia were included.Follow-up was performed considering the occurrence of death, myocardial infarction, or revascularization in a 12-month period admission. ResultsFourteen (14.6%) patients had events. According to survival analysis, the variables related with events were a history of angina (hazard ratio [HR], 4.5; P ≤ .01), an ischemic electrocardiogram (HR, 4.0; P ≤ .01), the abnormal RMPI (HR, 11.4; P ≤ .05), and the RMPI score (HR, 1.1; P ≤ .0001). When the variables of interest were forced into a multivariate model, the χ2 associated with the model that includes clinical and electrocardiogram information was 16.3 (P ≤ .005) and in the model that also includes RMPI score, it was 23.0 (P ≤ .0005). ConclusionIn a low- to intermediate-risk group of patients with suspected acute myocardial ischemia, RMPI gives not only diagnostic information but adds prognostic value to the traditional ED risk stratification tools.

Is It Time for HDL to Change Its Tune?

Over the course of the past century, increasing evidence has accumulated to implicate a central role for atherogenic lipoproteins in the pathogenesis of atherosclerotic cardiovascular disease. This is supported by the importance of cholesterol measurement for risk prediction and the use of lipid-modifying therapies in primary and secondary prevention. Recent reports have suggested that particle-based measurements of atherogenic lipoproteins may provide additional information in risk stratification.1 In particular, persistently elevated measures of low-density lipoprotein (LDL) particles in patients whose LDL cholesterol appears optimally controlled may identify individuals more likely to benefit from more intensive lipid lowering. Article see p 1189 In parallel, there has been considerable interest in the potential protective properties of high-density lipoproteins (HDL) for the development of new risk-prediction markers and cardiovascular therapeutics. This is based on observations from large population cohorts of an inverse relationship between HDL cholesterol (HDL-C) levels and prospective risk of cardiovascular events2 and of favorable effects with HDL-targeted interventions in animal models of atherosclerosis.3 Although HDL-C is used in traditional risk stratification, and raising HDL-C levels may contribute to the clinical …

Gleason pattern 5 is the strongest pathologic predictor of recurrence, metastasis, and prostate cancer–specific death in patients receiving salvage radiation therapy following radical prostatectomy

The presence of Gleason pattern 5 (GP5) at radical prostatectomy (RP) has been associated with worse clinical outcome; however, this pathologic variable has not been assessed in patients receiving salvage radiation therapy (SRT) after a rising prostate-specific antigen level. A total of 575 patients who underwent primary RP for localized prostate cancer and subsequently received SRT at a tertiary medical institution were reviewed retrospectively. Primary outcomes of interest were biochemical failure (BF), distant metastasis (DM), and prostate cancer-specific mortality (PCSM), which were assessed via univariate analysis and Fine and Grays competing risks multivariate models. On pathologic evaluation, 563 (98%) patients had a documented Gleason score (GS). The median follow-up post-SRT was 56.7 months. A total of 60 (10.7%) patients had primary, secondary, or tertiary GP5. On univariate analysis, the presence of GP5 was prognostic for BF (hazard ratio [HR] 3.3; P < .0001), DM (HR:11.1, P < .0001), and PCSM (HR:8.8, P < .0001). Restratification of the Gleason score to include GP5 as a distinct entity resulted in improved prognostic capability. Patients with GP5 had clinically worse outcomes than patients with GS8(4+4). On multivariate analysis, the presence of GP5 was the most adverse pathologic predictor of BF (HR 2.9; P < .0001), DM (HR 14.8; P < .0001), and PCSM (HR 5.7; P < .0001). In the setting of SRT for prostate cancer, the presence of GP5 is a critical pathologic predictor of BF, DM, and PCSM. Traditional GS risk stratification fails to fully utilize the prognostic capabilities of individual Gleason patterns among men receiving SRT post-RP.

The prevalence and characteristics of coronary atherosclerosis in asymptomatic subjects classified as low risk based on traditional risk stratification algorithm: assessment with coronary CT angiography

ObjectiveTo evaluate the prevalence and characteristics of coronary atherosclerosis in asymptomatic subjects classified as low risk by National Cholesterol Education Program (NCEP) guideline using coronary CT angiography (CCTA).DesignAn observational study.SettingA...

Clinical Relevance of the Fusion Transcripts Distribution Pattern in Mexican Children With Acute Lymphoblastic Leukemia

Chromosomal translocation-generated fusion genes in childhood acute lymphoblastic leukemia (ALL) are well-known indicators of prognostic outcome. This study was conducted to establish the clinical relevance of the fusion genes distribution pattern in Mexican children with newly diagnosed ALL. Multiplex RT-PCR assays were used to detect 4 commonest fusion transcripts in 261 Mexican children with B-cell precursor ALL aged 1 to 14 years old, comparing differences in the distribution of the patients between molecular subgroups to a common collection of clinical parameters. We documented a 13% significant proportion of all patients who are more than 10 years of age, harboring fusion transcripts associated with leukocytosis and poor response to remission-induction chemotherapy, than those negative children for chimeric transcripts (P<0.001). Most notable observation was identified a significant number of e2a-pbx1-positive patients who showed a more aggressive disease at diagnosis. As presented here, this report gives an overview of the clinical implications of the fusion gene positivity in Mexican children with ALL in the context of traditional risk stratification variables. Our data support the existence of important ethnic and geographic differences in Mexican population.

Predicting Lung Transplant Waitlist Survival with the Lung Allocation Score in British Columbia, Canada

Purpose The Lung Allocation Score (LAS), implemented in 2005 in the United States, allocates donor organs according to predicted pre and post-lung transplant mortality based on clinical parameters. In Canada, allocation is based on a dichotomous Status ranking of 1 (active and stable) or 2 (urgent, rapidly deteriorating). The purpose of this study was to assess if LAS scores predicted waitlist and post-transplant mortality in our population, and to compare its ability to do so in comparison to the traditional Status risk stratification. Methods and Materials LAS scores were retrospectively calculated for all patients listed for lung transplantation between January 2007 and July 2012 in British Columbia, Canada. Using measures of model goodness-of-fit (Akaike Information Criterion [AIC]), we compared proportional hazards regression for time to death on the waitlist and post-transplant with either LAS score or Status at time of activation as the predictor. Likelihood-ratio tests were used to test if models with LAS or status as predictors were significantly better than models without any predictor. Results 125 patients were listed for transplant. 96 were listed Status 1 (mean LAS 35.46, SD 5.32) and 9 listed Status 2 (Mean LAS 50.38, SD 15.22). Pulmonary diagnoses included IPF (31%), COPD (25%), CF (19%) and PAH (9%). Mortality on the waitlist was 23.2% (n=29), 48.8% (n=61) patients were transplanted and 28% (n=35) were still awaiting transplant or deactivated. In predicting death on the waitlist, LAS score outperformed Status (AIC of 149.66 versus 154.44; likelihood ratio p=0.008). In predicting post-transplant mortality, however, neither model with LAS (likelihood ratio p=0.19) or Status ranking (likelihood ratio p=0.051) were shown to be different than models without any predictor. Conclusions In this single center study, LAS score was a better predictor of waitlist mortality than the currently implemented Status ranking. Further analysis including other Canadian transplant centers is underway to validate these findings.

Gleason pattern 5 as a pathologic predictor of recurrence, development of metastasis, and prostate cancer-specific death for patients receiving salvage radiation therapy following radical prostatectomy.

151 Background: The presence of primary, secondary, and tertiary Gleason pattern 5 (GP5) in prostate cancer has been shown to predict outcomes and improve risk stratification following radical prostatectomy (RP) and external beam radiation therapy (EBRT). However, the predictive value of GP5 has not been assessed in salvage EBRT (SRT) for a rising PSA after RP. We sought to assess the prognostic capability of the presence of GP5 in this setting. Methods: 575 patients who received SRT at a single institution for biochemical recurrence after RP were retrospectively reviewed in an IRB approved analysis. We assessed the impact of GP5 on biochemical failure (BF), distant metastasis (DM), prostate cancer-specific mortality (PCSM), and overall survival (OS) using Kaplan-Meier and Cox Proportional Hazards models. Results: Median follow up was 56.7 months post SRT. On pathologic evaluation, 563 patients had a documented Gleason score (GS). 60 patients (10.7%) had primary, secondary, or tertiary GP5. GP5 was the strongest pathologic predictor of DM (p&lt;0.01 HR: 1.9 [95%CI: 1.3-2.9]) and PCSM (p&lt;0.01 HR: 4.0 [95%CI: 2.1-7.7]) on univariate analysis. The presence of GP5 was a better predictor of BF, DM, PCSM, and OS than stratification by GS8-10. Patients with GP5 had clinically worse outcomes than GS8 patients without GP5. There was no difference in outcome between primary, secondary, and tertiary GP5. On multivariate analysis, GP5 was the strongest pathologic predictor of BF (p&lt;0.01 HR: 2.7 [95%CI: 1.6-4.5]), DM (p&lt;0.01 HR: 11.2 [95%CI: 3.9-32.2]), and PCSM (p&lt;0.01 HR: 6.0 [95%CI: 1.8-19.6]). Conclusions: In SRT, where pathologic factors including extra-capsular extension, seminal vesicle invasion, and margin status are known, the presence of GP5 is the strongest pathologic predictor of BF, DM, and PCSM. Traditional GS risk stratification fails to fully utilize the prognostic capabilities of individual GP’s for SRT patients following RP. Intensification of treatment regimens, such as early use of androgen deprivation therapy or adjuvant radiation, may be appropriate for patients with GP5 in this setting.

Effect of Carotid Plaque Screening Using Contrast-Enhanced Ultrasound on Cardiovascular Risk Stratification

Cardiovascular risk stratification of asymptomatic patients is based on the assessment of risk factors. Noninvasive imaging of subclinical atherosclerosis may improve cardiovascular risk stratification, especially in patients with co-morbidities. The aim of this study was to investigate the effect of contrast-enhanced ultrasound (CEUS) of the carotid arteries on cardiovascular risk assessment. The study population consisted of 100 consecutive asymptomatic patients with ≥1 clinical risk factor for atherosclerosis. Cardiovascular risk was estimated by calculating the Prospective Cardiovascular Münster Heart Study (PROCAM) risk score. This score was divided into 3 subgroups: low (≤5%), intermediate (6% to 19%), and high (≥20%). Subclinical carotid atherosclerosis was assessed using standard ultrasound for intima-media thickness and plaque screening and CEUS for additional plaque screening. CEUS was performed using SonoVue contrast agent. Patients with subclinical atherosclerosis were considered to be at high cardiovascular risk. McNemar's test was used to compare PROCAM score to ultrasound findings. The mean PROCAM risk score was 9 ± 10; the PROCAM risk score was low in 72 patients (72%), intermediate in 17 patients (17%), and high in 11 patients (11%). A total of 21 patients (21%) had abnormal carotid intima-media thickness, 77% had plaques on conventional carotid ultrasound, and 88% had plaques on standard carotid ultrasound combined with CEUS. Detection of atherosclerosis led to the reclassification of 79 patients (79%) to high cardiovascular risk (p <0.001). In conclusion, CEUS changes the risk category as estimated by a traditional risk stratification model in most asymptomatic patients. CEUS may thus be an additional method for cardiovascular risk prediction in patient groups with co-morbidities.

Reclassification of Cardiovascular Risk in Patients With Normal Myocardial Perfusion Imaging Using Heart Rate Response to Vasodilator Stress

Previous studies have shown that patients with normal vasodilator myocardial perfusion imaging (MPI) findings remain at a greater risk of future cardiac events than patients with normal exercise MPI findings. The aim was to assess improvement in risk classification provided by the heart rate response (HRR) in patients with normal vasodilator MPI findings when added to traditional risk stratification. We retrospectively studied 2,000 patients with normal regadenoson or adenosine MPI findings. Risk stratification was performed using Adult Treatment Panel III framework. Patients were stratified by HRR (percentage of increase from baseline) into tertiles specific to each vasodilator. All-cause mortality and cardiac death/nonfatal myocardial infarction (MI) ≤2 years from the index MPI were recorded. During follow-up, 11.8% patients died and 2.7% patients experienced cardiac death/nonfatal MI in the adenosine and regadenoson groups, respectively. The patients who died had a greater Framingham risk score (12 ± 4 vs 11 ± 4, p= 0.009) and lower HRR (22± 16 vs 32 ± 21, p <0.0001). In an adjusted Cox model, the lowest tertile HRR was associated with an increased risk of mortality (hazard ratio 2.1) and cardiac death/nonfatal MI (hazard ratio 2.9; p <0.01). Patients in the highest HRR tertile, irrespective of the Adult Treatment Panel III category, were at low risk. When added to the Adult Treatment Panel III categories, the HRR resulted in net reclassification improvement in mortality of 18% and cardiac death/nonfatal MI of 22%. In conclusion, a blunted HRR to vasodilator stress was independently associated with an increased risk of cardiac events and overall mortality in patients with normal vasodilator MPI findings. The HRR correctly reclassified a substantial proportion of these patients in addition to the traditional risk classification models and identified patients with normal vasodilator MPI findings, who had a truly low risk of events.

Associations among different functional and structural arterial wall properties and their relations to traditional cardiovascular risk factors in healthy subjects: a cross-sectional study

BackgroundThe arterial wall possesses several functional and structural properties that define arterial health. Once they become impaired, cardiovascular risk increases. We aimed to ascertain the pattern of correlations among different arterial wall properties and to explore their relations to traditional risk factors and cardiovascular risk stratification. To allow such an investigation a middle-aged healthy population was recruited.MethodsThis cross-sectional study included 100 healthy males (aged 41.9 ± 6.4 years). Pulse wave velocity (PWV), β-stiffness and intima-media thickness (IMT) of the carotid artery, and brachial artery flow-mediated dilation (FMD) were measured by a standardized ultrasound approach.ResultsNo correlation between FMD and IMT was found; only relatively poor correlations between PWV (or β-stiffness) and FMD existed, as well as between PWV (or β-stiffness) and IMT. PWV and β-stiffness highly correlated. Unexpectedly, only weak associations between PWV, β-stiffness, FMD, IMT and traditional risk factors were revealed. Hence, traditional risk factors (mainly age) explained only 10-50% of variability for PWV, β-stiffness, FMD and IMT. Although the subjects had low cardiovascular risk according to their Framingham score, their arterial wall properties were already impaired, particularly FMD.ConclusionsIn healthy middle-age males we found: i) absent or poor correlations among arterial stiffness, IMT and endothelial function; ii) a low impact of traditional risk factors on the studied variables, and iii) the presence of impaired arterial wall properties despite low calculated cardiovascular risk. These results provide a deepened understanding of arterial wall properties and could help to improve cardiovascular risk stratification.

Can Eliminating Risk Stratification Improve Medical Residentsʼ Adherence to Venous Thromboembolism Prophylaxis?

Hospital-acquired venous thromboembolism (VTE) is a common and preventable adverse event that most patients are at risk of developing during their hospital stay. VTE prophylactic anticoagulation (chemoprophylaxis) is the preferred pharmacological assignment for reducing risk of VTE, but it is underused in current practices involving risk stratification (RS) for VTE prevention. The purpose of this study was to determine whether a protocol that eliminates the RS step (non-RS protocol) is more likely to lead residents to evidence-based VTE assignment than the currently used RS protocol. The non-RS protocol follows a methodology that reduces complexity by assuming that the risk of VTE is present and uses contraindications to determine appropriate VTE assignment. In 2009, 41 medicine residents at the Nebraska Western Iowa Veterans Affairs clinic participated in an online comparison of two different protocols (RS and non-RS) for assigning chemoprophylaxis for VTE. Six validated, hypothetical patient scenarios were used to compare appropriate (evidence-based) VTE assignments for VTE and completion times for each protocol. Statistical analyses found that the non-RS protocol produced significantly faster (P < .001) scenario completion times and significantly more (P < .001) appropriate VTE assignments than the RS protocol for four of the six patient scenarios. This study used a new, streamlined protocol (non-RS), which improved VTE assignment and the use of chemoprophylaxis and simplified the process when compared with the use of a traditional RS protocol.

39 Value of 2D-Echocardiography in Patients With Chest Pain and Suspected Acute Coronary Syndromes

Chest pain is a major reason for admission to the emergency department (ED). Traditional risk stratification strategy still results in a proportion of patients being inadequately evaluated and discharged. Echocardiogram is a potential tool to optimize this evaluation. We sought to evaluate the impact of echocardiography on the outcome of patients with suspected acute coronary syndromes. We prospectively studied 735 chest pain patients referred to ED with suspected acute coronary syndrome. Of those, 409 patients (Group I) had an echocardiogram performed at presentation with regional and global left ventricular function (VF) information provided to the attending physician. Those without an echo composed Group II. Patients were followed for 12-months regarding survival and percutaneous coronary intervention. Information on traditional risk stratification factors was available for all. Echocardiogram was performed at presentation in 55.7% of patients. Group I (2.9/10.0; 95%CI 2.0;3.9) had lower unadjusted mortality rate than Group II (4.9/10.0;95%CI 3.6;6.4) (logrank test p=0.01). The difference persisted significant after adjustment for a wide range of covariates (HR 0.50 - 95%CI 0.31;0.82). Having an echo implied greater odds for percutaneous coronary intervention among patients without ST elevation (2.57-95%CI 1.23; 5.37). Information about global VF was associated with lower HR for death even after adjustment (0.78-95%CI 0.65; 0.92). Global VF had an incremental value over traditional risk stratification (24.0 × 31.1global chi-square; p<0.05). Echocardiogram at presentation of patients with suspected acute coronary syndrome has shown an incremental value over traditional risk stratification and was significantly associated with increased survival. It is likely that the additional information prompts the physicians to a more aggressive therapeutic approach.