Prognostic value of pharmacological stress echocardiography in diabetic patients.

Our study was undertaken to assess the prognostic significance of pharmacological stress echocardiography in 325 diabetic patients. Pharmacological stress echocardiography was performed for diagnosis of coronary artery disease in 128 patients, and for risk stratification in 197 patients. Follow-up was 34 months. Cardiac-related death and non-fatal myocardial infarction were considered hard events. During the follow-up period, there were 38 deaths and 23 acute non-fatal myocardial infarctions. By univariate analysis, a pharmacological stress echocardiography positive response for ischaemia indicated an increased risk of cardiovascular death. However, by multivariate analysis, advanced age and peak ejection fraction <40% were the only independent predictors of cardiac death. The same peak ejection fraction (EF) <40%, rest wall motion score index and previous myocardial infarction were independent predictors of hard events. After dividing the population into two subgroups on the basis of EF at rest, only a peak EF <40% and a pharmacological stress echocardiography positive test were powerful independent predictors of cardiovascular mortality.     

Prognostic value of predischarge dobutamine stress echocardiography in chest pain patients with a negative cardiac troponin T

OBJECTIVES: We prospectively studied the prognostic value of predischarge dobutamine stress echocardiography (DSE) in low-risk chest pain patients with a normal or nondiagnostic electrocardiogram (ECG) and a negative serial troponin T. BACKGROUND: Noninvasive stress testing is recommended before discharge or within 72 h in patients with low-risk chest pain. The prognostic value of immediate DSE has not been studied in a blinded, prospective fashion. METHODS: Patients presenting at the emergency room within 6 h of symptom onset and a normal or nondiagnostic ECG were eligible. Dobutamine stress echocardiography was performed after unstable coronary artery disease was ruled out by a standard rule-out protocol and a negative serial troponin T; the occurrence of any new wall motion abnormality was considered positive. Results were kept blinded. End points were cardiac death, myocardial infarction, rehospitalization for unstable angina or revascularization. RESULTS: In total, 377 patients were included. There were 2 deaths, 2 myocardial infarctions, 8 rehospitalization for unstable angina, and 10 revascularizations at six-month follow-up. The end points occurred in 8/26 (30.8%) patients with a positive versus 14/351 (4.0%) patients with a negative DSE (odds ratio, 10.7; 95% confidence interval, 4.0 to 28.8; p < 0.0001). By multivariate analysis, DSE remained a predictor of end points (p < 0.0001). CONCLUSIONS: A predischarge DSE had important, independent prognostic value in low-risk, troponin negative, chest pain patients.     

Prognostic value of echocardiographic finding of valvular vegetations in patients with infectious endocarditis

42 consecutive patients with infective endocarditis on native valves, according to Pelletier and Petersdorf's criteria of definite (13 pts), probable (12 pts.) and possible (17 pts) endocarditis, were identified and prospectively followed-up with M-mode and two-dimensional echocardiography, since 1980. We compared: 1) these three groups; 2) survivors not referred for surgery versus surgical patients plus nonsurvivors; 3) patients who suffered embolic events versus those who did not; 4) patients with severe-moderate heart failure versus those with no failure or mild failure; 5) patients with aortic valve echocardiographic vegetations versus those with mitral valve vegetations. Furthermore 11 of these patients who did not undergo surgery (9 with mitral and 2 with mitro-aortic vegetations on echo) were serially followed-up with echocardiography for 6-42 months (average: 32 months). The presence of ultrasound detectable vegetations itself and their size, without considering their site, did not identify a major risk of embolization, heart failure, death or need of surgery. The site of vegetations was the only significant feature in our series. It identified a high-risk group and a relatively low-risk group. Aortic valve involvement, with echocardiographic vegetations, was related to severe or moderate heart failure (P less than 0.01), death or need of surgery (P less than 0.05). Mitral valve involvement carried on a relatively low risk. The 9 patients with mitral valve vegetations only, not referred for surgery and followed-up, did well on medical treatment and returned to work. They did not have relapses or embolization. On serial echocardiographic examinations, mitral vegetations become smaller in the long run. Two years after the acute episode, usually echocardiography did not allow identification of vegetations.     

Prognostic value of preoperatively determined end-systolic left ventricular diameter in patients with chronic aortic insufficiency--an echocardiographic study

Serial echocardiographic studies of Henry et al. (Circulation 61, 471 [1980]) in patients with chronic aortic regurgigation (AR) indicate that preoperative left ventricular end-systolic dimension (ESD) greater than 55 mm and fractional shortening (FS) less than 25% may identify patients with reduced postoperative survival. We retrospectively analyzed the onedimensional echocardiograms of 33 patients with AR without coronary artery disease who underwent operation from 1977 to 1981. Twenty-three patients with ESD less than or equal to 55 mm (group A, mean age 48 +/- 10 years) were followed 36 +/- 14 months postoperatively, ten patients with ESD greater than 55 mm (group B, eight patients with FS less than 25%; mean age 48 +/- 12 years) 40 +/- 10 months. In both groups there were no perioperative or late deaths. In group A the average preoperative NYHA functional class decreased from 2.6 to 1.4 postoperatively, in group B from 3.0 to 1.5 (A vs. B: NS). Preoperative FS was 35 +/- 8% in group A and 22 +/- 3% in group B, preoperative ESD 44 +/- 5 mm in group A and 62 +/- 7 in group B. Three years after operation, end-diastolic dimension was 54 +/- 8 mm compared with 68 +/- 5 mm preoperatively in group A (p less than 0.001) and 61 +/- 11 mm compared to 79 +/- 8 mm preoperatively in group B (p less than 0.001). According to these data, a significant postoperative decrease of end-diastolic dimension can be expected in most patients with AR and ESD greater than 55 mm. The long-term prognosis of this subgroup is not so impaired as to recommend aortic valve replacement to asymptomatic patients a priori.     

Coronary artery disease screening in type II diabetic patients: Prognostic value of rest and stress echocardiography

Aim:Presence of inducible ischemia in type II diabetic patients is associated with an adverse outcome, but less is known about prognostic value of resting wall motion abnormalities (WMA).Materials and methods: From October 2006 to May 2008, 278 patients underwent to CAD screening, according to ADA criteria, by dobutamine stress echocardiography (DSE). Between July and September 2009, all patients were contacted to verify the occurrence of new cardiac events.ResultsResting-WMA were present in 63 patients; 88 subjects showed inducible ischemia. During the follow-up, we observed 24 new cardiac events; patients with a good outcome showed less frequently resting WMA (19 vs 50%). Inducible ischemia (71% vs 28%; p < 0.001) and a more extensive area of inducible ischemia, expressed by a higher value of peak WMSI (1.63 ± 0.45 vs 1.17 ± 0.31; p < 0.0001), were more frequent in patients with adverse outcome. A Cox regression analysis showed that only a higher peak WMSI (HR 6.645, 95% CI 2.782–15.874, p < 0.0001) was associated with a bad outcome. Event-free survival was lower in presence of rest WMA (79% vs 94%, p < 0.0001) and a higher peak WMSI (66% vs 95%, p < 0.0001).ConclusionsIn diabetic patients presence of an extensive inducible ischemia was independently associated with a worst outcome; resting WMA were associated with reduced event-free survival.     

Prognostic value of tissue Doppler echocardiographic imaging in elderly patients with acute myocardial infarction

Background: The ratio of mitral end‐diastolic velocity and mitral annular early diastolic motion velocity (E/e’) has predictive value in patients with acute coronary syndromes (ACS). Both E and e’ velocities change with age. The prognostic value of E/e’ in elderly patients with ACS has not been established yet. The aim of the study was to assess the prognostic significance of E/e’ in patients over 65 with ACS. Method: The study involved 168 patients, mean age 79 years. Echocardiography was performed within first 24 hours of ACS. Clinical evaluation, 6‐minute walk test, echocardiography and plasma level of NT pro‐BNP were performed 12 months later. Results: Patients, who were still alive after 1‐year follow‐up had significantly lower E/e’ during hospitalization: 11.1 ± 3 versus 15.1 ± 5 (P < 0.05). The optimal cutoff value of E/e’ differentiating survivors and nonsurvivors after 12 month follow‐up was 12. Initial E/e’ was an independent predictor of mortality during 1‐year follow‐up. E/e’ ratio during hospitalization significantly correlated with NT pro‐BNP concentration (r = 0.48, P < 0.001) and 6‐minute walking distance: (r =–0.32, P < 0.05) after 1‐year follow‐up. Conclusions: (1) In patients over 65 with myocardial infarction, E/e’ above 12 is an independent predictor of death during 1‐year follow‐up. (2) E/e’ ratio in acute phase of myocardial infarction correlated significantly with N pro‐BNP level and 6‐minute walking distance after 1‐year follow‐up. (Echocardiography 2011;28:298‐302)     

Prognostic value of serum liver enzymes levels in type 2 diabetic patients

BACKGROUND: Elevated liver enzymes are associated with cardiovascular disease, while their relationship with cancer-related mortality has not been assessed so far in diabetic patients. METHODS: An observational cohort study was performed on a consecutive series of 1952 type 2 diabetic patients. The association of liver enzymes with all-cause and cause-specific mortality was assessed. Information on all-cause mortality was obtained by the City of Florence Registry Office. RESULTS: The average duration of follow-up was 6.4 +/- 2.7 years. Over that period, 362 deaths were recorded (26.9%), with a yearly mortality rate of 4.2%. Age- and sex-adjusted HR of all-cause mortality for gamma glutamyl-transpeptidase (gamma-GT) gamma-GT > 40 U/l was 1.610 [1.245-2.082]. An increased cardiovascular mortality rate was observed in patients with elevation of gamma-GT, and gamma-GT and/or alanine aminotransferase (ALT), when compared with the rest of the sample (15.3 vs 10.8%, p < 0.05; and 15.2 vs 10.7%, p < 0.05, respectively). Similar results were observed when considering cancer-related mortality.The association of higher gamma-GT levels with all-cause, cardiovascular, and cancer-related mortality was confirmed at a multivariate analysis after adjustment for potential confounders. CONCLUSIONS: The present study shows that, in type 2 diabetic patients, higher gamma-GT, but not ALT, is associated with increased mortality for cardiovascular disease and malignancies.     

Prognostic value of pharmacological stress echocardiography in diabetic and nondiabetic patients with known or suspected coronary artery disease.

OBJECTIVES: We sought to compare the prognostic value of pharmacological stress echocardiography (SE) in diabetic and nondiabetic patients with known or suspected coronary artery disease. BACKGROUND: Although SE is a useful tool for risk stratification of patients with diabetes, it has not been established whether it retains the same prognostic information in diabetic patients compared with nondiabetic patients. METHODS: A total of 5,456 patients (749 diabetics) undergoing dipyridamole (n = 3,306) or dobutamine (n = 2,150) SE were prospectively followed up for the occurrence of hard events (death and/or nonfatal myocardial infarction). RESULTS: During a median time of 31 months, 411 deaths and 236 infarctions occurred. There were 132 events in diabetic patients and 515 in nondiabetic patients (18% vs. 11%, respectively; p < 0.0001). Moreover, 1,607 (29%) patients underwent coronary revascularization and were censored. Ischemia at SE, resting wall motion score index, and age were independent predictors of death and hard events in both diabetic and nondiabetic patients. Compared with a normal test, ischemia and scar test patterns were associated to significantly lower age-corrected five-year hard event-free survival in diabetic as well as nondiabetic patients. However, a normal test was associated with a greater than two-fold annual event rate in diabetic patients as compared with nondiabetics who were either younger (2.6% vs. 1.0%) or older (5.5% vs. 2.2%) than 65 years of age. CONCLUSIONS: Stress echocardiography is equally effective in risk stratifying diabetic and nondiabetic patients independently of age. However, the normal test result predicts a less favorable outcome in diabetic than in nondiabetic patients.     

Prognostic value of negative dobutamine stress echo in women with intermediate probability of coronary artery disease

Women with an intermediate pretest probability of coronary artery disease represent a significant proportion of patients referred for the investigation of chest pain. Dobutamine stress echocardiography can be used to restratify these patients into a low-risk group without resorting to cardiac catheterization.     

Prognostic value of C-reactive protein in patients with stress induced myocardial ischemia

OBJECTIVE: Inflammation plays a critical role in the pathogenesis of atherosclerosis. Possible association between C-reactive protein (CRP), stress-induced myocardial ischemia and clinical outcome was investigated. DESIGN, PATIENTS AND RESULTS: We correlated scintigraphic scan and CRP values of 101 consecutive out-patients who performed an exercise stress test for evaluation of chest pain (n=49) or scheduled control after myocardial infarction (n=52). CRP levels were determined before and after exercise. Twenty-three patients had reversible defects and presented CRP levels [mean (S.D.) 5.6 (3.3) mg/l] greater than subjects with fixed [mean (S.D.) 4.6 (4.5) mg/l] or no [mean (S.D.) 2.8 (2.9) mg/l] defects. Odds ratio for the association between high (3rd, tertile, >4.7 mg/l) CRP levels and reversible defects was 5.6 (95% CI 1.6 to 20; p=0.009). During a follow-up of 2.3 (0.7) years, 18 patients reached a clinical end-point consisting in one Q-wave myocardial infarction, eight non-Q-wave myocardial infarction or unstable angina and nine percutaneous coronary interventions. When the impact of different risk factors on the development of clinical endpoint was evaluated, the hazard ratio associated with high CRP levels was 11.0 (95% CI 3.0 to 41; p<0.001). CONCLUSIONS: These findings suggest that in ambulatory patients, high CRP levels may predict exercise-induced ischemia and patient outcome.     

Prognostic value of negative transesophageal dobutamine stress echocardiography in men at high risk for coronary artery disease

Recently published reviews have called into question the sensitvity of transthoracic stress echocardiography to predict cardiac events, especially when the test is negative, compared with myocardial perfusion imaging studies. To our knowledge there are a lack of data assessing the prognostic value of transesophageal echocardiography-dobutamine stress echocardiography (TEE-DSE) in predicting cardiac events. Because TEE-DSE has been reported to be highly accurate for detecting ischemia in patients with suspected coronary artery disease, we tested the hypothesis that a negative TEE-DSE can identify a low-risk group in a population with a high likelihood of coronary artery disease. Between October 1996 and December 1997, 46 high-risk patients with negative TEE-DSE were identified. Annualized pretest risk for all cardiac events using the Framingham model was 4% based on risk factors. Mean age was 64 years. Mean follow-up time was 16.2 months. There were no cardiac deaths. There were 6 soft and 1 hard cardiac event. The annualized combined ischemic cardiac event rate was 3.8%, and for hard cardiac events it was 1.1%. By Kaplan-Meier analysis, 97% of the population remained free of any ischemic event at the end of 1 year and 93% were free at 22 months. We conclude that optimal image quality and enhanced endocardial definition for assessing wall motion changes with TEE translates into better prognostication and approaches that of myocardial perfusion imaging for negative studies. Advances in ultrasound medicine such as contrast enhancement of myocardial definition, which improve diagnostic accuracy of DSE, should translate into better prognostication.     

Prognostic value of pharmacologic stress echocardiography in patients with left bundle branch block

PURPOSE: Although coronary artery disease is a frequent cause of left bundle branch block, the prognostic value of myocardial ischemia in patients with this conduction abnormality has not been defined. We investigated the value of pharmacologic stress echocardiography in risk stratification of patients with left bundle branch block. PATIENTS AND METHODS: Three hundred eighty-seven patients [230 men and 157 women, mean (+/- SD) age, 64 +/- 9 years] with complete left bundle branch block on the resting electrocardiogram underwent dobutamine (n = 217) or dipyridamole (n = 170) stress echocardiography to evaluate suspected or known coronary artery disease. A summary wall motion score (on a one to four scale) was calculated. The primary end points were cardiac death and nonfatal myocardial infarction. RESULTS: A positive echocardiographic result (evidence of ischemia) was detected in 109 (28%) patients. During a mean follow-up of 29 +/- 26 months, there were 21 cardiac deaths and 20 myocardial infarctions, 63 patients underwent coronary revascularization, and 1 patient received a heart transplant. In a multivariate analysis, four clinical and echocardiographic variables were associated with increased risk of cardiac death: resting wall motion score index [hazard ratio (HR) = 7.5 per unit; 95% confidence interval (CI), 2.8 to 20; P = 0.001], previous myocardial infarction (HR = 2.9; 95% CI, 1.1 to 7.3; P = 0.02), diabetes (HR = 2.7; 95% CI, 1.1 to 6.6; P = 0.03), and the change in wall motion score index from rest to peak stress (HR = 3.0 per unit; 95% CI, 1.0 to 8.6; P = 0.04). The 5-year survival was 77% in the ischemic group and 92% in the nonischemic group (P = 0.02). Four variables were associated with increased risk of cardiac death or infarction: previous myocardial infarction (HR = 3.4; 95% CI, 1.7 to 6.8; P = 0.0005), diabetes (HR = 2.4; 95% CI, 1.2 to 4.6; P = 0.01), resting wall motion score index (HR = 2.2 per unit; 95% CI, 1.1 to 4.1; P = 0.02), and positive echocardiographic result (HR = 2.2; 95% CI, 1.1 to 4.5; P = 0.03). The 5-year infarction-free survival was 60% in the ischemic group and 87% in the nonischemic group (P < 0.0001). Stress echocardiography significantly improved risk stratification in patients without previous myocardial infarction (P = 0.0001), but not in those with previous myocardial infarction (P = 0.08). In particular, it provided additional value over clinical and resting echocardiographic findings in predicting cardiac events among patients without previous infarction. CONCLUSIONS: Myocardial ischemia during pharmacologic stress echocardiography is a strong prognostic predictor in patients with left bundle branch block, particularly in those without previous myocardial infarction.     

Prognostic value of exercise stress myocardial perfusion imaging in patients with permanent pacemakers

One hundred eight patients with single- or dual-chamber pacemakers underwent exercise myocardial perfusion imaging with thallium-201 or technetium-99m sestamibi. A high-risk scan (a large fixed defect, a large reversible defect, or evidence of cardiomyopathy) identified patients at high risk for cardiac death on both a univariate and multivariate basis.     

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.