Quantitative assessment of left ventricular function during contrast-enhanced dobutamine stress echocardiography predicts future cardiac events in diabetic patients.

BACKGROUND: Non-invasive diagnosis and risk stratification of coronary artery disease are important for the selection and optimization of therapeutic interventions in diabetic patients, which may improve survival. The aim of this study was to determine the incremental value of contrast-enhanced dobutamine stress echocardiography (CE-DSE) for risk stratification. METHODS AND RESULTS: CE-DSE was performed in 326 patients with diabetes mellitus (mean age; 66 +/- 10 years, 223 men). All patients were followed up for a mean of 29 months (1-61 months). Dobutamine was infused in a standard protocol with an intravenous contrast agent. The primary endpoints for hard cardiac events included cardiac death and nonfatal myocardial infarction. The primary endpoints for total cardiac events included hard cardiac events, unstable angina pectoris, congestive heart failure, and late coronary revascularization (> 3 months). Cardiac events occurred in 74 patients. The addition of the CE-DSE results, including abnormal left ventricular end-systolic volume response and left ventricular ejection fraction at peak stress < 50%, to the clinical and rest echocardiography model provided incremental information in predicting total cardiac events (increase in chi-square value for the model from 17 to 24, p < 0.05) and hard cardiac events (increase in chi-square value for the model from 18 to 24, p < 0.05). CONCLUSIONS: Quantitative assessment of left ventricular function during CE-DSE provides incremental prognostic information in predicting cardiac events in diabetic patients.     

Prognostic value of exercise echocardiography in 2,632 patients > or = 65 years of age

OBJECTIVES: We sought to determine the prognostic value of exercise echocardiography in the elderly. BACKGROUND: Limited data exist regarding the prognostic value of exercise testing in the elderly, a population which may be less able to exercise and is at increased risk of cardiac death. METHODS: Follow-up (2.9 +/- 1.7 years) was obtained in 2,632 patients > or = 65 years who underwent exercise echocardiography. RESULTS: There were 1,488 (56%) men and 1,144 (44%) women (age 72 +/- 5 years). The rest ejection fraction was 56 +/- 9%. Rest wall motion abnormalities were present in 935 patients (36%). The mean work load was 7.7 +/- 2.3 metabolic equivalents (METs) for men and 6.5 +/- 1.9 METs for women. New or worsening wall motion abnormalities developed with stress in 1,082 patients (41%). Cardiac events included cardiac death in 68 patients and nonfatal myocardial infarction in 80 patients. The addition of the exercise electrocardiogram to the clinical and rest echocardiographic model provided incremental information in predicting both cardiac events (chi-square = 77 to chi-square = 86, p = 0.003) and cardiac death (chi-square = 71 to chi-square = 86, p < 0.0001). The addition of exercise echocardiographic variables, especially the change in left ventricular end-systolic volume with exercise and the exercise ejection fraction, further improved the model in terms of predicting cardiac events (chi-square = 86 to chi-square = 108, p < 0.0001) and cardiac death (chi-square = 86 to chi-square = 99, p = 0.004). CONCLUSIONS: Exercise echocardiography provides incremental prognostic information in patients > or = 65 years of age. The best model included clinical, exercise testing and exercise echocardiographic variables.     

Functional and prognostic significance of exercise-induced ventricular arrhythmias in patients with suspected coronary artery disease

Our aims were to assess (1) the relation between exercise-induced ventricular arrhythmia (VA) and myocardial wall motion abnormalities during exercise echocardiography in patients with suspected coronary artery disease (CAD), and (2) the effect of this relation on outcome. We studied the clinical and prognostic significance of exercise-induced VA in 1,460 patients (mean age 64 +/- 10 years; 867 men) with intermediate pretest probability of CAD and no history of previous myocardial infarction or revascularization who underwent exercise echocardiography. Exercise-induced VA occurred in 146 patients (10%). Compared with patients without VA, those with VA had a greater prevalence of abnormal exercise echocardiographic findings (48% vs 29%, p = 0.001) and ischemia on exercise echocardiography (39% vs 22%, p = 0.001), greater increase in wall motion score index with exercise (0.14 +/- 0.28 vs 0.06 +/- 0.18, p <0.0001), and a greater percentage of abnormal segments with exercise (21 +/- 30% vs 9 +/- 19%, p <0.0001). During follow-up (median 2.7 years), cardiac death and nonfatal myocardial infarction occurred in 36 patients. In multivariate analysis of combined clinical and exercise stress test variables, independent predictors of cardiac events were exercise-induced VA (chi-square 4.7, p = 0.03) and exercise heart rate (chi-square 18, p = 0.0001). The percentage of abnormal myocardial segments with exercise echocardiography was the most powerful predictor of VA (chi-square 31, p = 0.0001) and cardiac events (chi-square 15, p = 0.0001). In patients with suspected CAD, exercise-induced VA is associated with a greater risk of cardiac death and nonfatal myocardial infarction. This risk is attributed to the relation between VA and the extent and severity of left ventricular functional abnormalities with exercise.     

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.     

Prognostic value of dobutamine stress echocardiography in patients with systemic hypertension and known or suspected coronary artery disease

Currently, there are no outcome data to suggest an incremental value of stress echocardiography in the risk stratification of patients who have hypertension after controlling for the left ventricular mass index (LVMI). This study assessed the incremental value of dobutamine stress echocardiography (DSE) for the prediction of mortality rate and cardiac events in patients who have hypertension. We studied 596 patients who had hypertension (mean age 62 +/- 12 years; 382 men) and who underwent DSE for evaluation of known or suspected coronary artery disease. End points during follow-up were hard cardiac events (cardiac death and nonfatal myocardial infarction) and total mortality rate. Left ventricular hypertrophy was detected by echocardiography in 119 patients (20%). During a median follow-up of 3 years, 101 patients (17%) died (43 cardiac deaths) and 19 patients had nonfatal myocardial infarction. In an incremental multivariate analysis model, clinical predictors of hard cardiac events were age, history of congestive heart failure, and LVMI. The percentage of abnormal myocardial segments examined with DSE was incremental to the clinical model (chi square 41 vs 27, p <0.001). Clinical predictors of total mortality rate were age, smoking, hypercholesterolemia, history of congestive heart failure, and LVMI. The peak wall motion score index was incremental to the clinical model (chi square 45 vs 40, p <0.05). DSE provides incremental data for the prediction of mortality rate and hard cardiac events in patients who have hypertension after adjustment for clinical data and LVMI.     

Prognostic value of exercise echocardiography in 5,798 patients: is there a gender difference?

OBJECTIVES: This study was designed to determine the effect of gender on the prognostic value of exercise echocardiography. BACKGROUND: Limited information exists regarding gender differences in prognostic value of exercise echocardiography. METHODS: We obtained follow-up (3.2 +/- 1.7 years) in 5,798 consecutive patients who underwent exercise echocardiography for evaluation of known or suspected coronary artery disease. RESULTS: There were 3,322 men (mean age 62 +/- 12 years) and 2,476 women (mean age 62 +/- 12 years) (p = 0.7). New or worsening wall motion abnormalities developed with exercise in 35% of men and 25% of women (p = 0.001). Cardiac events, including cardiac death (107 patients) and nonfatal myocardial infarction (148 patients), occurred in 5.3% of men and 3.1% of women (p = 0.001). Addition of the percentage of ischemic segments to the clinical and rest echocardiographic model provided incremental information in predicting cardiac events for both men (chi(2) = 137 to 143, p = 0.014) and women (chi(2) = 72 to 76, p = 0.046). By multivariate analysis, exercise electrocardiographic and exercise echocardiographic predictors of cardiac events in both men and women were workload and exercise wall motion score index. There was no significant interaction effect of rest echocardiography (p = 0.79), exercise electrocardiography (p = 0.38) or exercise echocardiography (p = 0.67) with gender. CONCLUSIONS: Although cardiac events occurred more frequently in men, the incremental value of exercise echocardiography was comparable in both genders. Of all exercise electrocardiographic and exercise echocardiographic variables, workload and exercise wall motion score index had the strongest association with outcome. The results of exercise echocardiography have comparable implications in both men and women.     

Prognostic value of exercise echocardiography in patients with classic angina pectoris

The role of stress echocardiography in the prognostic evaluation of patients with angina pectoris is not well defined. This study included 437 patients (241 men and 196 women) with angina pectoris and a pretest probability of coronary artery disease (CAD) of > or = 0.7 who were referred for exercise echocardiography. No patient had a history of acute myocardial infarction or coronary revascularization. Mean age was 65 +/- 10 years. During a median follow-up of 2.7 years, hard cardiac events (cardiac death or nonfatal myocardial infarction) occurred in 19 patients and 53 patients underwent coronary revascularization. Event-free survival rates in patients with normal versus abnormal stress echocardiograms were 98% versus 83% at 1 year, 96% versus 75% at 3 years, and 87% versus 69% at 5 years, respectively. In a multivariate analysis of clinical, exercise stress, and echocardiographic parameters, independent predictors of hard cardiac events were Q waves on the electrocardiogram (chi-square 8.7, p = 0.003) and the presence of wall motion abnormalities during exercise in multivessel distribution (chi-square 5.3, p = 0.02). In an incremental model of clinical, exercise, and echocardiographic variables for the prediction of all cardiac events, the addition of echocardiographic data increased the chi-square of the model from 62 to 78 (p = 0.0003). Exercise echocardiography provides useful information in the risk stratification of patients with suspected CAD and a high pretest probability of CAD. Patients with normal exercise echocardiograms have a low event rate and therefore can be exempted from invasive procedures during the 3 years after a normal exercise echocardiogram.     

Prognostic value of stress echocardiogram in patients with angiographically significant coronary artery disease

The purpose of this study was to evaluate the prognostic value of stress echocardiography in patients with angiographically significant coronary artery disease (CAD). Two hundred sixty patients (mean age 63 ± 10 years, 58% men) who underwent stress echocardiography (41% treadmill, 59% dobutamine) and coronary angiography within 3 months and without intervening coronary revascularization were evaluated. All patients had significant CAD as defined by coronary stenosis ≥70% in major epicardial vessels or branches (45% had single-vessel disease, and 55% had multivessel disease). The left ventricle was divided into 16 segments and scored on a 5-point scale of wall motion. Patients with abnormal results on stress echocardiography were defined as those with stress-induced ischemia (increase in wall motion score of ≥1 grade). Follow-up (3.1 ± 1.2 years) for nonfatal myocardial infarction (n = 23) and cardiac death (n = 6) was obtained. In patients with angiographically significant CAD, stress echocardiography effectively risk stratified normal (no ischemia, n = 91) in contrast to abnormal (ischemia, n = 169) groups for cardiac events (event rate 1.0%/year vs 4.9%/year, p = 0.01). Multivariate logistic regression analysis identified multivessel CAD (hazard ratio 2.53, 95% confidence interval 1.16 to 5.51, p = 0.02) and number of segments in which ischemia was present (hazard ratio 4.31, 95% confidence interval 1.29 to 14.38, p = 0.01) as predictors of cardiac events. A Cox proportional-hazards model for cardiac events showed small, significant incremental value of stress echocardiography over coronary angiography (p = 0.02) and the highest global chi-square value for both (p = 0.004). In conclusion, in patients with angiographically significant CAD, (1) normal results on stress echocardiography conferred a benign prognosis (event rate 1.0%/year), and (2) stress echocardiographic results (no ischemia vs ischemia) added incremental prognostic value to coronary angiographic results, and (3) stress echocardiography and coronary angiography together provided additive prognostic value, with the highest global chi-square value.     

Risk stratification and prognosis in octogenarians undergoing stress echocardiographic study

BACKGROUND: The prognostic value of stress echocardiography (SE) for the diagnosis and risk stratification of coronary artery disease in octogenarians is not well defined. METHODS: Follow-up of 5 years (mean 2.9 +/- 1.0 years) for confirmed nonfatal myocardial infarction (n = 17) and cardiac death (n = 37) was obtained in 335 patients, age > or =80 years (mean age 84 +/- 3 years, 44% male), undergoing SE (33% treadmill, 67% dobutamine). Left ventricular (LV) regional wall motion was assessed by a consensus of two echocardiographers and scored as per standard five-point scale, 16-segment model of wall motion analysis. Ischemic LV wall segment was defined as deterioration in the thickening and excursion during stress (increase in wall-motion score index (WMSI) > or =1). RESULTS: By univariate analysis, inducible ischemia (chi-square = 38.4, P < 0.001), left ventricular ejection fraction (chi-square = 41.2, P < 0.001), a history of previous myocardial infarction (chi-square = 22.3, P < 0.01), hypertension (chi-square = 33, P < 0.01), and age (chi-square = 27.7, P < 0.01) were significant predictors of future cardiac events. WMSI, an index of inducible ischemia, provided incremental prognostic information when forced into a multivariable model where clinical and rest echocardiography variables were entered first. WMSI effectively stratified octogenarians into low- and high-risk groups (annualized event rates of 1.2 versus 5.8%/year, P < 0.001). CONCLUSIONS: Stress echocardiography yields incremental prognostic information in octogenarians and effectively stratifies them into low- and high-risk groups. Precise therapeutic decision making in very elderly patients should incorporate combined clinical and stress echocardiography data.     

Prognostic value of combined perfusion and function by stress technetium-99m sestamibi gated SPECT myocardial perfusion imaging in patients with suspected or known coronary artery disease

The incremental prognostic value of combined regional wall motion and perfusion over perfusion alone by gated single-photon emission computed tomographic myocardial perfusion scintigraphy has not been evaluated. Of the 402 consecutive patients who underwent stress single-photon emission computed tomographic myocardial perfusion scintigraphy for suspected myocardial ischemia, we identified 333 patients (217 men, mean age 63 +/- 10 years; exercise in 249 and dipyridamole adminstered to 84). Visual scoring of perfusion images and regional wall motion used 20 segments and a scale of 0 to 4. Resting and poststress left ventricular ejection fraction was automatically generated. On follow-up (median 13 months), 30 hard cardiac events (17 cardiac deaths, 13 nonfatal acute myocardial infarctions) and 66 total cardiac events (including hard events, 26 with unstable angina, and 10 who underwent late revascularization) occurred. After adjustment for prescan information, the best independent predictors of hard events were summed stress score for wall motion (Wald's chi-square 8.3, p <0.004) and several vascular territories with ischemia by perfusion/function (Wald's chi-square 6.2, p <0.01). The strongest predictors of all cardiac events were the number of ischemias (Wald's chi-square 32.1, p <0.0001) and the number of ischemic vascular territories by perfusion (Wald's chi-square 13.1, p <0.0001). Addition of function data to the combined model of perfusion data yielded an incremental value of 26% for predicting hard events but not for all events. In conclusion, the assessment of combined perfusion/function provides incremental prognostic information for further hard events with perfusion data alone; perfusion data best predict all cardiac events.     

Prognostic stratification of diabetic patients by exercise echocardiography

OBJECTIVES: The aim of this study was to assess the incremental value of exercise echocardiography for the risk stratification of diabetic patients. BACKGROUND: There are currently insufficient outcome data in diabetic patients to define the role of stress echocardiography as a prognostic tool. METHODS: We studied the prognostic value of exercise echocardiography in 563 patients with diabetes mellitus (mean age 64 +/- 11 years, 336 men) and known or suspected ischemic heart disease (IHD). RESULTS: Cardiac events occurred in 50 patients (cardiac death in 23 and nonfatal myocardial infarction [MI] in 27) during a median follow-up period of three years. Event rate was lower in patients with normal as compared to those with abnormal exercise echocardiography at one year (0% vs. 1.9%), three years (1.8% vs. 11.9%), and five years (7.6% vs. 23.3%), respectively (p = 0.0001). Patients with multivessel distribution of echocardiographic abnormalities had the highest event rate (2.9% at one year, 15.2% at three years, and 32.8% at five years). In an incremental multivariate analysis model, exercise echocardiography increased the chi-square of the clinical and exercise ECG model from 29 to 44.8 (p = 0.0001). CONCLUSIONS: Exercise echocardiography provides incremental data for risk stratification of diabetic patients with known or suspected IHD. Patients with a normal exercise echocardiogram have a low event rate. Patients with multivessel distribution of exercise echocardiographic abnormalities are at the highest risk of cardiac events, as one-third of these patients experience cardiac death or nonfatal MI during the five years following exercise echocardiography.     

Relation of QRS duration on the surface 12-lead electrocardiogram with mortality in patients with known or suspected coronary artery disease

The aim of this study was to assess the relation between QRS duration and mortality in patients with known or suspected coronary artery disease, after adjustment for myocardial functional abnormalities, as assessed by exercise echocardiography. We studied 4,033 patients (age 62 +/- 12 years; 2,360 men, 18% with previous myocardial infarction) who underwent symptom-limited exercise echocardiography. The QRS duration was electronically measured from the 12-lead electrocardiogram. The incremental value of the QRS duration for predicting mortality was assessed by adding the QRS duration at the end of each of these modeling steps: clinical data, exercise electrocardiographic, and exercise echocardiographic variables. The QRS duration correlated positively with age, the wall motion score index at rest, and percentage of ischemic segments and negatively with workload (p = 0.0001). Of the 4,033 patients, 252 died during a median follow-up of 3 years. The QRS duration was univariately associated with an increased risk of death (relative risk 8.5, 95% confidence interval CI 4.4 to 16.4, p <0.0001). In an incremental multivariate model, the clinical predictors of mortality were age, male gender, previous infarction, and diabetes mellitus (chi-square 122). Workload was incremental to clinical data in the exercise test model (chi-square 193, p <0.0001). The exercise wall motion score index was incremental to both models (chi-square 211, p <0.001). The QRS duration was associated with an incremental risk of death when added to the clinical model (chi-square 133, p = 0.009), exercise test model (chi-square = 203, p = 0.002), and echocardiographic model (chi-square = 216, p = 0.03). A QRS duration > or =105 ms best identified patients at increased risk. In conclusion, QRS duration is associated with an increased risk of death, even after adjustment for clinical factors, exercise capacity, left ventricular function, and exercise-induced myocardial ischemia.     

Prognostic Implications of Exercise Echocardiography in Women With Known or Suspected Coronary Artery Disease

Objectives. The purpose of this study was to define the value of exercise echocardiography as an independent predictor of cardiac events in women with known or suspected coronary artery disease (CAD), incremental to the data provided by clinical evaluation and exercise testing.Background. Exercise echocardiography is more accurate than exercise electrocardiography for the identification of CAD in women. However, the prognostic implications of exercise echocardiography, especially relative to exercise electrocardiography, are undefined.Methods. Symptom-limited exercise echocardiography was performed in 549 consecutive women between 1989 and 1993. Echocardiography and electrocardiography were performed before and after treadmill exercise; an abnormal result on exercise electrocardiography was defined by ST segment depression >0.1 mV, ischemia by exercise echocardiography as a new or worse wall motion abnormality after exercise and scar by akinesia or dyskinesia at rest. After exclusion of six patients with uninterpretable studies (1%) and 35 (6%) lost to follow-up, 508 women (mean [±SD] age 55 ± 11 years) were followed up for 41 ± 10 months for cardiac-related death, infarction or late revascularization.Results. The group attained 92 ± 10% of age-predicted maximal heart rate, with an exercise capacity of 7 ± 2 metabolic equivalents. Of 420 women with an interpretable electrocardiogram, significant ST segment changes were present in 68 (16%). Results of exercise echocardiography were normal in 413 (81%) women, positive for ischemia in 66 (13%) and scar only in 29 (6%). No events occurred in 444 patients (89%), and 19 underwent primary revascularization (within 3 months of exercise test). Cardiac events occurred in 36 women (7%), including 17 who died of cardiac causes and 19 who had a myocardial infarction or required late revascularization for progressive symptoms. On univariate analysis, the variables associated with cardiac mortality and total cardiac events were a history of CAD, diabetes, left ventricular hypertrophy, exercise capacity and echocardiographic evidence of myocardial ischemia and infarction. A Cox proportional hazards model showed the independent predictors of outcome to be known CAD (odds ratio [OR] 6.6, 95% confidence interval [CI] 3.2 to 13.7, p < 0.00001) and echocardiographic ischemia (OR 4.3, 95% CI 2.1 to 8.7, p < 0.0001). The prognostic value of exercise echocardiography incremental to clinical and exercise variables was demonstrated using sequential Cox models.Conclusions. In this large cohort of women, exercise echocardiography provided key prognostic information incremental to clinical and exercise testing data.     

Significance of echocardiographic atrioventricular plane displacement for the evaluation of left ventricular filling and end-diastolic pressure in patients with coronary artery disease

The aim of this study is to assess the left ventricular filling and estimate the end-diastolic pressure of the left ventricle in patients with coronary artery disease (CAD) by echocardiographic measurement of the atrioventricular plane displacement (AVPD). In 101 patients (mean age 59 ±12 years) with CAD, a complete transthoracic echocardiographic study was performed, just prior to cardiac catheterization. The AVPD was recorded by Mmode echocardiography, from apical four and two chamber views. The recordings were obtained at four sites, corresponding to the septal, lateral, anterior and inferior walls of the left ventricle. The mean AVPD resulting from atrial systole (At), the mean total (T) diastolic AVPD, the ratio At/T(%) and the ratio of mitral annulus excursion during early and late diastole [(T-At)/At] were calculated. Firty-two age-matched healthy subjects served as control group. Both At and At/T were significantly greater in patients with CAD than in the controls (6.06 ±0.94 vs 5.53 ±0.55 mm, p<0.01 and 43.4 ±5.9% vs 33.49 ±4.45%, p<0.001 respectively). The ratio [(T-At)/At] correlated with the E/A ratio of transmitral flow, both in healthy subjects (r=0.850, p<0.001) and in patients with CAD (r = 0.722, p<0.001). Correlation also existed both in patients with segmental wall motion abnormality (SWMA) (r = 0.691, p<0.001) and in patients with SWMA (r=0.818, p<0.001). In patients with CAD, At/T further correlated with the left ventricular end-diastolic pressure (r=0.517, p<0.001). In patients with SWMA and in patients without, a correlation was also found (r=0.516, p<0.001 and r=0.566, p<0.001 respectively). In conclusion, AVPD measured by echocardiography can be used as a simple noninvasive parameter to evaluate left ventricular filling in patients with CAD and for the gross estimation of end-diastolic pressure of left ventricle.     

Sex, clinical symptoms, and angiographic findings in patients with diabetes mellitus and coronary artery disease (from the Bypass Angioplasty Revascularization Investigation [BARI] 2 Diabetes trial)

Previous studies have reported differences in presenting symptoms and angiographic characteristics between women and men undergoing evaluation for suspected coronary artery disease (CAD). We examined the relation between symptoms and extent of CAD in patients with type 2 diabetes mellitus and known CAD enrolled in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Of 1,775 patients (533 women, 30%, and 1,242 men, 70%), women were more likely than men to have angina (65% vs 56%, p <0.001) or an atypical angina/anginal equivalent (71% vs 58%, p <0.001). More women reported unstable angina (17% vs 13%, p = 0.047) or were in a higher Canadian Cardiology Society class compared to men (Canadian Cardiology Society classes II to IV 78% vs 68%, p = 0.002). Fewer women than men had no symptoms (14% vs 22%, p <0.001). Women had a lower mean myocardial jeopardy index (42.5 ± 24.3 vs 47.9 ± 24.3, p <0.001), smaller number of total significant lesions (2.3 ± 1.7 vs 2.7 ± 1.8, p <0.001), and fewer jeopardized left ventricular regions (p <0.001 for distribution) or long-term occlusions (29% vs 42%, p <0.001). After adjustment for relevant covariates, the odds of having CAD symptoms were still higher in women than men (odds ratio for angina 1.31, 95% confidence interval 1.02 to 1.69; odds ratio for atypical angina 1.52, 95% confidence interval 1.17 to 1.96). In conclusion, in a high-risk group of patients with known CAD and diabetes mellitus, women were more symptomatic than men but had less obstructive CAD. These data suggest that factors other than epicardial CAD severity influence symptom presentation in women in this population.     

Prognostic importance of wall motion abnormalities in patients with ischemic cardiomyopathy and an implantable cardioverter-defibrillator

Patients with extensive regional wall motion abnormalities are predisposed to development of ventricular tachyarrhythmia. The prognostic effect of this in patients with an implantable cardioverter-defibrillator (ICD) and coronary artery disease (CAD) is not known. Echocardiographic left ventricular systolic indexes, wall motion score index (WMSI), and extent of regional akinesia in 140 patients (65 +/- 10 years old; 92% men) with an ICD and CAD were studied. Arrhythmic events requiring ICD therapy and causing death (n = 41, 29%) were recorded over a mean follow-up of 1.4 +/- 0.8 years. Left ventricular basal fractional shortening, ejection fraction, global WMSI, and extent of akinesia, especially in the inferoposterior regions of a right coronary artery territory, were univariate predictors (all p values <0.05). Global WMSI (hazard ratio 2.18, 95% confidence interval 1.03 to 4.65, p = 0.04) and fractional shortening (hazard ratio 0.93, 95% confidence interval 0.88 to 1.00, p = 0.04) were multivariate predictors. Global WMSI (p = 0.04) and > or =2 right coronary region akinetic segments (p = 0.05) provided incremental risk prediction to left ventricular ejection fraction in a global risk-assessment model (chi-square p = 0.001). Presence of right coronary region akinesia better identified those at increased risk of events (p = 0.02) compared with the presence of left anterior descending region akinesia (p = 0.2), independent of systolic function. In conclusion, global WMSI and left ventricular basal fractional shortening were important additional risk predictors of ICD events in CAD. Global WMSI and right coronary region inferoposterior akinesia provided independent and incremental risk assessment to left ventricular ejection fraction and improved identification of those at increased risk of ICD-related events in patients with ischemic cardiomyopathy.     

The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis.

OBJECTIVES: The purpose of this work was to determine the prognostic value of normal exercise myocardial perfusion imaging (MPI) tests and exercise echocardiography tests, and to determine the prognostic value of these imaging modalities in women and men. BACKGROUND: Exercise MPI and exercise echocardiography provide prognostic information that is useful in the risk stratification of patients with suspected coronary artery disease (CAD). METHODS: We searched the PubMed, Cochrane, and DARE databases between January 1990 and May 2005, and reviewed bibliographies of articles obtained. We included prospective cohort studies of subjects who underwent exercise MPI or exercise echocardiography for known or suspected CAD, and provided data on primary outcomes of myocardial infarction (MI) and cardiac death with at least 3 months of follow-up. Secondary outcomes (unstable angina, revascularization procedures) were abstracted if provided. Studies performed exclusively in patients with CAD were excluded. RESULTS: The negative predictive value (NPV) for MI and cardiac death was 98.8% (95% confidence interval [CI] 98.5 to 99.0) over 36 months of follow-up for MPI, and 98.4% (95% CI 97.9 to 98.9) over 33 months for echocardiography. The corresponding annualized event rates were 0.45% per year for MPI and 0.54% per year for echocardiography. In subgroup analyses, annualized event rates were <1% for each MPI isotope, and were similar for women and men. For secondary events, MPI and echocardiography had annualized event rates of 1.25% and 0.95%, respectively. CONCLUSIONS: Both exercise MPI and exercise echocardiography have high NPVs for primary and secondary cardiac events. The prognostic utility of both modalities is similar for both men and women.     

Prognostic impact of plasma brain natriuretic peptide for cardiac events in elderly patients with congestive heart failure

BACKGROUND: Plasma brain natriuretic peptide (BNP) has been reported to be useful in determining the prognosis of patients with ischemic heart disease and cardiomyopathy. However, aging increases the level of plasma BNP; therefore, the prognostic impact of plasma BNP in elderly patients with congestive heart failure has not been fully established. OBJECTIVE: We sought to determine whether plasma BNP could predict recurrent cardiac events in elderly patients with congestive heart failure. METHODS: Forty-eight consecutive elderly patients (>65 years old) were enrolled in the present study. All patients were admitted with their first episode of congestive heart failure. Clinical characteristics, plasma BNP, left ventricular ejection fraction, and left ventricular mass index were compared between patients with and those without recurrent cardiac events. RESULTS: During the follow-up period, twelve cardiac events were observed. The New York Heart Association functional class was signi- ficantly higher in patients with cardiac events than in those without (p < 0.05). The plasma BNP level in pa- tients with cardiac events was significantly higher than in those without (521.0 +/- 156.0 vs. 126.8 +/- 20.1 pg/ml, p<0.001), despite more frequent treatment with angiotensin-converting enzyme inhibitors (75 vs. 28%, p<0.05). The left ventricular ejection fraction was significantly lower and the left ventricular mass index higher in patients with cardiac events as compared with those without (38.1 +/- 5.0 vs. 49.2 +/- 2.4%, p < 0.05; 193.8 +/- 14.3 vs. 132.6 +/- 7.8 g/m(2), p < 0.001, respectively). The plasma BNP was selected as an independent factor associated with cardiac events besides New York Heart Association functional class, left ventricular ejection fraction, and left ventricular mass index using multivariate Cox proportional-hazards regression analysis (hazard ratio = 2.656, p<0.05). The cardiac event rate was significantly higher in patients with a plasma BNP concentration >132 pg/ml using Kaplan-Meier analysis (p < 0.001). Moreover, the plasma BNP level correlated inversely with the length of time from hospital discharge to a cardiac event (r = -0.575, p<0.05). CONCLUSION: Measuring the plasma BNP level before hospital discharge in elderly patients with congestive heart failure was more useful than other conventional examinations for predicting the recurrence of cardiac events.     

Novel stress echocardiographic model incorporating the extent and severity of wall motion abnormality for risk stratification and prognosis

The prognostic value of stress echocardiography to predict future cardiac events using the extent and severity of wall motion abnormalities is not well defined. The objective of this study was to develop and validate a prognostic model for interpretation of stress echocardiographic studies by using the extent and severity of wall motion abnormalities. We evaluated 1,500 patients (59 +/- 13 years old; 51% men) who underwent stress echocardiography (34% on the treadmill exercise and 66% on dobutamine). Left ventricular regional wall motion was assessed by consensus of 2 experienced echocardiographers. Follow-up periods (mean 2.7 +/- 1.0 years) for confirmed myocardial infarction (n = 31) and cardiac death (n = 44) were identified. Multivariate regression analysis identified 2 independent predictors of cardiac events: the number of left ventricular wall segments with new wall motion abnormalities (an index of the extent of ischemia) and the maximal magnitude of new wall motion abnormalities (an index of the severity of ischemia). The ischemic extent (chi-square 48.7, p <0.0001) and maximal severity (chi-square 52.0, p <0.0001) were exponentially correlated with an increase in event rate. On the basis of these data, a prognostic model was defined that uses ischemic extent and maximal severity as stress-dependent orthogonal variables. With this 3-dimensional model, the predicted event rate ranged over sevenfold, from a low of 0.9%/year in patients without any wall motion abnormalities to a high of 6.7%/year in patients with extensive and severe wall motion abnormalities. The extent and severity of wall motion abnormalities by stress echocardiography are independent and cumulative predictors of prognosis in patients who have suspected or known ischemic heart disease.