Impact of restenosis 10 years after coronary angioplasty

Aims The aim of the study was to compare the 10-year follow-up resultsof patients with or without restenosis following single-vesselpercutaneous transluminal coronary angioplasty (PTCA). Methods and Results A total of 313 patients with successful PTCA (20% reductionin luminal diameter narrowingwithout acute complications) anda control angiography 6 months after PTCA were included in thestudy. Events during the follow-up period were defined as death,myocardial infarction, bypass surgery, or repeat PTCA. Statisticalevaluation was performed by the Fisher test, logistic regression,and life-table analysis. Restenosis (loss of >50% of the initialgain and diameter stenosis of <50%) was found in 87 (28%)patients. During follow-up, 11 patients (5%) without restenosis(group A) and 11 (13%) patients with restenosis (group B) died(P<0·05). In group A, 17 (8%) patients and in groupB, 11 (13%) patients suffered myocardial infarction (ns); 17group A (8%) patients and 25 (29%) group B patients had bypasssurgery (P<0·0001), and 34 (15%) group A patientsand 55 (63%) group B patients underwent repeat PTCA (P<0·0001).Logistic regression analysis identified restenosis as an independentrisk factor that increases the risk of death 2·8-fold(P=0·02), bypass surgery 5·6-fold (P<0·0001),and repeat PTCA 10-fold (P<0·0001). Conclusion: We conclude that patients with restenosis had a poorer long-termoutcome than patients without restenosis. Although most patientswith restenosis underwent repeat PTCA, the survival rate withoutany serious adverse events was only 59%, compared with 83% inpatients without restenosis (P<0·0001).     

Long-term reduction of cardiac mortality after myocardial infarction: 10-year results of a comprehensive rehabilitation programme

The long-term outcome of different methods of post-MI care hasbeen studied in two non-selected groups of MI patients: an interventiongroup (n = 147), participating in a cardiac rehabilitation (CR)programme, was compared to a reference group receiving standardcare (n = 158). The CR programme included a post-MI clinic,physical training, information on smoking and diet, and psychologicalsupport. After 5 years there was no difference in mortality (29.3 vs31.6%), but the recurrence rate of non-fatal MI (17.3 vs 33.3%P <0.05) and of total cardiac events (39.5 vs 53.2%, P <0.05) was lower in the intervention gro up, and more patientswere still at work (51.8 vs 27.4% P < 0.01). After 10 years there was a reduction in total (42.2 vs 57.6%P < 0.001) and cardiac mortality (36.7 vs 48.1% P < 0.001).Fewer patients in the intervention group suffered from non-fatalreinfarction (28.6 vs 39.9%, P < 0.001). Among those patientswho had not yet reached the age of retirement more patientshad resumed employment (58.6 vs 22.0% P < 0.05). We conclude, that the secondary preventive effect of the programmehas contributed to the higher rate of survival.     

Chronic atrial fibrillation does not influence the magnitude of sympathetic overactivity in patients with heart failure

Aims In this study we sought to assess the influence of atrialfibrillation (AF) on sympathetic nervous system overactivityin congestive heart failure (CHF) patients. Methods and results We studied 133 consecutive patients withmoderate to severe CHF. Subjects underwent haemodynamic assessment(right heart catheterization) and assessment of total systemicand cardiac sympathetic activity by the norepinephrine (NE)spillover method. The study population included 108 patientsin sinus rhythm (SR) and 25 in AF. While AF patients had a lowercardiac output (CO) (SR vs AF: 4.2±0.1 vs 3.7±0.2l/min,P<0.05), the groups were otherwise matched for systemic bloodpressure (BP), heart rate and filling pressures. In conjunction,total body NE spillover (SR vs AF: 5.8±0.4 vs 4.9±0.5nmol/min,P>0.05) and cardiac NE spillover (SR vs AF: 339±21 vs393±49pmol/min, P>0.05) were not significantly differentbetween the two groups, while the systemic clearance rate forNE was lower in the AF group (SR vs AF: 2.2±0.1 vs 1.6±0.1l/min,P<0.05). Conclusion Congestive heart failure patients in AF do not appearto have heightened sympathetic tone compared to CHF patientsin SR.     

Long-term outcome of patients with incomplete vs complete revascularization after multivessel PTCA: A report from the NHLBI PTCA Registry

Background Incomplete revascularization is frequently the goalas well as the final outcome in patients with multivessel coronarydisease undergoing PTCA. However, the long-term impact of incompleterevascularization is not known and this common PTCA strategydeserves further scrutiny. Methods and results Complete revascularization was achievedin 132 of 757 patients with multivessel disease in the 1985–86NHLBI PTCA Registry. Compared to patients in whom complete revascularizationwas achieved, patients with incomplete revascularization wereolder (P<0·05), more likely to be females (P<0·05)and to have recent myocardial infarction (P<0·05),unstable angina (P<0·001), and urgent or emergentPTCA (P<0·001). Early death, Q wave myocardial infarctionand CABG rates were higher in patients with incomplete thanin those with complete revascularization [significantly different(P<0·05) only for emergency and elective CABG]. At9 years, nearly twice as many patients with incomplete revascularizationexperienced recurrent angina (19% vs 10% for patients with completerevascularization,P<0·05). Patients with completerevascularization were more likely to undergo repeat PTCA thanthose with incomplete revascularization (40% vs 30%,P<0·05).Patients with incomplete revascularization were more likelyto undergo CABG than patients with complete revascularization(32% vs 14%,P<0·001; adjusted risk 2·56, 95%CI 1·60, 4·10). Among patients with incompleterevascularization, those in whom PTCA was intended but not attemptedhad the highest early event rates and late CABG rates. Finally,the adjusted risk of dying, having a Q wave myocardial infarction,recurrent angina or repeat PTCA was not different at 9-yearfollow-up among patients with and without complete revascularization. Conclusions Complete revascularization achieved by PTCA reduceslate occurrence of CABG, but not adjusted rates of death, Qwave myocardial infarction, recurrent angina, and repeat PTCAin patients with multivessel coronary disease. These data tendto support the PTCA strategy of incomplete revascularizationin patients with multivessel disease when complete revascularizationis not feasible or not planned before the procedure.     

Prognostic significance of silent myocardial ischaemia during maximal exercise testing after a first acute myocardial infarction

Clinical, exercise, and angiographic variables, and long-termfollow-up were compared in patients, who, during maximal Bruceexercise testing after a first acute myocardial infarction (AMI),had positive responses to exercise testing (n = 116, 38% of303) with (n % 23, group I) or without (n = 93, group II) angina.Group I patients more often (52 vs 19%, P < 0.001) had ahistory of pre-infarction angina. Group II had a greater proportion(75 vs 52%, P < 0.05) of inferior wall AMI, whereas groupI had a greater proportion (30 vs 19%, P < 0.01) of non-Qwave AMI. Total exercise duration was significantly (P <0.01) longer in group II (7.6 ± 3.2 vs 5.5 ± 3.1min). Maximal exercise heart rate (144 ± 22 vs 133 ±21, beats . min^–1 P < 0.05 was also higher in groupII. A greater proportion of group II patients (37 vs 9%, P <0.05) had single-vessel disease, whereas multivessel diseasewas more common (91 vs 63% P < 0.03) in group I. Left ventricularfunction was similar in both groups. During follow-up (48 ±22 months) the incidence of cardiac death (group I, 3.3%, groupII, 4.8%), of recurrent infarction (group I, 4.8%, group II3.3%), and of revascularization procedures (group I, 28.5%,group II, 19.8%) were similar in both groups. Although asymptomaticexercise-induced ischaemia was associated with better exerciseperformance and less extensive coronary disease than symptomaticischaemia, it had the same long-term prognostic implications.     

Is gout associated with reduced quality of life? A case-control study

Objectives. To compare quality of life (QOL) between gout casesand controls in a primary care population and to investigatewhether impaired QOL in gout is secondary to co-morbid factorsor to intrinsic factors related to gout itself. Methods. A postal questionnaire was sent to all adults agedover 30 yrs registered with two general practices. The questionnaireassessed a history of gout (doctor diagnosed, or episodes suggestiveof acute crystal synovitis) and medical and musculoskeletalco-morbidities. QOL was assessed using the WHOQoL-Bref instrument.Possible cases of gout attended for clinical assessment wherethe diagnosis was verified on clinical grounds. Overall QOL,satisfaction with health and QOL across four domains were comparedbetween gout cases and controls and then entered into a linearregression model adjusting for gout, age, gender, body massindex and medical and musculoskeletal co-morbidities. Results. Of 13 684 questionnaires mailed, 3082 completed questionnaireswere returned (23%). From 289 suggested cases of gout, 137 caseswere confirmed by clinical assessment. Compared with controls,cases had impaired overall QOL (15.67 vs 16.41, P = 0.003),satisfaction with health (13.16 vs 14.45, P < 0.001) andphysical health-related QOL (14.08 vs 15.95, P < 0.001).On multi-variate analysis, gout remained associated with impairedphysical health-related QOL (ß = –0.059, P =0.001) but not overall QOL (ß = –0.024, P =0.198) or satisfaction with health (ß = –0.028,P = 0.142). Conclusions. Gout associates with poor overall QOL mainly resultingfrom associated co-morbidity. Physical health-related QOL, however,remains impaired after adjustment for co-morbidities. KEY WORDS: Gout, Quality of life, General practice Submitted 11 January 2007; revised version accepted 2 May 2007.     

Possible role for mast cell-derived cathepsin G in the adverse remodelling of stenotic aortic valves

Aims Aortic stenosis (AS) is characterized by extensive remodellingof the valves, including infiltration of inflammatory cells,extracellular matrix degradation, and fibrosis. The molecularmechanisms behind this adverse remodelling have remained obscure.In this article, we study whether cathepsin G, an angiotensinII (Ang II)-forming elastolytic enzyme, contributes to progressionof AS. Methods and results Stenotic aortic valves (n=86) and controlvalves (n=17) were analysed for cathepsin G, transforming growthfactor-ß1 (TGF-ß1), and collagens I andIII with RT–PCR and immunohistochemistry. Valvular collagen/elastinratio was quantified by histochemistry. In stenotic valves,cathepsin G was present in mast cells and showed increased expression(P<0.001), which correlated positively (P<0.001) withthe expression levels of TGF-ß1 and collagens I andIII. TGF-ß1 was also present in mast cell-rich areasand cathepsin G induced losartan-sensitive TGF-ß1expression in cultured fibroblasts. Collagen/elastin ratio wasincreased in stenotic valves (P<0.001) and correlated positivelywith smoking (P=0.02). Nicotine in cigarette smoke activatedmast cells and induced TGF-ß1 expression in culturedfibroblasts. Fragmented elastin was observed in stenotic valvescontaining activated cathepsin G-secreting mast cells and innormal valves treated with cathepsin G. Conclusion In stenotic aortic valves, mast cell-derived cathepsinG may cause adverse valve remodelling and AS progression.     

Anti-atherogenic and anti-inflammatory properties of high-density lipoprotein are affected by specific antibodies in systemic lupus erythematosus

Objective. To determine whether antibodies against high-densitylipoprotein (aHDL) and apolipoprotein A-I (aApo A-I) interferewith the anti-atherogenic functions of high-density lipoprotein(HDL) and relate to disease activity and damage in SLE. Methods. Seventy-seven SLE patients were compared with an age-and sex-frequency matched control group. Immunoglobulin G (IgG)aHDL, IgG aApoA-I, soluble vascular cell and intracellular celladhesion molecules (VCAM-1 and ICAM-1, respectively) were measuredby ELISA, paraoxonase (PON) activity by spectrophotometry, nitricoxide (NOx) metabolites by the Griess reaction, and total anti-oxidantcapacity (TAC) by chemiluminescence. Results. Compared with controls, SLE patients showed highertitres of IgG aHDL (P < 0.0001) and IgG aApo A-I (P <0.0001), lower PON activity (P < 0.0001), increased NOx (P< 0.0001), VCAM-1 (P < 0.0001) and ICAM-1 (P = 0.0008)and lower TAC (P = 0.0006). Titres of IgG aHDL positively correlatedwith IgG aApo A-I (r = 0.64, P < 0.0001), NOx (r = 0.32,P = 0.007), inversely correlated with PON activity (r = –0.34,P = 0.002) and TAC (r = –0.43, P = 0.0004) and were independentlyassociated with ICAM-1 (t = 3.509, P = 0.001). IgG aApo A-Ititres correlated positively with NO (r = 0.37, P = 0.007),inversely with PON activity (r = –0.31, P = 0.006), TAC(r = –0.47, P < 0.0001) and were independently associatedwith HDL (t = –2.747, P = 0.008) and VCAM-1 (t = 3.311,P = 0.002), the latter alongside NOx (T = 2.271, P = 0.02).Elevated titres of IgG aHDL and IgG aApo A-I and reduced PONactivity related to increased disease score (BILAG) and damageindex (SLICC/ACR DI). Conclusion. In SLE, IgG aHDL and aApo A-I associate with diseaseactivity and damage and interfere with the anti-oxidant andanti-inflammatory functions of HDL favouring atherogenesis. KEY WORDS: Systemic lupus, Antibodies against high-density lipoprotein, Antibodies against Apolipoprotein A-I, Paraoxonase, Nitric oxide, Endothelial dysfunction Submitted 6 March 2008; revised version accepted 15 September 2008.     

Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project

Background: with increasing prevalence of diabetes in olderpeople, it is important to understand factors that affect theiroutcomes. The Informatics for Diabetes Education and Telemedicine(IDEATel) project is a demonstration project to evaluate thefeasibility and effectiveness of telemedicine with diverse,medically underserved, older diabetes patients. Subjects wererandomised to telemedicine case management or usual care. Thisintervention has been shown to result in improved medical outcomesand self-efficacy. Self-efficacy refers to one's belief that(s)he can successfully engage in a behaviour. Self-efficacyhas been shown to relate to behaviour change and glycaemic controlin middle-aged individuals, but not studied in older individuals. Objectives: to assess whether (a) diabetes self-efficacy relatesto the primary medical outcome of glycaemic control, and tosecondary outcomes (blood pressure and cholesterol), and (b)whether, after an intervention, change in diabetes self-efficacyrelates to change in these medical outcomes in a group of older,ethnically diverse individuals. Methods: three waves of longitudinal data from participantsin IDEATel were analysed. Results: diabetes self-efficacy at baseline correlated withglycaemic control, blood pressure and cholesterol. An increasein diabetes self-efficacy over time was related to an improvementin glycaemic control (P < 0.0001), but not in blood pressureand lipid levels. The intervention was significantly relatedto improved self-efficacy over time (P < 0.0001), and bothdirectly (P = 0.022) and indirectly through self-efficacy (P< 0.001) to improved glycaemic control. The mediation effectof self-efficacy was also significant (P< 0.004). Conclusions: diabetes self-efficacy is a relevant constructfor older diabetes patients. Thus, interventions that targetenhanced self-efficacy may also result in improved glycaemiccontrol.     

Trajectory of Decongestion and Mortality in Young Adults with Acute Heart Failure

Although the prevalence of HF in young adults (age <50 years) is increasing, there are limited data on the trajectory of decongestion and short-term outcomes in young adults with acute heart failure (AHF). We pooled patients from 3 randomized trials of AHF conducted within the Heart Failure Network (the Diuretic Optimization Strategies trial, the Renal Optimization Strategies Trial, and the Cardiorenal Rescue Study in Acute Decompensated Heart Failure). The association between young age (<50 years and >50 years) and in-hospital changes in various measures of decongestion as well as short-term outcomes including risk for rehospitalization, and all-cause mortality was evaluated. Of 762 patients, 72 (10.3%) patients were young. Young adults were more likely to be African American (53.8% vs 19.3%), to have a lower rate of ischemic HF etiology (25.6% vs 60.4%, P <0.001), and a lower burden of hypertension, chronic kidney disease and atrial fibrillation. Young adults had a lower left ventricular ejection fraction (median 20% vs 33%, P < 0.001); they had a higher admission weight (median 242.7 lbs vs 201.5 lbs, P < 0.001), but lower NT-pro BNP levels (median 3622 pg/mL vs 4676 pg/mL, P = 0.003). After covariate adjustment, there was no difference in the change in NT-pro BNP (P = 0.25), net fluid loss (P = 0.42), or renal function (P = 0.56) between young and older adults by 72 or 96 hours of randomization. There was no difference in orthodema congestion score or the composite clinical endpoint during the follow-up (all-cause mortality or any rehospitalization) (adjusted odds ratios (95% confidence intervals): 2.51 (0.78-8.01), P = 0.12). In this pooled analysis of 3 clinical trial cohorts, compared with older adults, younger adults had a unique demographic and clinical profile. Despite these differences, there was no difference by age group in in-hospital decongestion or post-discharge readmission or mortality.     

The impact of frailty on the utilisation of antithrombotic therapy in older patients with atrial fibrillation

Objective: to investigate the impact of frailty on the utilisationof antithrombotics and on clinical outcomes in older peoplewith atrial fibrillation (AF). Design: prospective study of a cohort of 220 acute inpatientsaged 70 years with AF, admitted to a teaching hospital in Sydney,Australia (April–July 2007), with 207 followed up over6 months. Results: a total of 140 patients (64%) were identified as frailusing a validated tool. Frail patients were less likely to receivewarfarin than non-frail on hospital admission (P = 0.002) anddischarge (P < 0.001). During hospitalisation, the proportionof frail participants prescribed warfarin decreased by 10.7%and that of non-frail increased by 6.3%. Over the 6-month follow-up,43 major or severe haemorrhages (20.8%), 20 cardioembolic strokes(9.7%) and 40 deaths (19.2%) were reported. Compared to non-frail,frail participants were significantly more likely to experienceembolic stroke (RR 3.5, 95% CI 1.0–12.0, P < 0.05),had a small non-significant increase in risk of major haemorrhage(RR 1.5, 95% CI = 0.7–3.0, P = 0.29) and had greater mortality(RR 2.8, 95% CI 1.2–6.5, P = 0.01). Conclusion: frail older inpatients with AF are significantlyless likely to receive warfarin than non-frail and appear morevulnerable to adverse clinical outcomes, with and without antithrombotictherapy.     

Effect of physical training on ventricular repolarization in type 1 long QT syndrome: a pilot study in asymptomatic carriers of the G589D KCNQ1 mutation

Aims High-intensity physical exercise and competitive sportshave been traditionally avoided in long QT syndrome. However,endurance training increases vagal activity and thus may improvecardiac electrical stability in healthy subjects. We hypothesizedthat controlled submaximal endurance training would not adverselyaffect ventricular repolarization in asymptomatic carriers ofa KCNQ1 gene mutation of type 1 long QT syndrome (LQT1). Methods and results Previously, sedentary carriers of a missensemutation of KCNQ1 gene (LQT1, n=7) and healthy controls (n=8)exercised on a bicycle ergometer 3–4 times a week, 30 mina day at 60–75% of maximal heart rate (HR) for a maximumof 3 months. Body surface potential mapping (BSPM) was recordedand QT intervals were determined automatically from 14 channelsover the left chest area. Maximal work capacity increased by4±1% in LQT1 and by 14±2% in controls (both P<0.05),and left ventricular (LV) mass by 8±1% and 9±1%,respectively (P<0.05). Resting corrected QT interval shortenedby 10±1% (P<0.05) and QT interval dispersion by 25±9%(P<0.05) in LQT1, but not significantly in controls. QT intervalsat specified HRs during workload and recovery phases were notchanged in either group. Conclusion In this pilot study of asymptomatic carriers of aKNCQ1 gene mutation, submaximal endurance training did not harmfullyaffect arrhythmia risk markers. Confirmatory studies in a broaderspectrum of LQT1 genotypes are needed before any generalizationcan be made.     

A preliminary study of the safety, feasibility and cognitive efficacy of soy isoflavone supplements in older men and women

Background: a small number of reports exist on the cognitiveeffects of soy isoflavones, the findings from which are mixed.Isoflavone efficacy is dependent upon conversion of glycosidescontained in soy foods and supplements to the biologically activeaglycons. Of particular interest is the production of the metabolite,equol, which is dependent upon intestinal microflora and anintegrous digestive system, both being altered by age and age-associatedconditions. Unfortunately, few studies enrolled adults overthe age of 70, and none included older men. Objective: we examined safety, feasibility and cognitive efficacyof soy isoflavone administration in older nondemented men andwomen (age 62–89 years). Design and Methods: in this randomised, placebo-controlled,double-blind pilot study, subjects ingested either 100 mg/daysoy isoflavones (glycoside weight) or matching placebo tabletsfor 6 months. Results: active and placebo-treated subjects exhibited a comparableside-effect profile. Plasma levels of genistein and daidzein(P < 0.001), but not equol, increased with isoflavone administration.While similar at baseline, the two groups differed across 6months of treatment on 8 of 11 cognitive tests administered.Isoflavone-treated subjects improved on tests of visual-spatialmemory (P < 0.01) and construction (P = 0.01), verbal fluency(P < 0.01) and speeded dexterity (P = 0.04). Placebo-treatedparticipants were faster than isoflavone-treated subjects ontwo tests of executive function (P < 0.05). Conclusions: these data suggest that administration of 100 mg/dayof isoflavones was well tolerated. Plasma genistein and daidzeinlevels, but not equol, increased with isoflavone administration.Finally, data support the potential cognitive effects of soyisoflavones in older adults.     

Hyperleptinaemia in chronic heart failure: Relationships with insulin

Background Leptin, a product of theobgene, is known to increaseenergy expenditure. Given that chronic heart failure is a hypercatabolicstate, we sought to determine whether congestive heart failureinvolves elevations in plasma leptin levels. Since leptin secretionis up-regulated by insulin, we also explored whether in congestiveheart failure, a hyperinsulinaemic state, plasma leptin levelsrelate to plasma insulin levels. Methods Male patients with weight-stable congestive heart failure(n=25, aged 55·5±2·0, mean±SEM,body mass index=27·4±0·8, radionuclideleft ventricular ejection fraction=29·3±3·0%)and 18 controls, matched for age, sex and body fat (dual energyX-ray absorp-tiometry), underwent measurement of fasting plasmaleptin (radioimmunoassay) and insulin levels. Results Compared to controls, patients with congestive heartfailure had higher plasma leptin [8·12 (–1·12,+1·31)vs 4·48 (–0·61,+0·70) ng.ml^–1,mean±asymmetrical SEM,P=0·003], 41·5% higherplasma leptin per percent body fat mass (P<0·001),and higher fasting insulin levels [67·8 (–11·1,+13·3)vs 32·9 (–5·7,+6·9) pmol.l^–1,P=0·010].In the congestive heart failure group, plasma leptin correlatedwith total body fat (r=0·66) and fasting insulin (r=0·68)(bothP<0·001). In multivariate regression analysesof the congestive heart failure group, fasting insulin (standardizedcoefficient=0·41,P=0·011) emerged as a predictorof plasma leptin levels, independent of total body fat (standardizedcoefficient=0·73,P=0·002, R²=0·66,P<0·001). Conclusions Plasma leptin levels are raised in patients withcongestive heart failure. The observation of a positive relationshipbetween plasma leptin and insulin concentrations suggests thatthe insulin–leptin axis may be related to the increasedenergy expenditure observed in patients with congestive heartfailure.     

Dipyridamole echocardiography evaluation of acute inferior myocardial infarction with concomitant anterior ST segment depression

The significance of anterior ST segment depression in inferioracute myocardial infarction (AMI) remains controversial. Theaim of this study was to relate precordial ST segment depressionto the topography of residual myocardial ischaemia, with myocardialmapping of the asynergic area and coronary anatomy. Twenty-fivepatients with first inferior AMI (15 patients with anteriorST segment depression: group A and 10 patients without anteriorST segment shift: group B), all underwent: (1) electrocardiographicevaluation on admission to the Coronary Care Unit and at 24h intervals thereafter; (2) 2D-echocardiographic study within3 h of CCU admission: (3) dipyridamole echocardiographic test(DET) (doses of dipyridamole up to 0.84 mg.kg^–1 i.v. over10 min) 4 days after AMI; (4) coronary arteriography within14 days from AMI. To assess regional left ventricular wall motion,a 16 segment model was used and a wall motion score index (WMSI)was derived. The results of DET were correlated to the anatomyof the infarct-related vessel. Compared to group B, group Apatients showed a significantly greater maximal ST segment elevationin inferior limb leads (lead III: 3.9±1.9 mm vs 2.2±1.1mm, P<0.05; aVF: 3.5±13 mm vs 1.7±0.8 mm, P<0.001).Group A patients showed greater WMSI (1.35±0.22 vs 117±0.12,P<0.05), with more frequent postero-lateral wall involvement(72% vs 20%, P<0.05). No patient of either group showed asynergyof the anterior, anterolateral or anteroseptal segments. Nodifferences in the distribution of coronary artery disease wereobserved. Left anterior descending coronary artery disease waspresent in only three patients (20%) in group A and in one patientin group B. DET was positive in eight patients (53%) in groupA and in three (30%) in group B (P = statistically not significant).In all patients DET induced new wall motion abnormalities locatedin the territory of the infarct-related artery. None of thepatients developed new wall motion abnormalities remote fromthe infarct zone or adjacent to the infarct zone, but locatedin different vascular regions. In conclusion, anterior ST segmentdepression in inferior A MI appears to indicate a more extensivearea of asynergy, with frequent involvement of the posterolateralwall. The topography of DET-induced residual myocardial ischaemiadoes not support the hypothesis of concomitant anterior ischaemia.     

Changing attitudes to cardiopulmonary resuscitation in older people: a 15-year follow-up study

Background: while it is well established that individual patientpreferences regarding cardiopulmonary resuscitation (CPR) maychange with time, the stability of population preferences, especiallyduring periods of social and economic change, has received littleattention. Objective: to elicit the resuscitation preferences of olderIrish inpatients and to compare the results with an identicalstudy conducted 15 years earlier. Methods: one hundred and fifty older medical inpatients awaitingdischarge in a university teaching hospital or a district generalhospital subjects were asked about resuscitation preferences.Results were compared to those elicited from a hundred subjectsin 1992. Results: most patients (94%) felt it was a good idea for doctorsto discuss CPR routinely with patients, compared with 39% in1992. In their current health, 6% in 2007 and 76% in 1992 wouldrefuse CPR. The independent predictors of refusal of CPR incurrent health on logistic regression were age and year of assessment.In the final model, those aged 75–84 years [OR 2.77 (95%CI 1.25–6.13), P = 0.02] and 85 years or more [OR 15.19(4.26–54.15), P < 0.0001] were more likely than thoseaged 65–74 years (reference group) to refuse CPR. Thosequestioned in 2007 [OR 0.04 (0.02–0.81), P < 0.0001]were less likely than those questioned in 1992 (reference group)to refuse CPR. Conclusions: there has been a significant shift in the attitudesof older Irish inpatients over 15 years towards favouring greaterpatient participation in decision making and an increased desirefor resuscitation.     

QT interval dispersion as a predictor of arrhythmic events in congestive heart failure: Importance of aetiology

Aims Identification of patients with congestive heart failure atrisk of sudden death remains problematic and few data are availableon the prognostic implications of QT dispersion. We sought toassess the predictive value of QT dispersion for arrhythmicevents in heart failure secondary to dilated cardiomyopathyor ischaemic heart disease. Methods and Results Twelve-lead ECGs calculated for QT dispersion, 24h Holter ECGsand signal-averaged ECGs were prospectively recorded in 205heart failure patients in sinus rhythm. The 86 patients withischaemic heart disease and the 119 with dilated cardiomyopathywere not significantly different as regards NYHA grades (51vs 49% in grades III–IV), cardiothoracic ratio (57±7vs 57±6%) and ejection fraction (28±8 vs 29±9%).The mean QT dispersion (66±29 vs 65±27ms), thefrequency of non-sustained ventricular tachycardia (37 vs 38%)and ventricular late potentials (41 vs 40%) were not significantlydifferent in patients with ischaemic or dilated cardiomyop-athy.QT dispersion was not significantly related to other arrhythmogenicmarkers. During follow-up (24±16 months), 66 patientsdied, 22 of them died suddenly and seven presented a spontaneoussustained ventricular tachycardia. In patients with dilatedcardiomyopathy, in multivariate analysis, only a QT dispersion>80ms was an independent predictor of sudden death (RR: 4·9,95% CI 1·4–16·8,P<0·02) and arrhythmicevents (RR: 4·5, 95% CI 1·5–13·5,P<0·01).In patients with ischaemic heart disease, no studied parameterwas found significantly related to sudden death or arrhythmicevents. Conclusion: In congestive heart failure, abnormal QT dispersion can identifypatients with dilated cardiomyopathy who are at high risk ofarrhythmic events.     

Coronary vasodilator reserve in primary and secondary left ventricular hypertrophy: A study with positron emission tomography

Objectives Coronary vasodilator reserve is reduced in hypertrophiccardiomyopathy and secondary left ventricular hypertrophy despiteangiographically normal coronaries. The aim of the present studywas to assess whether quantitative differences exist betweenthese conditions. Methods Using positron emission tomography with H₂¹⁵O, myocardialblood flow was measured at baseline and following intravenousdipyridamole (0·56 mg. kg ^–1) in 12 hypertrophiccardiomyopathy patients (age 34 (11) years, mean (SD), all male),16 secondary left ventricular hypertrophy patients (age 58 (20)years, P<0·01 vs hypertrophic cardiomyopathy; 10 female)and 40 normal controls (age 54 (20), 13 female). In view ofthe known decline of post-dipyridamole myocardial blood flowwith age, myocardial blood flow was compared between the patientgroups and appropriately matched subsets of the total controlgroup. Results Baseline myocardial blood flow in the hypertrophic cardiomyopathypatients was 0·82 (0·23) ml. min^–1 . g^–1vs 0·94 (0·14) ml. min^–1 . g^–1 inits matched control group, P=ns. For the secondary left ventricularhypertrophy patient group, baseline myocardial blood flow was1·17 (0·40) ml . min^–1 . g^–1 vs 1·06(0·28) ml . min^–1 . g^–1 for the secondaryleft ventricular hypertrophy matched control group, P=ns. Followingdipyridamole, myocardial blood flow was 1·64 (0·44)ml . min^–1 . g^–1 in hypertrophic cardiomyopathypatients vs 3·50 (0·95) ml . min^–1 . g^–1forthe hypertrophic cardiomyopathy matched control group, P=0·0001.For the left ventricular hypertrophy patients, post-dipyridamolemyocardial blood flow was 2·27 (0·60)ml . min^–1. g^–1 vs 2·94(1·29) ml . min^–1 . g^–1for the left ventricular hypertrophy controls, P 0·06.Coronary vasodilator reserve (dipyridamole-myocardial bloodflow/baseline-myocardial blood flow) was 2·05 (0·61)for hypertrophic cardiomyopathy patients vs 3·81 (0·98)for the hypertrophic cardiomyopathy controls (P=0 0001, patientsvs controls) and 2·06 (0·62) for left ventricularhypertrophy patients vs 2·90 (1·38) for the leftventricular hypertrophy controls, P<0·03 patientsvs controls. After correction of baseline myocardial blood flowfor baseline heart rate x systolic pressure product, coronaryvasodilator reserve for the hypertrophic cardiomyopathy patientswas 2·06 (1·06) vs 4·34 (1·54) forthe hypertrophic cardiomyopathy controls, P=0·0002 andin the secondary left ventricular hypertrophy patients, thevalues were 2·13 (0·64) vs 2·89 (1·42)in the secondary left ventricular hypertrophy controls, P<0·05. Conclusions In both hypertrophic cardiomyopathy and secondaryleft ventricular hypertrophy, the computed coronary vasodilatorreserve is impaired, even after correction for baseline cardiacwork. However, the extent of the reduction is greater in thehypertrophic cardiomyopathy patients. In the blunting of vasodilatorreserve of secondary left ventricular hypertrophy, the patients'greater hyperaemic response is partly offset by the higher baselinemyocardial blood flow.     

Esophagectomy for cancer in octogenarians

Because of changes in life expectancy, there is an increasing number of elderly patients with esophageal cancer. The aim of this study was to assess the outcome of esophagectomy for cancer in patients 80 years or older. A retrospective review was performed of the records of all patients who underwent esophagectomy for cancer from 1992 to 2007. A cardiac and pulmonary evaluation was obtained on an individual basis in the younger patients and in all octogenarians. Among 560 patients with esophagectomy for cancer, 47 patients (8%) were octogenarians. The median age of the younger group (n= 513) was 63 years (interquartile range 56–71). Octogenarians had significantly more stage III disease (49% vs 31%, P= 0.02) but received less neoadjuvant therapy than younger patients (2% vs 21%, P= 0.0004). In octogenarians, the transhiatal resection was more common than in the younger group (79% vs 36%, P < 0.0001). Weight loss prior to surgery was similar in both groups, but body mass index was significantly lower in octogenarians (25 vs 28 kg/m², P= 0.0002). Major complications occurred in 26% in octogenarians and 31% in the younger group (P= 0.51). Hospital mortality was similar (9% for octogenarians vs 4% in the younger group, P= 0.13). The median postoperative hospital stay was similar at 16 days (P= 0.69). There was no difference in cancer‐related survival (median survival 48.9 vs 59.3 months, P= 0.31 log‐rank test). Esophagectomy can be performed safely in carefully selected octogenarians with good cardiac and pulmonary function. Patients should not be denied an esophagectomy based only on their age.     

Time domain analysis of the signal averaged electrocardiogram in patients with a conduction defect or a bundle branch block

Doubts have been expressed about the clinical usefulness oftime domain analysis of the signal averaged electrocardiogramin patients with prolonged QRS complex duration. We studied147 patients using a signal averaged ECG (40–250 Hz) whoseQRS complex was longer than 100 ms. A baseline electrophysiologystudy was also performed in 128 of these patients. Seventy-sevenpatients had a minor (QRS <120 and >100 ms) conductiondefect. Thirty-seven of these 77 had either induced or spontaneoussustained ventricular tachycardia (group I) and 40 had no sustainedventricular tachycardia (group II). Seventy patients had a major(QRS120 and >100 ms) conduction defect, 44 of whom had sustainedventricular tachycardia (group A). The remaining 26 withoutthis condition formed Group B. Group I compared to group IIpatients had a longer filtered QRS duration (120.8 ±14 vs 104.5 ± 9.5 ms, P<0.001), a longer low amplitudesignal duration (41 ± 12.1 vs 31 ± 12.6 ms, P<0.0001)and a lower root mean square of the last 40 ms of the filteredQRS complex (27 ± 29.8 vs 35 ± 25.3 µV,P=ns). Group A compared to group B had a longer filtered QRSduration (157.7±20.2 vs 140.7± 15.7 ms, P<0.001),a longer low amplitude signal duration (57.3 ±24.9 vs37.8 ± 20.3 ms P<0.001) and a lower root mean squareof the last 40 ms of the filtered QRS complex (14.3 ±11.2 vs 22.0 ± 10.5 1 P<0.01). Using conventionallate potential criteria, the sensitivity and specificity ofthe signal averaged ECG for the detection of sustained ventriculartachycardia patients with a minor conduction defect were 89%and 75%, respectively. The same criteria applied to patientswith a major conduction defect were sensitive (sensitivity:87%) but non-specific (specificity: 50%). However, by usingmodified late potential criteria, such as the presence of twoof any of the following three signal averaged parameters: filteredQRS duration 145 ms, low amplitude signal duration 50 ms,root mean square of the last 40 ms of the filtered QRS complex17.5µV, we derived a non-optimal but still acceptablecombination of sensitivity (68%) and specificity (73%). We concludethat traditional late potential criteria can be applied in patientswith a minor conduction defect, but modification of these criteriais necessary to derive useful clinical information for riskstratification of patients with a QRS complex duration 120ms.