Evaluation of cardiovascular risk factors and bone mineral density in patients undergoing coronary angiography and relation of findings to mitral annular calcium

Prevalences of mitral annular calcium (MAC), osteoporosis, and coronary artery disease (CAD) increase with aging and often usually coexist. Correlates of MAC including cardiovascular risk factors and bone mineral density (BMD) have never been evaluated in men and women undergoing coronary angiography. Accordingly, we assessed the association between cardiovascular risk factors, BMD, and MAC in patients undergoing coronary angiography. The study population consisted of 484 consecutive patients (180 women, mean 60 +/- 10 years of age; 304 men, mean 60 +/- 10 years of age) who underwent coronary angiography. Complete transthoracic echocardiographic studies were performed in all patients. Diagnosis of MAC was made by M-mode and cross-sectional transthoracic echocardiography. All patients were referred to the nuclear medicine department to measure BMD (T score) using dual-energy x-ray absorptiometry. The following clinical and demographic parameters were recorded: age, gender, body mass index, hypertension, diabetes mellitus, CAD, hypercholesterolemia, and smoking status. Prevalence of MAC in our study population was 20%. There were no statistically significant differences between groups with respect to body mass index, diabetes mellitus, hypercholesterolemia, and presence of CAD (p >0.05 for all comparisons). Prevalence of hypertension and mean age were significantly higher in patients with MAC than in those without MAC (hypertension 74% vs 52%, p <0.001; age 68 +/- 9 vs 58 +/- 10 years, p <0.001, respectively). Age and hypertension were found to be independent positive risk factors for MAC, whereas T score and age-gender adjusted T score were found to be negatively and independently associated with MAC. In conclusion, we found that MAC in patients undergoing coronary angiography is independently and positively associated with age and hypertension and negatively associated with T-score measurement of BMD.     

A prospective trial of variable stiffness colonoscopes with different tip diameters in unsedated patients

OBJECTIVES: Few data exist comparing the clinical versatility of variable stiffness (VS) colonoscopes with different tip diameters and stiffness ranges. We compared the intubation time and success rate, maneuvering ease, and patient comfort of three colonoscopes: pediatric VS (PVSC), nonmagnifying adult VS (AVSC), and magnifying VS (MVSC).
METHODS: Two hundred sixteen consecutive patients scheduled for routine colonoscopy were randomized to undergo colonoscopy with one of the three different colonoscopes (PVSC N = 72, AVSC N = 72, MVSC N = 72). Outcome measurements included time required for cecal intubation, success rate for cecal intubation, maneuvering ease, and patient comfort.
RESULTS: The overall success rate for cecal intubation was 95.83%. Intubation time was significantly different among the groups (PVSC 12.88 ± 7.11 min, AVSC 9.25 ± 5.16 min, MVSC 9.62 ± 5.55 min; P < 0.01). Intubation time with PVSC required about 3 min more when compared with AVSC or MVSC. Multivariate analyses revealed that colonoscopy with AVSC required 3 min less when compared with PVSC ( P = 0.03). Age greater than 55 yr, waist circumference, prior hysterectomy, and pain experienced by patients were also factors affecting intubation time.
CONCLUSIONS: In this study, a PVSC might not decrease patient discomfort or intubation time. The ideal colonoscope is the AVSC that has a modest diameter and stiffness range and thus is capable of achieving both a short intubation time and an acceptable comfort level. We also should bear in mind that MVSC has an additional function of magnifying observation.     

Aortic valve calcification: its significance and limitation as a marker for coronary artery disease

Aortic valve calcification (AVC) is correlated with atherosclerotic risk factors; however, its significance remains largely unknown. The aim of this study was to investigate whether AVC detected by transthoracic echocardiography can be a useful marker for the identification of significant coronary artery disease (CAD), particularly in elderly patients. The study included 432 consecutive patients with suspected CAD who were admitted for the first time for coronary angiography. Two-dimensional transthoracic echocardiography and selective coronary angiography were performed in all patients. Aortic valve calcification was defined as bright dense echoes of > 1 mm on one or more cusps and decreased mobility of the involved cusp. Aortic valve calcification was detected in 64 of the 337 patients with significant CAD, but only in 9 of 95 cases with normal or mildly stenotic coronary arteries (19% vs 9%, p < 0.001). The severity of coronary artery disease (defined as the number of obstructed vessels) was not related to the presence of AVC (p > 0.05). Stepwise multiple logistic regression analysis of the study patients revealed only age (p=0.003, odds ratio= 1.56) and AVC (p<0.001, odds ratio = 2.03) as independent predictors of CAD. When the study population was divided into two groups as those below (n = 338) and above (n = 94) 75 years old, AVC failed to be a predictor of CAD in those >75 years old (p > 0.05, odds ratio = 0.8) while it remained the most significant predictor of CAD (p<0.001, odds ratio=2.19 in patients aged <75 years. In conclusion, detection of AVC by transthoracic echocardiography may be a useful noninvasive marker for identification of significant CAD in patients younger than 75 years old. Its clinical usefulness is limited in elderly patients.     

Coronary Doppler intensity changes during handgrip: a new method to detect coronary vasomotor tone in coronary artery disease.

OBJECTIVES: This study evaluates whether a quantitative measurement of Doppler intensity during handgrip may disclose coronary vasomotor dysfunction in patients with coronary artery disease (CAD). BACKGROUND: Atherosclerotic coronary segments show an exaggerated constrictive response to handgrip. The intensity of the scattered Doppler signal is proportional to the number of blood cells flowing through the vessel, and should be reduced during vasoconstriction. Therefore, changes in coronary flow during handgrip may be detected by measuring Doppler intensity rather than velocities. METHODS: The distal left anterior descending coronary artery (LAD) was imaged by high-resolution transthoracic color Doppler echocardiography during handgrip in 47 patients: 15 with normal coronary arteries and 32 with significant CAD involving the LAD. The Doppler signal was acquired at 70 dB dynamic range at baseline, 30-s handgrip and 5 min recovery. Peak and mean flow velocity, pressure half-time, deceleration time (ms), deceleration rate (cm/s2) and mean gray level intensity (intensity units [IU]) of the Doppler spectrum were measured in diastole. RESULTS The velocity parameters did not change significantly during handgrip both in normal and CAD patients. The Doppler intensity significantly decreased during handgrip (from 87.0 +/- 32.8 to 57.7 +/- 35.3 IU; p < 0.001) in patients with CAD, and it increased or remained unchanged in normals (from 74.1 +/- 27.3 to 85.1 +/- 31.2 IU; p = NS). The sensitivity of Doppler intensity in detecting CAD was 84.4%, specificity 93.3%, negative predictive value 73.7% and positive predictive value 96.4%. CONCLUSIONS: Doppler intensity measured by transthoracic echocardiography during handgrip allows the detection of CAD and coronary vasomotor dysfunction.     

Aortic valve sclerosis, mitral annular calcium, and aortic root sclerosis as markers of atherosclerosis in men

Aortic valve sclerosis (AVS) and mitral annular calcium (MAC) as detected by transthoracic echocardiography have been associated with atherosclerosis. Aortic root sclerosis (ARS) may have a similar association, but has not been studied. This study evaluates, by transesophageal echocardiography, the association of AVS, MAC, and ARS with aortic atheromatous disease and cardiovascular disease. Multiplane transesophageal echocardiography with evaluation of AVS, MAC, ARS, and aortic atheromatous disease by 2 experienced observers unaware of clinical data was performed in 157 male patients > or =50 years old. The presence of cardiovascular disease, defined as coronary, carotid, or peripheral artery disease, was determined by specific criteria. The prevalence of AVS, MAC, ARS, and aortic atheromatous disease was 42%, 30%, 48%, and 71%, respectively. The presence of AVS, MAC, or ARS was highly associated with aortic atheromatous disease (odds ratio 4.9 to 12.0, confidence interval 1.4 to 35.8, p <0.001). ARS was also associated with cardiovascular disease (odds ratio 2.2, confidence interval 1.0 to 4.5, p = 0.038). The presence of AVS, MAC, or ARS had a sensitivity of 77%, specificity of 72%, a positive predictive value of 88%, and a negative predictive value of 55% for aortic atheromatous disease. We concluded that the prevalence of AVS, MAC, or ARS by transesophageal echocardiography in men is common, and their presence is highly associated with aortic atheromatous disease and coronary, carotid, or peripheral artery disease.     

The relation between mitral annular calcification and mortality in patients undergoing diagnostic coronary angiography

To determine whether the observed association between mitral annular calcification (MAC) and mortality is independent of the severity of coronary artery disease (CAD), we analyzed data from 134 male veterans (age 63 +/- 10 years) followed for 5 years who had undergone diagnostic coronary angiography and transthoracic echocardiography within 6 months of each other. Echocardiograms were retrospectively reviewed for the presence of MAC. The relation of MAC to all-cause mortality was analyzed using logistic regression, and odds ratios (OR) were calculated. MAC was present in 49 (37%) subjects. Over the 5-year follow-up period, 38 (28%) patients expired. Five-year survival was 80% for subjects without MAC and 56% for subjects with MAC (P = 0.003). MAC (OR = 3.16, 95% confidence interval [CI]= 1.43-6.96, P = 0.003), ejection fraction (OR = 0.76, 95% CI = 0.59-0.97, P = 0.02), and left main CAD (OR = 2.70, 95% CI = 1.11-6.57, P = 0.02) were significantly associated with mortality in univariate analysis. After adjusting for left ventricular ejection fraction, number of obstructed coronary arteries and the presence of left main coronary artery stenosis, MAC significantly predicted death (OR = 2.48, 95% CI = 1.09-5.68, P = 0.03). Similarly, after adjusting for predictors of MAC, including ejection fraction, age, diabetes, peripheral vascular disease, and heart failure, MAC remained a significant predictor of death (OR = 2.38, 95% CI = 1.02-5.58, P = 0.04). MAC also predicted death independent of smoking status, hypertension, serum creatinine, low density lipoprotein cholesterol, high density lipoprotein cholesterol, and C-reactive protein levels (OR = 3.98, 95% CI = 1.68-9.40, P = 0.001). MAC detected by two-dimensional echocardiography independently predicts mortality and may provide an easy-to-perform and inexpensive way to improve risk stratification.     

Heart valve calcification in young patients with systemic lupus erythematosus: a window to premature atherosclerotic vascular morbidity and a risk factor for all-cause mortality

The objective of the study was to evaluate the association between heart valve calcification and atherosclerosis and outcome in systemic lupus erythematosus (SLE). One-hundred and seven patients with SLE (mean age 45.9 +/- 14.7 years) were studied by 2D transthoracic echocardiography. Mitral annulus calcification (MAC) was detected in 24 patients (22.6%) and aortic valve calcification (AVC) in 22 (20.1%). Both MAC and AVC were associated with older age (r = 0.2, p = 0.02; r = 0.40, p 相似文献   

Association between mitral annulus calcification and peripheral arterial atherosclerotic disease

The authors previously demonstrated a significant association between the presence of mitral annulus calcification (MAC) and aortic atheroma, carotid atherosclerotic disease, and coronary artery disease. The present study was designed to determine whether an association exists between MAC and peripheral arterial atherosclerotic disease. Of the 805 patients in whom the diagnosis of MAC was made by transthoracic echocardiography between 1995 and 1997, 77 patients (40 men and 37 women; mean age, 73.1 +/- 11.4 years; range, 44-90 years) underwent peripheral arterial testing for various indications, and comprised the study group. They were compared with 58 age-matched and sex-matched patients without MAC (30 men and 28 women; mean age, 73.2 +/- 11.8 years; range, 31-93 years) who underwent peripheral arterial testing during the same period for the same indications (control group). MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet detected by transthoracic echocardiography. An ankle/brachial systolic pressure index (ABI) was calculated by dividing the higher dorsalis pedis or posterior tibial Doppler-derived pressures by the higher of the 2 upper extremity systolic pressures. ABI was graded as follows: normal > or = 1, abnormal < 1, mild 0.71 to 0.99, moderate 0.41 to 0.7, and severe < or = 0.4. No differences were found between the groups in indications for referral for peripheral arterial testing and in risk factors for atherosclerosis except for hypertension, which was found to be significantly more prevalent in the study group (66% vs 41%, p = 0.004). The study group included 151 limbs, and the control group included 113 limbs. The mean ABI was significantly lower for all limbs in the MAC group (0.56 +/- 0.27 vs 0.87 +/- 0.24, p = 0.0001), abnormal ABI < 1 (94% vs 68%, p = 0.001), moderate peripheral arterial disease (44% vs 25%, p = 0.001), and a severe disease (27% vs 1%, p = 0.001). Of the 77 patients with MAC, 73 (95%) had a disease (right and/or left limbs) compared with 40 of 58 (69%) in the control group (p = 0.001). Bilateral disease (Doppler index < 1 for both right and left limbs), and severe bilateral disease (Doppler index < or = 0.4 for both right and left limb) were also found to be significantly more prevalent in the MAC group (87% vs 60%, p = 0.001; and 12% vs 0%, p = 0.007, respectively). There is a significant association between the presence of MAC and peripheral arterial disease. This information strengthens our hypothesis that MAC may be an important marker for generalized vascular atherosclerotic disease.     

Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus.

In type 2 diabetes mellitus (DM2) patients, coronary artery disease (CAD) generally is detected in an advanced stage, whereas an asymptomatic stage is commonly missed. Abnormal myocardial perfusion during stress myocardial contrast echocardiography (MCE) and significant CAD were similar, irrespective of risk factor (RF) profile in our patients, but coronary anatomy differed. An "aggressive" diagnostic approach, requiring coronary angiography in asymptomatic DM2 patients with < or = 1 associated RF for CAD and abnormal MCE, identified silent CAD, characterized by a more favorable angiographic anatomy. The criterion of > or = 2 RFs did not help to identify patients with a higher prevalence of CAD and is only related to a more severe coronary atherosclerosis with unfavorable anatomy.OBJECTIVES: We sought to verify the effectiveness of current American Diabetes Association screening guidelines in identifying asymptomatic patients with coronary artery disease (CAD) in type 2 diabetes mellitus (DM2). BACKGROUND: In DM2 patients, CAD generally is detected in an advanced stage with an extensive atherosclerosis and poor outcome, whereas CAD in an asymptomatic stage is commonly missed. METHODS: This study included 1,899 asymptomatic DM2 patients (age < or = 60 years). Of these, 1,121 had > or = 2 associated risk factors (RFs), group A, and the remaining 778 had < or = 1 RF, group B, for CAD. All patients underwent dipyridamole myocardial contrast echocardiography (MCE), and in those with myocardial perfusion defects, the anatomy of coronary vessels was analyzed by selective coronary angiography. RESULTS: In the two study groups, the prevalence of abnormal MCE (59.4% vs. 60%, p = 0.96) and of a significant CAD (64.6% vs. 65.5%, p = 0.92) was similar, irrespective of RF profile. But coronary anatomy differed: group B had a lower prevalence of three-vessel disease (7.6% vs. 33.3%, p < 0.001), of diffuse disease (18.0% vs. 54.9%, p < 0.001), and of vessel occlusion (3.8% vs. 31.2%, p < 0.001), whereas one-vessel disease was more frequent (70.6% vs. 46.3%, p < 0.001). Coronary anatomy did not allow any revascularization procedure in 45% of group A patients. CONCLUSIONS: An "aggressive" diagnostic approach, requiring coronary angiography in asymptomatic DM2 patients with < or =1 associated RF for CAD and abnormal MCE, identified patients with a subclinical CAD characterized by a more favorable angiographic anatomy. The criterion of > or =2 RFs did not help to identify asymptomatic patients with a higher prevalence of CAD and is only related to a more severe CAD with unfavorable coronary anatomy.     

Mitral annular calcification predicts mortality and coronary artery disease in end stage renal disease

BACKGROUND: We sought to determine whether mitral annular calcification (MAC) predicts mortality and cardiac disease in a group of renal transplant candidates. METHODS: Hundred and forty patients were prospectively studied. All had echocardiography and coronary angiography. Significant coronary artery disease (CAD) was defined as luminal stenosis >70% by visual estimation in at least one coronary artery. RESULTS: There were 21 deaths over a follow-up period of 2.2+/-0.7 years. MAC occurred in 56 patients (40%) and was associated with higher mortality (p=0.04). Patients with MAC were older (p=or<0.001), had larger left ventricular (LV) end systolic (p=0.005) and LV end diastolic (p=0.04) diameter, larger left atrial diameter (p=0.001), lower LV fractional shortening (p=0.003), larger LV mass index (p=0.04) and higher mitral E/Ea ratio (p=0.03) compared to those without. Plasma calcium (p=0.002), phosphate (p=0.004), cardiac troponin T (p=0.03), N-terminal Pro-B-type natriuretic peptide (p=0.004) concentrations were higher in those with MAC but gender, total cholesterol, haemoglobin and creatinine were similar in the two groups. The proportion diabetic (p=0.03), on dialysis (p=0.05), with significant CAD (p=or<0.001), taking calcium containing phosphate binders (p=0.02) and Vitamin D3 (p=0.04) was significantly higher in those with MAC. Significant CAD (OR 12, 95% CI 3.25, p=0.001) was the only independent associate of MAC. CONCLUSIONS: MAC is associated with increased mortality and significant CAD in ESRD. These patients have increased LV cavity size, poorer LV systolic function, higher LV filling pressures compared to patients without MAC.     

Predictive value of mitral annular calcification for the diagnosis of coronary artery disease in patients with dilated cardiomyopathy

Mitral annulus calcification (MAC) is an independent predictor of coronary artery disease (CAD). The present study was designed to determine whether an association exists between MAC and CAD in patients with dilated cardiomyopathy. Among the 286 patients with MAC on echocardiographic examination who underwent coronary angiography, 55 patients with echocardiographic findings of dilated cardiomyopathy (group I) were compared to 60 age-matched controls without MAC and an echocardiographic diagnosis of dilated cardiomyopathy (group II) who underwent coronary angiography during the same time. There were no differences in echocardiographic findings between two groups. The prevalence of CAD was higher in group I when compared to group II (74% vs 28%, p<0.001). With regard to severity of CAD, two-vessel, three-vessel, and left main coronary artery disease were found to be significantly frequent in group I (p<0.001). Multivariate analysis revealed that MAC (p=0.001), diabetes mellitus (p=0.048), and history of anginal chest pain (p=0.009) are the independent predictors for the presence of CAD in patients with dilated cardiomyopathy. In conclusion, MAC may be a marker for the presence of coronary artery disease in patients with dilated cardiomyopathy.     

Mechanisms of impaired coronary flow reserve in patients with aortic stenosis: transthoracic Doppler echocardiographic study

OBJECTIVES: Development of left ventricular hypertrophy in severe aortic stenosis is associated with coronary microcirculatory dysfunction, as demonstrated by impaired coronary flow reserve. Recently, coronary flow reserve can be assessed noninvasively by transthoracic Doppler echocardiography (TTDE). This study assessed the relationship between coronary flow reserve obtained by TTDE and the hemodynamic parameters and left ventricular mass index in patients with aortic stenosis. METHODS: Consecutive 29 patients (15 men, 14 women, mean age 72 +/- 11 years) with isolated mild to severe aortic stenosis were studied using TTDE to assess coronary flow reserve. Peak transvalvular pressure gradient across the aortic valve (peak AVG) and aortic valve area were measured by TTDE. Left ventricular mass index was measured by echocardiography. RESULTS: There were significant correlations between coronary flow reserve and peak AVG (r = -0.570, p = 0.001), left ventricular mass index (r = -0.620, p < 0.001), aortic valve area (r = 0.740, p < 0.001), and left ventricular rate pressure product (r = -0.660, p < 0.001). Multiple regression analysis showed that aortic valve area and peak AVG were independent factors for coronary flow reserve (p < 0.001, p = 0.048). CONCLUSIONS: Impairment of coronary flow reserve in patients with aortic stenosis is related to aortic valve area and peak AVG, rather than the degree of left ventricular hypertrophy.     

Supine bicycle echocardiography improved diagnostic accuracy and physiologic assessment of coronary artery disease with the incorporation of intermediate stages of exercise.

OBJECTIVES: The purpose of this work was to assess whether the incorporation of intermediate stages during supine bicycle exercise echocardiography (BEE) improves the accuracy of detection of coronary artery disease (CAD) through the evaluation of a biphasic response. BACKGROUND: Exercise echocardiography allows cardiac imaging throughout exercise. METHODS: Exercise echocardiography was performed in 104 patients (mean age 57 +/- 11 years, 37 women), 91 of whom underwent coronary angiography. The BEE protocol started at 25 W with increments of 25 W every 3-min stage. Images were digitized at rest, 25 W, 50 W, and peak exercise. Two experienced observers and 1 less experienced observer interpreted rest and peak exercise images, with and without the intermediate stages. RESULTS: Imaging during intermediate stages improved the sensitivity for detection of all individual vessel stenoses (78% vs. 58%, p < 0.001) and patients overall (94% vs. 74%, p = 0.001). The specificity was unchanged (all vessels: 83% vs. 81%, all patients: 64% vs. 60%). A change in left ventricular end-systolic volume from intermediate stage to peak exercise of >10% predicted CAD (sensitivity 94%, specificity 74%) and was more marked than changes observed from rest to peak exercise. The severity of coronary stenosis related to the double product achieved at the onset of ischemia during exercise (r = -0.61, p < 0.001) better than that at maximal exercise (r = -0.31, p < 0.01). CONCLUSIONS: During BEE, the acquisition and interpretation of intermediate stages of exercise in addition to peak exercise improves the detection of CAD and allows a better physiologic evaluation of the severity of coronary stenosis.     

Changes in left anterior descending coronary artery wall thickness detected by high resolution transthoracic echocardiography

Recently, it has been demonstrated that high-resolution transthoracic echocardiography (HRTTE) is able to detect differences in the wall thickness of the left anterior descending coronary artery (LAD) between patients with coronary artery disease (CAD) and normal volunteers. The aim of this study was to further validate this technique. One hundred ten volunteers, 58 patients with angiographically proved CAD and 52 control subjects, underwent assessments of their LADs using HRTTE. Anterior and posterior wall thicknesses differed between subjects in the CAD group and controls (1.9 +/- 0.6 vs 1.2 +/- 0.3 mm, p <0.001, and 1.8 +/- 0.5 vs 1.2 +/- 0.3 mm, p <0.001, respectively). External LAD diameter was also greater in subjects in the CAD group compared with controls (5.2 +/- 1.9 vs 4.4 +/- 0.9 mm, respectively, p = 0.01). However, there was no difference in luminal diameter between subjects in the CAD group and the controls (1.9 +/- 0.9 vs 2.1 +/- 0.8 mm, respectively, p = 0.3). In conclusion, HRTTE demonstrated that LAD wall thicknesses and external diameters in patients with CAD were significantly larger than in normal volunteers. Luminal diameter, however, was maintained in the 2 groups, indicating that subjects in the CAD group had undergone positive remodeling at the site measured. This objectively visualized evidence of coronary atherosclerosis with HRTTE would likely be undetected during coronary angiography.     

Relationship between mitral annular calcification and severity of carotid atherosclerosis in patients with symptomatic ischemic cerebrovascular disease

OBJECTIVES: Many studies have reported the association between mitral annular calcification (MAC) and stroke. MAC has been speculated to be a direct embolic source of stroke. Recently, the association between MAC and atherosclerosis in the coronary artery, aorta, and carotid artery has been reported. This prospective study investigated the association between MAC and severity of carotid atherosclerosis in patients with symptomatic ischemic cerebral disease to evaluate the association between MAC and atherosclerosis as a cause of stroke. METHODS: We studied 377 patients with ischemic cerebral disease (253 men, 124 women, mean age 68 +/- 11 years) who underwent echocardiography to determine the presence of MAC and carotid ultrasonography to determine the severity of carotid atherosclerosis. Plaque score was the sum of the maximum intimamedia thickness in the common carotid region, the bifurcation bulb region, and the internal carotid artery region, including both right and left arteries. RESULTS: MAC was found in 86 patients, and was more frequent in women, the elderly, and patients with diabetes or hyperlipidemia (p < 0.05). Plaque score was higher in patients with than without MAC (8.3 +/- 5.8 vs 5.2 +/- 5.2 mm, p < 0.001). Multivariate regression analysis identified MAC (r = 0.26, p < 0.0001), female sex (r = -0.12, p = 0.03), and age (r = 0.23, p < 0.0001) as independently associated with plaque score. CONCLUSIONS: MAC is independently associated with severity of carotid atherosclerosis in patients with symptomatic ischemic cerebral disease. This association suggests MAC may be indirectly related to cerebrovascular disease as a marker of the presence of progressive arteriosclerosis for thromboemboli causing stroke.     

Comparison of prevalence of >70% diameter narrowing of one or more major coronary arteries in patients with versus without mitral annular calcium and clinically suspected coronary artery disease

The prevalence of >70% narrowing of 1, 2, or 3 major coronary arteries and of 3 major coronary arteries was investigated in 2,465 patients (1,437 men, 1,028 women; mean age 69 +/- 13 years) with severe, moderate, mild, or no mitral annular calcium (MAC) diagnosed by 2-dimensional echocardiography who underwent coronary angiography for suspected coronary artery disease. Greater than 70% narrowing of 1, 2, or 3 major coronary arteries was present in 259 of 315 patients (82%) with severe MAC (group 1), in 835 of 1,052 patients (79%) with moderate or mild MAC (group 2), and in 756 of 1,098 patients (69%) with no MAC (group 3) (p <0.001 comparing group 1 with group 3 and group 2 with group 3). Greater than 70% narrowing of 3 major coronary arteries was present in 149 of 315 patients (47%) in group 1, in 366 of 1,052 patients (35%) in group 2, and in 325 of 1,098 patients (30%) in group 3 (p <0.001 comparing group 1 with group 3 and group 1 with group 2; p <0.01 comparing group 2 with group 3). In conclusion, MAC is associated with obstructive >or=1-vessel coronary artery disease and with obstructive 3-vessel coronary artery disease.     

Association of mitral annulus calcification, aortic valve sclerosis and aortic root calcification with abnormal myocardial perfusion single photon emission tomography in subjects age ≤65 years old

OBJECTIVES

We examined the hypothesis that mitral annulus calcification (MAC), aortic valve sclerosis (AVS) and aortic root calcification (ARC) are associated with coronary artery disease (CAD) in subjects age ≤65 years.

BACKGROUND

Mitral annulus calcification, AVS and ARC frequently coexist and are associated with coronary risk factors and CAD in the elderly.

METHODS

We studied 338 subjects age ≤65 years who underwent evaluation of chest pain with myocardial perfusion single photon emission computed tomography (SPECT) and a two-dimensional transthoracic echocardiogram for other indications. The association of MAC, AVS and ARC with abnormal SPECT was evaluated by using chi-square analyses and logistic regression analyses.

RESULTS

Compared with no or one calcium deposit and no or one coronary risk factor other than diabetes, multiple (≥2) calcium (or sclerosis) deposits with diabetes or multiple (≥2) coronary risk factors were significantly associated with abnormal SPECT in women age ≤55 years old (odds ratio [OR], 20.00), in women age >55 years old (OR, 10.00) and in men age ≤55 years old (OR, 5.55). Multivariate analyses identified multiple calcium deposits as a significant predictor for an abnormal SPECT in women (p < 0.001), younger subjects age ≤55 years (p < 0.05) and the total group of subjects (p < 0.01).

CONCLUSIONS

When coronary risk factors are also taken into consideration, the presence of multiple calcium deposits in the mitral annulus, aortic valve or aortic root appears to be a marker of CAD in men ≤55 years old and women.     

Gender differences and temporal trends in clinical characteristics, stress test results and use of invasive procedures in patients undergoing evaluation for coronary artery disease

OBJECTIVES: This study examined gender differences and temporal changes in the clinical characteristics of patients referred for nuclear stress imaging, their imaging results and subsequent utilization of coronary angiography and revascularization. BACKGROUND: Gender bias may influence resource utilization in patients with coronary artery disease (CAD). No study has analyzed gender differences and time trends in patients referred for noninvasive testing and subsequent use of invasive procedures. METHODS: Between January 1986 and December 1995, 14,499 patients (5,910 women and 8,589 men) without established CAD underwent stress myocardial perfusion imaging. The clinical characteristics, imaging results, coronary angiograms and revascularization outcomes were compared in women and men over time. RESULTS: The mean pretest probability of CAD was lower in women (45%) than in men (70%) (p < 0.001). More women (69%) than men (42%) had normal nuclear images (p < 0.001). Men (17%) were more likely than women (8%) to undergo coronary angiography (p < 0.001). Male gender was independently associated with referral for coronary angiography (multivariate model: chi-square = 16, p < 0.001) but was considerably weaker than the imaging variables (summed reversibility score: chi-square = 273, p < 0.001). Revascularization was performed in more men (46% of the population undergoing angiography) than women (39%) (p = 0.01), but gender was not independently associated with referral to revascularization. There were no significant differences in clinical, imaging or invasive variables between the genders over time. CONCLUSIONS: There was little evidence for a bias against women in this study. Women were somewhat less likely to undergo coronary angiography but were referred for stress perfusion imaging more liberally. Practice patterns remained constant over this 10-year period.     

Comparative accuracy of real-time myocardial contrast perfusion imaging and wall motion analysis during dobutamine stress echocardiography for the diagnosis of coronary artery disease

OBJECTIVE: This study sought to compare the accuracy of myocardial contrast echocardiography (MCE) and wall motion analysis (WMA) during submaximal and peak dobutamine stress echocardiography (DSE) for the diagnosis of coronary artery disease (CAD). BACKGROUND: The relative merits of MCE and WMA for the detection of CAD during DSE have not been studied in a large number of patients. METHODS: We studied 170 patients who underwent dobutamine (up to 50 microg/kg/min)-atropine stress testing and coronary angiography. The WMA and MCE (using repeated boluses of Optison [Mallinckrodt, St. Louis, Missouri] or Definity [Bristol-Myers Squibb, New York, New York]) were performed at rest, at intermediate stress (65% to 75% of maximal heart rate), and at peak stress. The diagnosis of CAD (>/=50% stenosis in >/=1 coronary artery) was based on reversible wall motion and perfusion abnormalities. RESULTS: Coronary artery disease was detected in 127 (75%) patients. Sensitivity of MCE was higher than that of WMA at maximal stress (91% vs. 70%; p = 0.001) and at intermediate stress (84% vs. 20%; p = 0.0001). Specificity was lower for MCE compared with WMA (51% vs. 74%; p = 0.01). Overall accuracy was higher for MCE than for WMA (81% vs. 71%; p = 0.01). Sensitivity for detection of CAD based on abnormalities in >/=2 vascular regions was higher for MCE than for WMA (67% vs. 28%; p < 0.01). CONCLUSIONS: The majority of inducible perfusion abnormalities occur at an intermediate phase of the stress test, without wall motion abnormalities. Myocardial contrast echocardiography provides better sensitivity than WMA, particularly in patients with submaximal stress and in identifying patients with multivessel CAD.     

Is carotid atherosclerosis more important in patients with mitral annular calcification than in those without?

It has been suggested that mitral annular calcification (MAC) may be a manifestation of generalized atherosclerosis. However, how the incidence and extent of coronary artery disease (CAD) are affected by the coexistence of carotid atherosclerosis (CAS) in patients with versus without MAC have not yet been studied. We studied 101 patients with echocardiographic MAC and 52 controls without MAC to investigate the clinical impact of CAS on the frequency and severity (defined as the number of obstructed vessels) of CAD in patients with MAC. Carotid Doppler ultrasonographic examination was performed on all patients before coronary angiography. In patients with both MAC and CAS, the incidences of CAD and multivessel disease (> or = 2 vessel or left main coronary artery disease) were significantly higher than in the control group with CAS alone (91% versus 68%, P = 0.008 and 76% versus 44%, P = 0.004, respectively). On the other hand, among study and control patients without CAS, although the frequencies of CAD and multivessel disease were higher in patients with MAC, interestingly, the differences were not statistically significant (37% versus 58% and 15% versus 26%, respectively, P > 0.05 for both). Stepwise multiple logistic regression analysis revealed that CAS (P < 0.001), MAC (P < 0.01) and, to a limited extent hypertension (P = 0.054), were independent predictors for the presence of CAD. In conclusion, the coexistence of CAS is more important in patients with MAC than in those without as it provides valuable information about the incidence and severity of underlying CAD. In cases with MAC but without CAS, MAC could be caused by factors other than atherosclerosis.