Prognostic value of FFRCT in patients with stable chest pain – a 3-year follow-up of the ADVANCE-DK registry

Introduction

The short-term safety of using coronary CT angiography (CTA) derived fractional flow reserve (FFRCT) to guide downstream testing after CTA is well documented. Whether the prognostic information provided by FFRCT can be extended to sustained follow-up and to patients with a high degree of coronary artery calcification (CAC) is unknown.

Purpose

To evaluate the association between FFRCT and clinical outcomes in new onset stable symptomatic patients with coronary stenosis up to 3 years after CTA index testing.

Methods

Multicenter 3-year follow-up study of 900 patients from the Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care (ADVANCE) registry at three Danish sites, the “ADVANCE-DK Registry”. All patients had at least one ≥30% coronary stenosis by CTA and underwent subsequent core laboratory FFRCT analysis by HeartFlow. The criterium for an abnormal FFRCT test result was an FFRCT value ≤0.80 (2 cm distal to stenosis). High CAC was defined as a CAC score ≥400. The primary endpoint (PE) was a composite of all-cause death and spontaneous myocardial infarction (MI). The secondary endpoint (SE) was a composite of cardiovascular (CV) death and spontaneous MI. Events were adjudicated by an independent clinical committee.

Results

Patient characteristics are given in Table 1. Coronary stenosis ≥50% was present in 750 (83%) patients. In total 36 patients suffered a PE (all-cause death, n=24; MI, n=12) and 22 an SE (CV death, n=10; MI, n=12). An abnormal vs a normal FFRCT test result was associated with an increased risk of the PE and of the SE both overall and in patients with high CAC; PE (all), 6.6% vs 2.1%, relative risk (RR): 3.1; 95% CI: 1.6–6.3, p<0.001, SE (all), 5.0% vs 0.6%, RR: 8.7; 95% CI: non assessable, p<0.001, PE (high CAC), 9.0% vs 2.2%, RR: 4.1; 85% CI: 1.4–11.8, p=0.001, and SE (high CAC), 6.6% vs 0.5%, RR: 12.0; 95% CI: non assessable, p=0.01, respectively, Figure 1. The observed increased risk in patients with an abnormal vs a normal FFRCT test result persisted after adjustment for degree of stenosis by CCTA (< / ≥50%) and amount of CAC (< / ≥400): PE, adjusted RR: 2.5; 95% CI: 1.2–5.2, p=0.02, and SE, adjusted RR: 8.0; 95% CI: 2.1–30.2, p=0.002.

Conclusion

Patients with stable chest pain, stenosis by CTA and a normal FFRCT test result have a low risk of adverse outcomes during 3 years of follow-up. An abnormal FFRCT identifies patients at increased risk of death or spontaneous MI. These associations are consistent in patients with high levels of CAC.

Funding Acknowledgement

Type of funding sources: None.

FFRCT and recurrent symptoms in patients with stable chest pain

Introduction

The major benefit of coronary revascularization when compared with optimal medical treatment (OMT) in patients with stable chest pain (CP) relates to improvement of symptoms and reduction of reinterventions. Non-invasive methods are warranted to discriminate between patients at low and high risk of recurrent CP for subsequent guidance of antianginal treatment (invasive or OMT).

Purpose

To evaluate the association between coronary CT angiography (CTA) derived fractional flow reserve (FFRCT), recurrent CP and quality of life (QOL) in patients with new onset stable CP and stenosis by CTA.

Methods

Multicenter cohort 3-year follow-up sub-study of 769 patients from the Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care (ADVANCE) registry at three Danish sites, the “ADVANCE-DK Registry”. All patients had at least one ≥30% coronary stenosis by CTA and underwent subsequent core laboratory FFRCT analysis by HeartFlow. An abnormal FFRCT was defined as the lowest in vessel FFRCT value ≤0.80. Patients were classified according to completeness of revascularization by FFRCT: 1) completely revascularized (CR-FFRCT), all coronary arteries with an abnormal FFRCT test result revascularized; 2) incompletely revascularized (IR-FFRCT), ≥1 coronary artery with an abnormal FFRCT test result not revascularized. All patients completed the Seattle Angina Questionnaire (SAQ-7), the EuroQol questionnaire (EQ-5D-5L) and graded (0–100) overall health using the EQ VAS scale at 3-year follow-up. Recurrent CP was defined as CP within the last 4 weeks prior to this follow-up.

Results

Patient characteristics are given in Table 1. At follow-up 23% patients reported recurrent CP. An abnormal vs a normal FFRCT increased the risk of recurrent CP, 27% vs 15%, RR: 1.82; 95% CI: 1.31–2.52, p<0.001. Amongst patients with abnormal FFRCT, revascularization (+/−) was associated to a numerical, but not statistical significantly, reduced risk of recurrent CP, 23% vs 30%, RR: 0.76; 95% CI: 0.56–1.03, p=0.07. IR-FFRCT vs CR-FFRCT had a higher risk for recurrent CP, 31% vs 13%, RR: 2.34; 95% CI: 1.48–3.68, p<0.001, whilst no difference was observed for CR-FFRCT vs normal FFRCT, 13% vs 15%, RR: 0.92; 95% CI: 0.54–1.54, p=0.74. IR-FFRCT vs CR-FFRCT or normal FFRCT, had lower SAQ-7, EQ-5D-5L and EQ-VAS scores, Table 1, all p<0.005. Scores for three selected SAQ-7 domains are shown in Figure 1. Use of antianginal medicine was higher in IR-FFRCT compared to CR-FFRCT and normal FFRCT, mean ± SD: 1.2±0.05 vs 1.0±0.04, p=0.02.

Conclusion

An abnormal FFRCT identifies patients with an increased risk of recurrent CP up to 3 years after index testing. Completeness of revascularization by FFRCT reclassifies patients with abnormal FFRCT into groups with low and high risk for recurrent CP and impaired QOL.

Funding Acknowledgement

Type of funding sources: None.

Completeness of revascularization by FFRCT and prognosis in stable chest pain

Introduction

Major randomized trials of patients with stable chest pain (CP) demonstrated no prognostic benefits of coronary revascularization over optimal medical treatment (OMT). However, in a recent large-scale study, completeness of revascularization was associated with a reduced risk of all-cause death and non-fatal myocardial infarction (MI).

Purpose

To evaluate the association between completeness of revascularization relative to the result of coronary CT angiography (CTA) derived fractional flow reserve (FFRCT) and 3-year prognosis in patients with new onset stable CP and coronary stenosis.

Methods

Multicenter cohort 3-year follow-up sub-study of 900 patients from the Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care (ADVANCE) registry at three Danish sites, the “ADVANCE-DK Registry”. All patients had at least one ≥30% coronary stenosis by CTA and underwent subsequent core laboratory FFRCT analysis by HeartFlow. The FFRCT result was abnormal when ≤0.80 (2 cm distal to stenosis). Patients were classified according to completeness of revascularization by FFRCT: 1) completely revascularized (CR-FFRCT), all coronary arteries with an abnormal FFRCT test result revascularized; 2) incompletely revascularized (IR-FFRCT), ≥1 coronary artery with an abnormal FFRCT test result not revascularized. The primary endpoint (PE) was a composite of all-cause death and spontaneous MI. The secondary endpoint (SE) was a composite of cardiovascular (CV) death and spontaneous MI.

Results

Patient characteristics are given in Table 1. In total 36 (4.0%) patients suffered a PE (all-cause death, n=24; MI, n=12) and 22 (2.4%) an SE (CV death, n=10; MI, n=12). Overall, an abnormal vs a normal FFRCT test result was associated with an increased risk of both the PE, 6.6% vs 2.1%, relative risk (RR): 3.1; 95% CI: 1.6–6.3, p<0.001 and of the SE, 5.0% vs 0.6%, RR: 8.7; 95% CI: non assessable, p<0.001. In patients with abnormal FFRCT, revascularization vs no revascularization did not reduce the risk of the PE or the SE (data not shown). Patients with IR-FFRCT vs CR-FFRCT had a numerical, but not statistical significantly, increased risk of the PE, 8.6% vs 4.2%, RR: 2.14; 95% CI: 0.87–5.26, p=0.10), and an increased risk of the SE, 7.1% vs 2.4%, RR: 3.13; 95% CI: 1.02–9.63, p=0.04, Figure 1. In CR-FFRCT versus normal FFRCT no difference in the risk of the PE or the SE was observed, Figure 1. Univariate sensitivity analyses performed in the IR-FFRCT group did not reveal any differences in the risk of the PE or the SE after adjustment for neither statin therapy at follow-up (−/+), baseline risk variables (< / ≥3), amount of CAC (< / ≥400), degree of stenosis by CTA (< / ≥50%) nor referral to ICA (−/+).

Conclusion

In symptomatic patients with coronary stenosis by CTA, incomplete revascularization determined by FFRCT is associated with an increased risk of adverse cardiovascular outcomes compared to complete revascularization.

Funding Acknowledgement

Type of funding sources: None.

456Risk of arterial calcification by conventional vitamin K antagonist treatment

Background

Vitamin K antagonists (VKA) are the most frequently prescribed oral anticoagulants worldwide although new oral anticoagulants (NOAC) have become an important alternative. VKA inhibits Vitamin K1 necessary to produce coagulation factors but also Vitamin K2, which is essential in the activation of matrix-Gla protein, thought to be a strong local inhibitor of arterial calcifications.

Purpose

The aim was to investigate, whether VKA treatment is associated with coronary artery calcification (CAC) in a population with no prior cardiovascular disease (CVD).

Methods

We collected data on cardiovascular risk factors and CAC scores from cardiac CT scans performed as part of clinical examinations (n=9,672) or research studies (n=14,166) in the period 2007–2017. Data on use of VKA and NOAC was obtained from the Danish National Health Service Prescription Database. The association between VKA treatment duration and categorized CAC score was investigated by ordered logistic regression while adjusting for covariates. The independent variables included in the model were: age, gender, smoking, body mass index (BMI), diabetes mellitus, hypertension, hypercholesterolemia and/or statin treatment, family history of CVD, estimated glomerular filtration rate, VKA treatment duration and NOAC treatment duration. The categorisation of CAC was: 0, 1–99, 100–399 and ≥400 AU, corresponding to no, mild, moderate and severe atherosclerotic plaque burden, respectively.

Results

The final study population consisted of 17,254 participants (median 67 years old, 75% males) with no prior CVD, of which 1,748 (10%) and 1,144 (7%) had been treated with VKA or NOAC, respectively. A longer duration of VKA treatment was associated with higher CAC categories (Figure). For each cumulative year of VKA treatment, the odds of being in a higher CAC category, i.e. having more severe atherosclerosis, increased (odds ratio (OR)=1.032, 95% CI 1.009–1.057). All traditional cardiovascular risk factors were also associated with CAC. In contrast, NOAC treatment duration was not associated with CAC category (OR=1.004, 95% CI 0.937–1.075). In a sensitivity analysis of patients without statin treatment (n=12,143), the association between VKA treatment and CAC category remained unchanged. There was no significant interaction between VKA treatment duration and age on CAC category.

Conclusion

Adjusted for cardiovascular risk factors, VKA treatment – in contrast to NOAC - is associated with more severe CAC. Additional studies are required to clarify the clinical importance of this association in terms of hard cardiovascular endpoints.

Acknowledgement/Funding

Novo Nordisk Foundation and Independent Research Fund Denmark

P6382The use of a mobile GPS-tracking system to activate volunteer first responders increases survival among patients with out-of-hospital cardiac arrest in residential areas

Background

In residential areas, survival in patients with out-of-hospital cardiac arrest (OHCA) is less than one third compared with the survival in patients with OHCA in public areas. New strategies are needed to improve outcomes in residential areas.

Purpose

To evaluate the effect on survival in OHCA patients in residential vs. public areas, when using a mobile GPS-tracking system to activate volunteer first responders (VFRs).

Methods

In 2012 a mobile GPS-tracking system was brought into use by a first aid volunteer corps on a rural island with a population of about 12,000 inhabitants. In all cases of emergency calls where an emergency medical service (EMS) was requested, the system was activated. Three VFRs were recruited and successively provided with distinct VFR roles. One of the VFRs was guided to the nearest automatic external defibrillator before approaching the patient.

We retrospectively screened all emergency ambulance journals in the years 2012–2017 to identify patients with OHCA. Additional information was collected from hospital records. Location was categorized as residential or public place. OHCAs witnessed by EMS, occurring at nursing homes or at uncertain locations were excluded. Clinical outcome was 30-day survival.

Results

During the 6-year period, there was a total of 114 OHCAs. Of these, 66 (57.9%) took place in residential areas, 16 (14.0%) in public areas and 32 (28.1%) were excluded. The 30-day survival in OHCA patients in residential vs. public areas was 15.2% and 12.5%, respectively (p=0.79).

Demographic and survival results Residential area (n=66) Public area (n=16) P value Age, mean (SD) 71 (13) 69 (13) 0.14 Male sex, no. (%) 47 (71) 13 (87) 0.22 Volunteer first responder activated, no. (%) 55 (83) 15 (94) 0.30 AED arrives before EMS, no. (%) 36 (55) 9 (56) 0.34 Shock given before EMS, no. (%) 8/63 (13) 3/15 (20) 0.88 First rhythm shockable by EMS, no. (%) 11/64 (17) 3 (19) 0.63 30-day survival, no. (%) 10 (15) 2 (13) 0.79 The table shows the differences in OHCA located at residential areas versus public areas. AED: Automated external defibrillator; EMS: Emergency medical service; OHCA: Out-of-hospital cardiac arrest; SD: Standard deviation.

Conclusion

The use of a mobile GPS-tracking system to activate VFRs increases the 30-day survival among patients with OHCA in residential areas to a level comparable with the survival observed in public areas.

Acknowledgement/Funding

One year grant from Odense University Hospital's PhD Fund. One year grant from University of Southern Denmark. A 500,000 DKKR grant from TV2 Funen and OUH

Coronary artery disease risk reclassification by a new acoustic-based score

To determine the potential of a non-invasive acoustic device (CADScor®System) to reclassify patients with intermediate pre-test probability (PTP) and clinically suspected stable coronary artery disease (CAD) into a low probability group thereby ruling out significant CAD. Audio recordings and clinical data from three studies were collected in a single database. In all studies, patients with a coronary CT angiography indicating CAD were referred to coronary angiography. Audio recordings of heart sounds were processed to construct a CAD-score. PTP was calculated using the updated Diamond-Forrester score and patients were classified according to the current ESC guidelines for stable CAD: low < 15%, intermediate 15–85% and high > 85% PTP. Intermediate PTP patients were re-classified to low probability if the CAD-score was ≤ 20. Of 2245 patients, 212 (9.4%) had significant CAD confirmed by coronary angiography ( ≥ 50% diameter stenosis). The average CAD-score was higher in patients with significant CAD (38.4 ± 13.9) compared to the remaining patients (25.1 ± 13.8; p < 0.001). The reclassification increased the proportion of low PTP patients from 13.6% to 41.8%, reducing the proportion of intermediate PTP patients from 83.4% to 55.2%. Before reclassification 7 (3.1%) low PTP patients had CAD, whereas post-reclassification this number increased to 28 (4.0%) (p = 0.52). The net reclassification index was 0.209. Utilization of a low-cost acoustic device in patients with intermediate PTP could potentially reduce the number of patients referred for further testing, without a significant increase in the false negative rate, and thus improve the cost-effectiveness for patients with suspected stable CAD.

The DanCavas Pilot Study of Multifaceted Screening for Subclinical Cardiovascular Disease in Men and Women Aged 65-74 Years

OBJECTIVE/BACKGROUND

This pilot study of a large population based randomised screening trial investigated feasibility, acceptability, and relevance (prevalence of clinical and subclinical cardiovascular disease [CVD] and proportion receiving insufficient prevention) of a multifaceted screening for CVD.

METHODS

In total, 2060 randomly selected Danish men and women aged 65-74 years were offered (i) low dose non-contrast computed tomography to detect coronary artery calcification (CAC) and aortic/iliac aneurysms; (ii) detection of atrial fibrillation (AF); (iii) brachial and ankle blood pressure measurements; and (iv) blood levels of cholesterol and hemoglobin A1c. Web based self booking and data management was used to reduce the administrative burden.

RESULTS

Attendance rates were 64.9% (n = 678) and 63.0% (n = 640) for men and women, respectively. In total, 39.7% received a recommendation for medical preventive actions. Prevalence of aneurysms was 12.4% (95% confidence interval [CI] 9.9-14.9) in men and 1.1% (95% CI 0.3-1.9) in women, respectively (p < .001). A CAC score > 400 was found in 37.8% of men and 11.3% of women (p < .001), along with a significant increase in median CAC score with age (p = .03). Peripheral arterial disease was more prevalent in men (18.8%, 95% CI 15.8-21.8) than in women (11.2%, 95% CI 8.7-13.6). No significant differences between the sexes were found with regard to newly discovered AF (men 1.3%, women 0.5%), potential hypertension (men 9.7%, women 11.5%), hypercholesterolemia (men 0.9%, women 1.1%) or diabetes mellitus (men 2.1%, women 1.3%).

CONCLUSION

Owing to the higher prevalence of severe conditions, such as aneurysms and CAC ≥ 400, screening for CVD seemed more prudent in men than women. The attendance rates were acceptable compared with other screening programs and the logistical structure of the screening program proved successful.

The coronary calcium score is a more accurate predictor of significant coronary stenosis than conventional risk factors in symptomatic patients: Euro-CCAD study

AIMS

In this retrospective study we assessed the predictive value of the coronary calcium score for significant (>50%) stenosis relative to conventional risk factors.

METHODS AND RESULTS

We investigated 5515 symptomatic patients from Denmark, France, Germany, Italy, Spain and the USA. All had risk factor assessment, computed tomographic coronary angiogram (CTCA) or conventional angiography and a CT scan for coronary artery calcium (CAC) scoring. 1539 (27.9%) patients had significant stenosis, 5.5% of whom had zero CAC. In 5074 patients, multiple binary regression showed the most important predictor of significant stenosis to be male gender (B=1.07) followed by diabetes mellitus (B=0.70) smoking, hypercholesterolaemia, hypertension, family history of CAD and age but not obesity. When the log transformed CAC score was included, it became the most powerful predictor (B=1.25), followed by male gender (B=0.48), diabetes, smoking, family history and age but hypercholesterolaemia and hypertension lost significance. The CAC score is a more accurate predictor of >50% stenosis than risk factors regardless of the means of assessment of stenosis. The sensitivity of risk factors, CAC score and the combination for prediction of >50% stenosis when measured by conventional angiogram was considerably higher than when assessed by CTCA but the specificity was considerably higher when assessed by CTCA. The accuracy of CTCA for predicting >50% stenosis using the CAC score alone was higher (AUC=0.85) than using a combination of the CAC score and risk factors with conventional angiography (AUC=0.81).

CONCLUSION

In symptomatic patients, the CAC score is a more accurate predictor of significant coronary stenosis than conventional risk factors.

Uncontrolled hypertension is associated with coronary artery calcification and electrocardiographic left ventricular hypertrophy: a case-control study

We conducted a 1:2 matched case-control study in order to evaluate whether the prevalence of coronary artery calcium (CAC) and electrocardiographic left ventricular hypertrophy (LVH) or strain was higher in patients with uncontrolled hypertension than in subjects from the general population, and evaluate the association between CAC and LVH in patients with uncontrolled hypertension. Cases were patients with uncontrolled hypertension, whereas the controls were random individuals from the general population without cardiovascular disease. CAC score was assessed using a non-contrast computed tomographic scan. LVH was evaluated using the Sokolow-Lyon voltage combination and Cornell voltage-duration product, respectively. Associations between CAC, LVH and traditional cardiovascular risk factors were tested by means of ordinal, conditional and classic binary logistic regression models. We found that uncontrolled hypertension was independently associated with both an ordinal CAC score category (odds ratio (OR) 3.9 (95% CI, 1.6-9.1), P = 0.002), the presence of CAC score>99 (OR 4.5 (95% CI, 1.4-14.7), P = 0.01) and electrocardiographic LVH (OR 10.1 (95% CI, 3.4-30.2), P < 0.001) on both univariate and multivariable analyses. There was, however, no correlation between CAC and LVH. The lack of an association between CAC and LVH suggests that they are markers of different complications of hypertension and may have independent predictive values. Patients with both CAC and LVH may be at higher risk than those in whom only one of these markers is present.

The relation between coronary artery calcification in asymptomatic subjects and both traditional risk factors and living in the city centre: a DanRisk substudy

OBJECTIVE

To evaluate the association between the risk factor for living in the city centre as a surrogate for air pollution and the presence of coronary artery calcification (CAC) in a population of asymptomatic Danish subjects.

DESIGN AND SUBJECTS

A random sample of 1825 men and women of either 50 or 60 years of age were invited to take part in a screening project designed to assess risk factors for cardiovascular disease (CVD). Noncontrast cardiac computed tomography was performed on all subjects, and their Agatston scores were calculated to evaluate the presence of subclinical coronary atherosclerosis. The relationship between CAC and several demographic and clinical parameters was evaluated using multivariate logistic regression.

RESULTS

A total of 1225 individuals participated in the study, of whom 250 (20%) were living in the centres of major Danish cities. Gender and age showed the greatest association with the presence of CAC: the odds ratio (OR) for men compared with women was 3.2 [95% confidence interval (CI) 2.5-4.2; P < 0.0001], and the OR for subjects aged 60 versus those aged 50 years was 2.2 (95% CI 1.7-2.8; P < 0.0001). Other variables independently associated with the presence of CAC were diabetes and smoking with ORs of 2.0 (95% CI 1.1-3.5; P = 0.03) and 1.9 (95% CI 1.4-2.5, P < 0.0001), respectively. The adjusted OR for subjects living in city centres compared to those living outside was 1.8 (95% CI 1.3-2.4; P = 0.0003).

CONCLUSION

Both conventional risk factors for CVD and living in a city centre are independently associated with the presence of CAC in asymptomatic middle-aged subjects.

Osteoprotegerin concentrations and prognosis in acute ischaemic stroke

AIM

Concentrations of osteoprotegerin (OPG) have been associated with the presence of vascular and cardiovascular diseases, but the knowledge of this marker in the setting of ischaemic stroke is limited.

METHODS AND RESULTS

In 244 patients with acute ischaemic stroke (age: 69 +/- 13 years), samples of OPG were obtained serially from presentation to day 5. Patients with overt ischaemic heart disease and atrial fibrillation were excluded. The patients were followed for 47 months, with all-cause mortality as the sole end-point. Multivariable predictors of OPG values at presentation included haemoglobin (T = -2.82; P = 0.005), creatinine (T = 4.56; P < 0.001), age (T = 9.66; P < 0.001), active smoking (T = 2.25; P = 0.025) and pulse rate (T = 3.23; P = 0.001). At follow-up 72 patients (29%) had died. Patients with OPG < or =2945 pg mL(-1) at baseline had a significantly improved survival rate on univariate analysis (P < 0.0001); other time-points did not add further prognostic information. In multivariate analysis, after adjustment for age, stroke severity, C-reactive protein levels, troponin T levels, heart and renal failure concentrations of OPG independently predicted long-term mortality after stroke (adjusted hazard ratio, 2.3; 95% CI: 1.1 to 4.9; P = 0.024).

CONCLUSION

Osteoprotegerin concentrations measured at admission of acute ischaemic stroke are associated with long-term mortality.

The influence of anaemia on stroke prognosis and its relation to N-terminal pro-brain natriuretic peptide

Anaemia is a negative prognostic factor for patients with heart failure and impaired renal function, but its role in stroke patients is unknown. Furthermore, anaemia has been shown to influence the level of N-terminal pro-brain natriuretic peptide (NT-proBNP), but this is only investigated in patients with heart failure, not in stroke patients. Two-hundred-and-fifty consecutive, well-defined ischemic stroke patients were investigated. Mortality was recorded at 6 months follow-up. Anaemia was diagnosed in 37 patients (15%) in whom stroke severity was worse than in the non-anaemic group, whilst the prevalence of renal affection, smoking and heart failure was lower. At 6 months follow-up, 23 patients were dead, and anaemia had an odds ratio of 4.7 when adjusted for age, Scandinavian Stroke Scale and a combined variable of heart and/or renal failure and/or elevation of troponin T using logistic regression. The median NT-proBNP level in the anaemic group was significantly higher than in the non-anaemic group, and in a multivariate linear regression model, anaemia remained an independent predictor of NT-proBNP. Conclusively, anaemia was found to be a negative prognostic factor for ischemic stroke patients. Furthermore, anaemia influenced the NT-proBNP level in ischemic stroke patients, an important aspect when interpreting NT-proBNP in these patients.

Serial Measurements of N-Terminal pro-Brain Natriuretic Peptide after Acute Ischemic Stroke

BACKGROUND

The exact time-course of N-terminal pro-brain natriuretic peptide (NT-proBNP) and the prognostic importance in the immediate phase of ischemic stroke have not been established.

METHODS

NT-proBNP was measured daily from admission to day 5 and again at 6-month follow-up in 250 consecutive patients with acute ischemic stroke.

RESULTS

NT-proBNP peaked the day after onset of symptoms (p = 0.007) followed by a decrease until day 5 (p = 0.001, ANOVA). At 6-month follow-up the difference in the level of NT-proBNP was unchanged compared to day 5 (p = 0.42). NT-proBNP levels > or =615 pg/ml at day 2 after onset of symptoms was associated with 6-month mortality.

CONCLUSION

NT-proBNP peaks the day after onset of symptoms in patients with acute ischemic stroke. A single measurement of NT-proBNP appears to be an indicator of 6-month mortality.

Different effects of calcium antagonist and beta-blocker therapy on left-ventricular diastolic function in ischemic heart disease. A direct comparison of the impact of mibefradil and atenolol

OBJECTIVE

To compare the effect of a calcium antagonist and a beta-blocker on left-ventricular diastolic function in patients with ischemic heart disease.

METHODS

138 patients with chronic stable angina pectoris were randomized in a multicenter, double-blind trial to treatment with either mibefradil or atenolol for 6 weeks (50 mg once daily for 2 weeks followed by 100 mg once daily for 4 weeks). The ratio between early (E) and late (A) diastolic mitral flow velocities (E/A), the E wave deceleration time (DT) and the left ventricular isovolumetric relaxation time (IRT) were measured by Doppler echocardiography as parameters of left-ventricular diastolic function initially, after 4 and after 6 weeks of treatment.

RESULTS

Mibefradil did not change the E/A ratio significantly (+4%, NS), while atenolol treatment resulted in a significant increase in the E/A ratio (+20%, p < 0.001). Mibefradil treatment, on the other hand, resulted in a significant decrease (-8%, p < 0.001) in IRT, while atenolol treatment did not change IRT. Neither mibefradil nor atenolol treatment changed DT significantly.

CONCLUSIONS

Both mibefradil and atenolol treatment significantly improves echocardiographic indices of left-ventricular diastolic function in patients with chronic stable angina. However, they affect different parameters and thus apparently act through different mechanisms.

[Acute myocardial infarction associated with a mild blunt thoracic trauma]

A case of acute myocardial infarction associated with a mild blunt thoracic trauma in a 60-year-old woman with normal coronary angiography is described. The underlying potential pathophysiological mechanisms are discussed. Lastly, the clinical and practical consequences of the new consensus document for the redefinition of acute myocardial infarction are briefly commented on.

Thrombolytic therapy preserves vagal activity early after acute myocardial infarction

OBJECTIVE

The purpose of this study was to evaluate the effects of thrombolytic therapy on vagal tone after acute myocardial infarction (AMI).

DESIGN

Holter monitoring for 24 h was performed at hospital discharge and 6 weeks after AMI in 74 consecutive male survivors of a first AMI, who fulfilled established criteria for thrombolytic therapy. Thirty-five patients received thrombolyses, while the remaining 39 patients did not (controls). In each Holter recording 24-h heart rate variability was calculated as pNN50, which represents the percentage of successive RR interval differences >50 ms. Alterations in pNN50 are known to reflect changes in vagal tone.

RESULTS

The analysis showed that controls early after AMI had low pNN50 values without any diurnal changes. Six weeks after AMI pNN50 values in controls exhibited a circadian rhythm with higher values during night-time. This pattern was similar to the pattern observed in thrombolysed patients early after AMI. In thrombolysed patients pNN50 values, particularly at night, were further improved 6 weeks after AMI (p = 0.037).

CONCLUSION

These observations indicate that thrombolytic therapy, given for a first AMI, preserves vagal activity when compared with patients who are not thrombolysed. The enhanced parasympathetic tone may be a part of the beneficial mechanisms responsible for the reduction in mortality after thrombolysis in AMI.

[The value of exercise test in acute coronary syndrome]

In general, exercise testing in acute coronary syndrome (ACS) has been used in the assessment of physical capacity and to obtain prognostic information. Within recent years, however, a number of randomized studies have addressed the role of exercise testing in identifying patients, who may benefit from an invasive versus a conservative treatment strategy. According to the literature, a normal exercise test result after ACS is associated with an excellent clinical outcome. Patients who for clinical reasons are unable to perform an exercise test comprise a high risk group for future cardiac events. An invasive strategy is warranted in patients who continue to have angina and exhibit significant ST-segment depression in the exercise-ecg or reversible defects on perfusion scintigraphy. Based on the results of a recent, large scale randomized study, patients with unstable angina or acute non-Q-wave infarction appear to benefit from an early invasive treatment strategy--regardless of the results of a preceding exercise test.

[Sexual activity in ischemic heart disease. Risk and therapeutic possibilities]

A major concern of patients with ischaemic heart disease is whether sexual activity is safe. In addition, patients are often reluctant to discuss sexual problems, including erectile dysfunction. Fear of sexual failure or fear of an acute ischaemic cardiac event as a result of sexual activity may create anxiety and lead to avoidance of sexual activity, which can significantly affect quality of life. In patients with a recent acute myocardial infarction the participation in a cardiac rehabilitation program should be strongly encouraged. The results are an improvement in physical capacity and self confidence. The performance of an exercise test at the time of hospital discharge following acute myocardial infarction is mandatory, and can be used in both risk stratification and cardiac rehabilitation. Patients who can manage a work capacity of at least 100 Watt without evidence of myocardial ischaemia or arrhythmias may without concerns take part in an active sexual life. Comprehensive information and appropriate use of pharmacologic agents for erectile dysfunction can add significantly to quality of life.

Cardiovascular autonomic neuropathy in insulin-dependent diabetes mellitus: prevalence and estimated risk of coronary heart disease in the general population

OBJECTIVES

The aim of the study was to estimate the prevalence of cardiovascular autonomic neuropathy (CAN) in Type 1 diabetes mellitus in the general population and to assess the relationship between CAN and risk of future coronary heart disease (CHD).

METHODS

The Type 1 diabetes mellitus population in the municipality of Horsens, Denmark, was delineated by the prescription method and a random sample of 120 diabetics aged 40-75 years was recruited. Type 1 diabetes mellitus was registered if fasting C-peptide was below 0.30 nmol L(-1). The E/I ratio was calculated as the mean of the longest R-R interval in expiration divided by the shortest in inspiration during deep breathing at 6 breaths min(-1) and taken to express the degree of CAN. A maximal symptom-limited exercise test was carried out and the VA Prognostic Score, indicating risk of cardiovascular death or non-fatal myocardial infarction, was computed. Additionally, the 10-year risk of CHD was calculated using the Framingham model.

RESULTS

A total of 84 people responded, of whom 71 had Type 1 diabetes mellitus. The E/I ratio was measured in 69 people. The prevalence of CAN expressed as an E/I ratio below the normal 5th percentile was 38%. The E/I ratio was significantly reduced in old age, long duration of diabetes, female gender, high fasting blood glucose, triglyceride, systolic blood pressure and urinary albumin excretion. A high risk of future CHD calculated using the Framingham model was associated with a low E/I ratio (r = -0.39, P = 0.001). Exercise capacity, rise in systolic blood pressure and heart rate were positively correlated with the E/I ratio. A high VA Prognostic Score was correlated with a low E/I ratio (r = - 0.58, P < 0.0005). The risks estimated by the two models were significantly correlated (r = 0.60, P < 0.0005).

CONCLUSION

The prevalence of CAN in the 40-75-year-old Type 1 diabetes mellitus population is estimated to be 38%. CAN is associated with exercise test parameters and a coronary risk factor profile indicating a high risk of future CHD.

[Coronary arteriography and coronary angioplasty in stable ischemic heart disease. Value in the prediction and prevention of future acute myocardial infarction]

Acute myocardial infarction (AMI) is usually caused by the sudden formation of an intracoronary thrombus that occludes the coronary artery at the site of a vulnerable atherosclerotic plaque. Coronary angiography (KAG) offers the opportunity to visualize and characterize coronary artery lesions. The demonstration of significant stenoses (> 50%) often leads to mechanical revascularization, including coronary angioplasty (PTCA). Several studies in which serial angiograms were performed on patients who subsequently had AMI have shown that most of these acute events develop from lesions that on the first KAG were nonsignificant (< 50%). The KAG method does not adequately predict the location of the culprit plaque that will subsequently produce AMI PTCA results in less severe angina, but the price may be a higher rate of procedure related acute events. Large scale trials comparing the prognostic effect of an intense medical therapy versus PTCA with and without stenting are required to better define the independent and combined roles of the different therapeutic modalities in stable ischaemic heart disease.

Serial Holter ST-segment monitoring after first acute myocardial infarction. Prevalence, variability, and long-term prognostic importance of transient myocardial ischemia

Based on serial Holter monitoring performed 7 times within 3 years after a first acute myocardial infarction, we assessed the prevalence, variability and long-term clinical importance of transient myocardial ischemia (TMI) defined as episodes of ambulatory ST-segment depression. In all, 121 consecutive male patients <70 years old were studied. The prevalence of TMI on different Holter recordings varied around 20% ranging between 18 and 27%. Fifty-five of the patients (46%) had TMI on at least 1 of the 7 Holter recordings. Considerable variability was found within and between patients for the presence of TMI. No high-risk group for cardiac death, nonfatal reinfarction or coronary revascularization during up to 10 years of follow-up could be identified by the detection of TMI. From these results we conclude that a routine search for TMI on serial Holter monitoring cannot be recommended in male survivors of an uncomplicated first acute myocardial infarction.

Prevalence and prediction of silent ischaemia in diabetes mellitus: a population-based study

OBJECTIVES

The aim of the study was to estimate the prevalence of silent ischaemia in diabetic subjects in the population, to compare the prevalence of silent ischaemia in diabetics and non-diabetics and to attempt to predict the presence of silent ischaemia in diabetic subjects.

METHODS

A random sample of 120 users of insulin and 120 users of oral hypoglycaemic agents aged 40-75 years living in the Danish municipality of Horsens were asked to participate in the study. Corresponding to the youngest half of the sample two non-diabetic controls were randomly selected from the Central Population Register. ST-depression of horizontal or descending character of at least 0.1 mV measured 80 ms after the J-point on either exercise ECG or Holter ECG was considered indicative of myocardial ischaemia. Angina pectoris was considered present if the Rose questionnaire was positive, or chest pain was registered simultaneously with ECG evidence of ischaemia. Individuals with ischaemia, but without angina pectoris, were defined as persons with silent ischaemia.

RESULTS

Seventy-four percent of the invited group were included. The observed prevalence of silent ischaemia in diabetics was 13.5% (95% CI = 8.5-19.8%). No association was found between silent ischaemia and gender (P = 0.83) or diabetes type (P = 0.67). In the group of diabetics who had controls, the prevalence was 11.4%, and among the controls the prevalence was 6.4% (OR = 1.87, one-sided P = 0.079). Systolic blood pressure was highly predictive of silent ischaemia in the diabetic subjects (P = 0.005). No predictive value could be shown for other variables.

CONCLUSION

This is the first population-based study of silent ischaemia in diabetes. The prevalence of silent ischaemia in diabetic subjects was 13.5%. The frequency of silent ischaemia did not differ significantly between diabetics and non-diabetics. Systolic blood pressure was predictive of silent ischaemia in diabetes.

Characteristics and prognostic importance of ST-segment elevation on Holter monitoring early after acute myocardial infarction

The correlation between episodes of ST-segment elevation on Holter monitoring, clinical characteristics, left ventricular function, exercise testing, and long-term prognosis was determined in 123 consecutive patients 55 +/- 8 years old (mean +/- SD) with a first acute myocardial infarction (AMI). During 36 hours of Holter recording 11 +/- 5 days after AMI, 11 patients (9%) had 91 episodes of ST-segment elevation (group 1), whereas 112 patients had no such episodes (group 2). Most episodes of ST-segment elevation occurred in leads with pathologic Q waves or small, indistinct R waves. Large, anterior Q-wave AMIs were more prevalent in group 1 than in group 2, and in-hospital heart failure also occurred more frequently in group 1 patients (82% vs 23%; p < 0.0005). Regional and global left ventricular function was reduced in group 1 compared with group 2: ejection fraction 33 +/- 11% vs 50 +/- 11% (p = 0.0001). All episodes of ST-segment elevation were asymptomatic and did not correlate with different indicators of myocardial ischemia. Indeed, exercise-induced ST-segment depression was more prevalent in group 2 than in group 1: 57 vs 18% (p < 0.035). Over a mean of 5 years (range 4 to 6) of follow-up, an association between episodes of ST-segment elevation on Holter monitoring and (1) cardiac death (Kaplan-Meier analysis; p < 0.005), and (2) cardiac death and nonfatal reinfarction (Kaplan-Meier analysis; p < 0.025) was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic significance of transient myocardial ischaemia after first acute myocardial infarction: five year follow up study

OBJECTIVE

To assess the five year prognostic significance of transient myocardial ischaemia on ambulatory monitoring after a first acute myocardial infarction, and to compare the diagnostic and long term prognostic value of ambulatory ST segment monitoring, maximal exercise testing, and echocardiography in patients with documented ischaemic heart disease.

DESIGN

Prospective study.

SETTING

Cardiology department of a teaching hospital.

PATIENTS

123 consecutive men aged under 70 who were able to perform predischarge maximal exercise testing.

INTERVENTIONS

Echocardiography two days before discharge (left ventricular ejection fraction), maximal bicycle ergometric testing one day before discharge (ST segment depression, angina, blood pressure, heart rate), and ambulatory ST segment monitoring (transient myocardial ischaemia) started at hospital discharge a mean of 11 (SD 5) days after infarction.

MAIN OUTCOME MEASURES

Relation of ambulatory ST segment depression, exercise test variables, and left ventricular ejection fraction to subsequent objective (cardiac death or myocardial infarction) or subjective (need for coronary revascularisation) events.

RESULTS

23 of the 123 patients had episodes of transient ST segment depression, of which 98% were silent. Over a mean of 5 (range 4 to 6) years of follow up, patients with ambulatory ischaemia were no more likely to have objective end points than patients without ischaemic episodes. If, however, subjective events were included an association between transient ST segment depression and an adverse long term outcome was found (Kaplan-Meier analysis; P = 0.004). The presence of exercise induced angina identified a similar proportion of patients with a poor prognosis (Kaplan-Meier analysis; P < 0.004). Both exertional angina and ambulatory ST segment depression had high specificity but poor sensitivity. The presence of exercise induced ST segment depression was of no value in predicting combined cardiac events. Indeed, patients without exertional ST segment depression were at increased risk of future objective end points (Kaplan-Meier analysis; P < 0.0045). These findings may be explained in part by a higher prevalence of left ventricular dysfunction in patients without ischaemic changes in the exercise electrocardiogram (P < 0.05).

CONCLUSION

There seem to be limited reasons to perform ambulatory ST segment monitoring in survivors of a first myocardial infarction who can perform exercise tests before discharge. Patients at high risk of future myocardial infarction or death from cardiac causes are not identified. Ambulatory monitoring and exertional angina distinguish a small subset of patients who will develop severe angina pectoris demanding coronary revascularisation during follow up. Patients without exercise induced ST segment depression comprise a high risk subgroup in terms of subsequent objective end points. The role of ambulatory ST segment monitoring performed in unselected patients immediately after infarction when risk is maximal remains to be clarified.

[Should silent ischemia be diagnosed and treated?]

Silent ischaemia (objective signs of myocardial ischaemia without symptoms) can be diagnosed using a conventional exercise-test or ambulatory Holter monitoring. Silent ischaemia is a frequent phenomenon in patients with ischaemic heart disease, i.e. patients with angina pectoris or previous myocardial infarction. The reason why ischaemia is symptomatic in some cases, and asymptomatic in others is unknown. Different possible mechanisms are discussed. Myocardial ischaemia, symptomatic or not is accompanied by a compromised function of the left ventricle, including reduced ejection fraction during exercise. In selected groups of patients, silent ischaemia is related to an impaired prognosis, while it does not seem to carry any prognostic information in other groups of patients. Silent ischaemia can be treated/reduced using antianginal medication or revascularization, but for the time being it is not known if treatment can improve prognosis. Studies concerning the latter are under way.