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.     

Monoclonal gammopathy of undetermined significance (MGUS) - 31 year follow up of a community study

Background : When unselected healthy adults in the community have their serum screened by cellulose acetate or paper electrophoresis, monoclonal gammopathy of undetermined significance (MGUS) may be found in 0.5-1%.
Aim : To report upon a 31 year follow up of MGUS in a New Zealand community.
Methods : Serum from 2192 subjects (82% of the adult population) of a New Zealand town was collected in 1967 and subsequently screened by cellulose acetate electrophoresis. Eleven of the 2192 (0.5%) were found to have MGUS. Clinical correlation was sought in 1970 and subsequently to elucidate the underlying cause.
Results : Seven of the 11 patients have developed a haematological malignancy. Two have been diagnosed as having Waldenstrom's macroglobulinaemia, one malignant lymphoma and acute myelomonocytic leukaemia and four developed myeloma. Myeloma developed at one, nine, 23 and 25 years after the original screening. One myeloma patient and one patient with MGUS are currently alive and well, 31 years after discovery of their gammopathy.
Conclusions : The incidence of MGUS in this community is only half that detected in a comparable study. The association with haematological malignancy in this study (64%) is considerably higher than that found in the Swedish study (6%), possibly because of the longer follow up in New Zealand. MGUS should not only be studied in depth at the time of its discovery, but needs very long term follow up as the underlying disease may not surface until the third decade.     

Ten year follow up of patients referred for coronary artery bypass grafting from a single district general hospital

Objective—To determine the status of patients 10 years after referral for coronary artery bypass graft (CABG) surgery.
Design—Retrospective analysis of case notes from all patients referred between 1 April 1981 and 31 March 1985. Full information gathered from hospital notes, GP records, and Registrar General for Scotland.
Setting—District General Hospital, West Lothian, Scotland.
Patients—102 patients referred for CABG during study period. Cardiac surgery was undertaken in Brompton Hospital, London, Royal Infirmary, Edinburgh, and Western Infirmary, Glasgow.
Results—At 10 years after operation 32 patients had died (27 cardiac, five non-cardiac causes). Full data were not available for five patients. Of the 65 remaining patients 24 had no angina, 13 had had a repeat procedure (CABG or angioplasty), and 28 had angina.
Conclusions—Long term benefits of CABG surgery is disappointing. Further steps are required to reduce progression of disease in this population.

Keywords: coronary artery bypass surgery;  repeat procedure;  survival;  audit     

Five year clinical follow up of patients who have had off pump coronary artery bypass grafting

Background: Off pump coronary artery bypass (OPCAB) has become a common technique for conducting coronary artery surgery. There has been some concern that the anastomoses might not be conducted as effectively on the beating heart, which could lead to poor long-term results. The aim of the present study was to follow up all patients who had undergone OPCAB at our institution to determine clinical outcomes up to 5 years postoperatively.

Methods: All living patients who had undergone OPCAB up until December 2000 were telephoned. For those who could be contacted, a detailed questionnaire was completed and the data were analysed.

Results: The technique of OPCAB was carried out on 312 patients. Thirteen of these patients died, five perioperatively. Actuarial survival at 5 years was 94.6% and freedom from cardiac related events was 92.1%. There were only two patients with angina worse than class I. Patients showed a high rate of compliance with risk factor management. Forty per cent of patients claimed to have had psychological problems related to the surgery.

Conclusions: Mid-term results of OPCAB are very satisfactory, but randomised trials are needed to see whether they are different from the results of conventional coronary artery bypass grafting.     

High level of lipoprotein (a) as a predictor of poor long-term prognosis after coronary artery bypass surgery

Study aim was to investigate the association of lipoprotein (a) [Lp(a)] level with the development of cardiovascular complications in long-term follow-up period after coronary artery bypass grafting (CABG). Patients with chronic ischemic heart disease (IHD) (n = 361, 88% men, mean age 55 +/- 9 years) who had had CABG were included in the study. Before surgery we assessed presence of classical risk factors, left ventricular ejection fraction, concentrations of lipids and Lp(a) in blood serum. During follow-up (from 1 to 140, mean 66 +/- 34 months) we registered cardiac deaths, nonfatal myocardial infarctions (MI), strokes, repeat procedures of revascularization, and hospitalizations due to relapse or progression of angina pectoris. Information on prognosis was obtained from 263 patients. In 109 of them we registered 142 serious events including cardiac death n = 20 (14%), nonfatal MI n = 14 (10%), myocardial revascularization (n = 35), 29 (20%) with stenting), repeat CABG n = 6 (4%), hospitalization due to angina pectoris n = 53 (37%), stroke n = 4 (3%), noncardiac outcome n = 16 (10%). In subjects with hyperlipidemia (a) [HLp(a) - Lp(a) > 30 mg/l] survival after CABG was lower (log rank p < 0.001): 11 of 93 (11.3%) and 9 of 170 (5.2%) patients died among those with Lp(a) > 30 and < 30 mg/I, respectively. Relative risk (RR) of any cardiovascular complication was 3.24 (95% confidence interval [CI] 2.18 to 4.83, p < 0.001), of death - 2.89 (95% CI 1.31 to 6.35, p < 0.01), and of MI A 1.01 (95% CI 1.00 to 1.02; p = 0.02). RR of development of MI and cardiac death in patients with HLp(a) in 5 years was 2.61 (95% CI 1.11 to 5.74; p = 0.02), in 10 years - 2.95 (95% CI 1.50 to 5.79; p < 0.001). In patients with chronic IHD high level of Lp(a) can serve as independent predictor of unfavorable events including death and nonfatal MI during 10 years after CABG.     

Effects of coronary artery bypass surgery and angioplasty on the total ischemic burden: a study of exercise testing and ambulatory ST segment monitoring.

To assess the effects of standard therapeutic interventions on the total ischemic burden, 86 patients with stable angina underwent 48 hours of ambulatory ST segment monitoring and treadmill exercise testing before and at a mean of 10 weeks after coronary artery bypass surgery (CABG) (group 1, N = 46) or percutaneous transluminal coronary angioplasty (PTCA) (group 2, N = 40). There were 72 male and 14 female patients with a mean age of 56.4 years. All patients had documented coronary artery disease (24, single-vessel; 28, two-vessel; 34, three-vessel disease). Both groups were characteristically similar apart from more severe coronary artery disease (p less than 0.001) and more previous myocardial infarctions (p less than 0.05) in group 1. Groups with CABG and PTCA had significant prolongation of exercise time after intervention (group 1: 7.6 to 9.8 minutes, p less than 0.0001; group 2: 8.1 to 10.0 minutes, p less than 0.001), and both interventions led to a significant reduction in ischemic responses (group 1: 33 to 4, p less than 0.001; group 2: 20 to 13, p less than 0.05) to exercise. During a total of 7643 hours of ST segment monitoring, 253 episodes of ischemia were recorded in 3768 hours before and 44 ischemic episodes in 3875 hours after intervention (group 1, 113 episodes in 24 patients and 21 episodes in 10 patients; group 2, 140 episodes in 13 patients and 23 episodes in six patients). Both interventions reduced the mean frequency of ischemia per 24 hours (group 1: 1.24 to 0.22 episodes per 24 hours; p less than 0.01; group 2: 1.9 to 0.3 episodes per 24 hours; p less than 0.05). Almost 28% (N = 24) of resting electrocardiographic findings were altered as a result of intervention.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prognostic value of exercise echocardiography in patients after coronary artery bypass surgery

To assess the prognostic value of exercise echocardiography in patients with prior coronary artery bypass surgery, follow-up was obtained in 718 patients (591 men [82%] and 127 women [18%], aged 67 +/- 9 years) who underwent clinically indicated exercise echocardiography 5.7 +/- 4.7 years after coronary bypass surgery. Resting wall motion abnormalities were present in 479 patients (67%). New or worsening wall motion abnormalities developed with exercise in 366 patients (51%). During a median follow-up of 2.9 years, cardiac events included cardiac death in 36 patients and nonfatal myocardial infarction in 40 patients. The addition of the exercise echocardiographic variables, abnormal left ventricular end-systolic volume response and exercise ejection fraction to the clinical, resting echocardiographic and exercise electrocardiographic model provided incremental information in predicting cardiac events (chi-square 37 to chi-square 42, p = 0.02) and cardiac death (chi-square 38 to chi-square 43, p <0.02). Exercise echocardiography provides prognostic information in patients after coronary artery bypass surgery, incremental to clinical, rest echocardiographic, and exercise electrocardiographic variables.     

Return to work after coronary artery bypass surgery in a population of long-term survivors

BACKGROUND: Return to paid employment may be facilitated by coronary artery bypass graft (CABG) surgery. We assessed work status in a population-based study of long-term outcomes of CABG. AIM: To determine the association between returning to work after CABG and clinical and socio-demographic factors. METHODS: A postal survey of 2,500 randomly selected patients 6-20 years post-CABG. The outcomes assessed were work status in the year before and after CABG and health-related quality of life (HRQOL) measured with SF-36. RESULTS: Response was 82% (n = 2,061). Employment fell from 56% in the year prior to CABG to 42% in the year after. Workers in 'blue-collar' occupations were more likely to reduce their work status than those in 'white collar' occupations (46% versus 29%, p < 0.001). Independent predictors of reducing employment were increasing age (9% per year, 99% CI: 1.06-1.11, p < 0.001), 'blue-collar' versus 'white collar' occupation (OR: 2.1, 99% CI: 1.4-3.1) and female sex (OR: 2.1, 99% CI: 1.1-3.6). HRQOL among participants under 60 years of age at follow-up was better for those who returned to work after CABG surgery. CONCLUSION: CABG surgery is followed by a net loss to paid employment of working age patients which increases with age, and is more likely for those in blue-collar occupations and women.     

Homocysteine and coronary heart disease in the Caerphilly cohort: a 10 year follow up

OBJECTIVE—Prospective assessment of the risk of coronary heart disease associated with total serum homocyst(e)ine (homocysteine) concentration.
DESIGN—Nested case-control study.
SETTING—Caerphilly and surrounding villages in south Wales, UK.
PARTICIPANTS—2290 men who participated in phase II of the study in 1984. After a mean follow up of 10 years, 312 men developed coronary heart disease and were compared with 1248 randomly selected, age frequency matched controls.
MAIN OUTCOME MEASURE—Acute myocardial infarction or death from coronary heart disease.
RESULTS—The geometric mean serum homocysteine concentration was higher in cases (12.2 µmol/l, 95% confidence interval (CI) 11.8 to 12.6 µmol/l) than in controls (11.8 µmol/l, 95% CI 11.3 to 12.5 µmol/l) (p = 0.09). There was a graded increase in the odds ratio of coronary heart disease across quintiles of the homocysteine concentration distribution compared with the first (p = 0.04), which was attenuated when adjusted for confounding variables (p = 0.4). There was a small but non-significant increase in the adjusted odds ratio of coronary heart disease per standard deviation change in the log distribution of homocysteine concentration (OR = 1.07 (95% CI .93 to 1.24), p = 0.34). Comparing the top quintile of the homocysteine concentration with the remaining 80%, the adjusted odds ratio of coronary heart disease was 1.03 (95% CI 0.73 to 1.45) (p = 0.8) and comparing the top 5% with the remaining 95% it was 1.05 (95% CI 0.56 to 1.95) (p = 0.9).
CONCLUSIONS—These findings do not support the hypothesis that a raised homocysteine concentration is a strong independent risk factor for coronary heart disease. Randomised controlled trials of homocysteine lowering treatment such as folic acid are needed before generalising the early positive results of observational studies.


Keywords: homocysteine; coronary heart disease; cohort     

Acute kidney injury and long-term risk of stroke after coronary artery bypass surgery

Background

Acute kidney injury (AKI) is associated with death, end-stage renal disease, and heart failure in patients with coronary heart disease. This study investigated the association between AKI and long-term risk of stroke.

Methods and results

50,244 patients who underwent coronary artery bypass grafting (CABG) in Sweden between 2000 and 2008 were identified from the SWEDEHEART registry. After exclusions 23,584 patients without prior stroke who underwent elective, primary, isolated, CABG were included. AKI was categorized according to absolute increases in postoperative creatinine values compared with preoperative values: stage 1, 0.3–0.5 mg/dL (26–44 μmol/L); stage 2, 0.5–1.0 mg/dL (44–88 μmol/L); and stage 3, > 1.0 mg/dL (≥ 88 μmol/L). Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for stroke. There were 1156 (4.9%) strokes during a mean follow-up of 4.1 years. After adjustment for confounders, HRs (95% CIs) for stroke in AKI stages 1, 2 and 3 were 1.12 (0.89–1.39), 1.31 (1.04–1.66) and 1.31 (0.92–1.87), respectively, compared with no AKI. This association disappeared after taking death into account in competing risk analysis. There was a significant association between AKI and stroke in men (HR: 1.26 [1.05–1.50]) but not in women (HR: 1.07 [0.75–1.53]), and in younger (< 65 years; HR: 1.57 [1.12–2.22]), but not elderly patients (HR: 1.17 [0.98–1.40]).

Conclusions

The long-term risk of stroke is weakly associated with AKI after primary isolated CABG, but this association is attenuated and not significant when considering death as a competing risk.     

Prognostic significance of nonsustained ventricular tachycardia identified postoperatively after coronary artery bypass surgery in patients with left ventricular dysfunction

INTRODUCTION: Nonsustained ventricular tachycardia (NSVT) occurs frequently in the postoperative period (< or = 30 days) after coronary artery bypass graft (CABG) surgery, a setting where many factors may play a role in its genesis. The prognosis of NSVT in this setting in patients with left ventricular (LV) dysfunction is unknown. This study was designed to assess its significance. METHODS AND RESULTS: We compared the outcome of untreated patients enrolled in the Multicenter Unsustained Tachycardia Trial with coronary artery disease (CAD), LV dysfunction, and NSVT identified postoperatively after CABG (n = 228; mean age 67 years, 84% males) versus nonpostoperative settings (n = 1,302; mean age 66 years, 85% males). Sustained monomorphic ventricular tachycardia was induced in 27% and 33% (P = 0.046) of patients with postoperative and nonpostoperative NSVT, respectively. The 2- and 5-year rates of arrhythmic events were 6% and 16%, respectively, in postoperative patients versus 15% and 29% in nonpostoperative patients (unadjusted P = 0.0020, adjusted P = 0.0082). The 2- and 5-year overall mortality rates were 15% and 36%, respectively, for postoperative patients versus 24% and 47% for nonpostoperative patients (unadjusted P = 0.0005, adjusted P = 0.027). Patients whose NSVT was identified early (<10 days) versus late (10-30 days) after CABG had significantly lower 2- (13% vs 23%) and 5-year (30% vs 52%) mortality rates (unadjusted P = 0.024, adjusted P = 0.018). CONCLUSION: In this population of patients with CAD and LV dysfunction, the occurrence of postoperative NSVT, especially within 10 days after CABG, portends a far better outcome than when it occurs in nonpostoperative settings. This suggests that in a such setting, NSVT represents a less specific risk factor for future events and should be considered when assigning risk and treatment of similar patients.     

Prognostic significance of coronary sinus filling time in patients with angina and normal coronaries at one year follow up

Background

Coronary sinus filling time (CSFT) has been proposed as a simple method for assessment of coronary microvascular function in patients with angina and normal coronaries. But its correlation with inducible ischemia and prognostic significance in predicting future cardiovascular events has not been studied. The present study assessed the prognostic significance of CSFT during one year of follow up.

Methods

We compared coronary sinus filling time of patients with angina and normal coronaries with that of control population. Control group was formed by those patients with supraventricular arrhythmia undergoing radiofrequency ablation and having normal coronaries. Baseline treadmill test (TMT) parameters like workload, duration and Duke Score were assessed. Patients were followed up for one year and a composite of cardiovascular mortality and non-fatal myocardial infarction was analyzed. Number of patients presenting to emergency or outpatient department with recurrent chest pain symptoms during one year follow up was considered for secondary outcome analysis. Coronary sinus filling time was analyzed with respect to cardiovascular events, repeat hospitalization for recurrent angina and TMT parameters.

Results

Total 72 patients and 16 controls were studied. Mean CSFT value in the study group was 5.31 ± 1.03 sec and in the control group was 4.16 ± 0.72 sec and the difference was significant (p value = 0.0001). No correlation was found between baseline and repeat TMT parameters with CSFT. There was no cardiovascular mortality or hospitalization for non-fatal MI during one year follow up. But patients with frequent emergency or outpatient department visits with chest pain had a high CSFT compared with asymptomatic patients (p value = 0.005).

Conclusion

Coronary sinus filling time may be used as a simple marker of microvascular dysfunction in patients with angina and normal coronaries. Patients with recurrent chest pain symptoms after one year follow up were found to have high CSFT compared to asymptomatic patients.     

Functional testing after coronary artery bypass graft surgery: a meta-analysis

BACKGROUND: A number of studies have examined the diagnostic abilities of various functional tests to assess graft stenosis or the progression of coronary artery disease after coronary artery bypass graft (CABG) surgery. However, a meta-analysis of these studies has not been performed. OBJECTIVES: To pool the results of studies examining the diagnostic abilities of exercise treadmill testing (ETT), stress myocardial perfusion imaging and stress echocardiography to predict graft stenosis or progression of disease in the native circulation post-CABG. METHODS: A MEDLINE search was conducted to identify studies examining post-CABG functional testing for the diagnosis of graft stenosis or progression of native disease. Sensitivities and specificities of these studies were pooled, and predictive values and likelihood ratios were calculated. RESULTS: A pooled analysis demonstrates that for the identification of graft stenosis or progression of native disease, ETT alone has a sensitivity of 45% (95% CI 36% to 54%) and a specificity of 82% (95% CI 68% to 95%). The use of stress myocardial perfusion imaging increased the sensitivity to 68% (95% CI 51% to 86%) and specificity to 84% (95% CI 78% to 91%). The use of stress echocardiography also resulted in an increased sensitivity of 86% (95% CI 78% to 94%) and specificity of 90% (95% CI 84% to 95%). CONCLUSION: If post-CABG functional testing is performed, stress ventricular imaging is superior to ETT alone for the diagnosis of graft stenosis or progression of disease in the native vessels.     

冠心病合并糖尿病患者冠状动脉旁路移植术长期预后及危险因素的探讨

目的 探讨糖尿病及其合并症对冠状动脉旁路移植术长期预后的影响。方法 将226例连续行冠状动脉主路移植术的冠心病患者分为糖尿病组（116例）和非糖尿病组（110例），应用多变量分析方法分析两组患者术前及术后的临床特征，并随访术后总死亡率及心脏性死亡的发生率，探讨糖尿病组心脏性死亡的预测因素。结果 两组术前及术后的临床特征、既往心肌梗死病史及冠状动脉病变支数等差异无显著性。结果 两组术前及术后的临床特征、既往心肌梗死病史及冠状动脉病变支数等差异无显著性。平均随访3.5年总死亡率两组差异无显著性，但心脏性死亡的发生率糖尿病组明显高于非糖尿病组（15％与3％，P＜0.01）。糖尿病和术后低左室射血分数与心脏性死亡的发生率密切相关（95％可信区间1.29-15.20)。糖尿病组的心脏性主要是猝死、心力衰竭和心肌梗死。术后低左室射血分数、女性及糖尿病肾病是主要预测因素。结论 冠心病合并糖尿病患者冠状动脉旁路移植术长期预后不良，特别在低左室射血分数、女性及糖尿病肾病患者心脏性死亡的发生率高，预后差。应加强对糖尿病患者冠状动脉旁路移植术后心、肾功能障碍的治疗。