Very Long-Term Prognostic Role of Admission BNP in Non-ST Segment Elevation Acute Coronary Syndrome

Background

BNP has been extensively evaluated to determine short- and intermediate-term prognosis in patients with acute coronary syndrome, but its role in long-term mortality is not known.

Objective

To determine the very long-term prognostic role of B-type natriuretic peptide (BNP) for all-cause mortality in patients with non-ST segment elevation acute coronary syndrome (NSTEACS).

Methods

A cohort of 224 consecutive patients with NSTEACS, prospectively seen in the Emergency Department, had BNP measured on arrival to establish prognosis, and underwent a median 9.34-year follow-up for all-cause mortality.

Results

Unstable angina was diagnosed in 52.2%, and non-ST segment elevation myocardial infarction, in 47.8%. Median admission BNP was 81.9 pg/mL (IQ range = 22.2; 225) and mortality rate was correlated with increasing BNP quartiles: 14.3; 16.1; 48.2; and 73.2% (p < 0.0001). ROC curve disclosed 100 pg/mL as the best BNP cut-off value for mortality prediction (area under the curve = 0.789, 95% CI= 0.723-0.854), being a strong predictor of late mortality: BNP < 100 = 17.3% vs. BNP ≥ 100 = 65.0%, RR = 3.76 (95% CI = 2.49-5.63, p < 0.001). On logistic regression analysis, age >72 years (OR = 3.79, 95% CI = 1.62-8.86, p = 0.002), BNP ≥ 100 pg/mL (OR = 6.24, 95% CI = 2.95-13.23, p < 0.001) and estimated glomerular filtration rate (OR = 0.98, 95% CI = 0.97-0.99, p = 0.049) were independent late-mortality predictors.

Conclusions

BNP measured at hospital admission in patients with NSTEACS is a strong, independent predictor of very long-term all-cause mortality. This study allows raising the hypothesis that BNP should be measured in all patients with NSTEACS at the index event for long-term risk stratification.     

Post-Acute Coronary Syndrome Alcohol Abuse: Prospective Evaluation in the ERICO Study

Background

Some studies have indicated alcohol abuse as one of the contributors to the development of cardiovascular disease, particularly coronary heart disease. However, this relationship is controversial.

Objective

To investigate the relationship between post-acute coronary syndrome (ACS) alcohol abuse in the Acute Coronary Syndrome Registry Strategy (ERICO Study).

Methods

146 participants from the ERICO Study answered structured questionnaires and underwent laboratory evaluations at baseline, 30 days and 180 days after ACS. The Alcohol Use Disorders Identification Test (AUDIT) was applied to assess harmful alcohol consumption in the 12 months preceding ACS (30 day-interview) and six months after that.

Results

The frequencies of alcohol abuse were 24.7% and 21.1% in the 12 months preceding ACS and six months after that, respectively. The most significant cardiovascular risk factors associated with high-risk for alcohol abuse 30 days after the acute event were: male sex (88.9%), current smoking (52.8%) and hypertension (58.3%). Six months after the acute event, the most significant results were replicated in our logistic regression, for the association between alcohol abuse among younger individuals [35-44 year-old multivariate OR: 38.30 (95% CI: 1.44-1012.56) and 45-54 year-old multivariate OR: 10.10 (95% CI: 1.06-96.46)] and for smokers [current smokers multivariate OR: 51.09 (95% CI: 3.49-748.01) and past smokers multivariate OR: 40.29 (95% CI: 2.37-685.93)].

Conclusion

Individuals younger than 54 years and smokers showed a significant relation with harmful alcohol consumption, regardless of the ACS subtype.     

Relation of coronary collateral circulation with epicardial fat volume in patients with stable coronary artery disease

Objective

To investigated the relationship between epicardial fat volume (EFV) and coronary collateral circulation (CCC) in patients with stable coronary artery disease (CAD).

Methods

The study population consisted of 152 consecutive patients with CAD who underwent coronary angiography and were found to have at least 95% significiant lesion in at least one major coronary artery. EFV was assessed utilizing 64-multislice computed tomography. The patients were classifield into impaired CCC group (Group 1, Rentrop grades 0−1, n = 58), or adequate CCC (Group 2, Rentrop grades 2−3, n = 94).

Results

The EFV values were significantly higher in paitients with adequate CCC than in those with impaired CCC. In multivariate logistic regression analysis, EFV (OR = 1.059; 95% CI: 1.035−1.085; P = 0.001); and presence of angina were independent predictors of adequate CCC. In receiver-operating characteristic curve analysis, the EFV value > 106.5 mL yielded an area under the curve value of 0.84, with the test sensitivity of 49.3%, and with 98.3% specifity.

Conclusions

High EFV, and the presence of angina independently predict adequate CCC in patients with stable coronary artery disease. This association offers new diagnostic opportinities to assess collateral flow by conventional ultrasound techniques.     

Clopidogrel resistance response in patients with coronary artery disease and metabolic syndrome: the role of hyperglycemia and obesity

Background Despite the proven benefits of clopidogrel combined aspirin therapy for coronary artery disease (CAD), CAD patients with metabolic syndrome (MS) still tend to have coronary thrombotic events. We aimed to investigate the influence of metabolic risk factors on the efficacy of clopidogrel treatment in patients with CAD undergoing percutaneous coronary intervention (PCI). Methods Cohorts of 168 MS and 168 non-MS subjects with CAD identified by coronary angiography (CAG) were enrolled in our study. MS was defined by modified Adult Treatment Panel III criteria. All subjects had taken 100 mg aspirin and 75 mg clopidogrel daily for more than 1 month, and administered loading doses of 600 mg clopidogrel and 300 mg aspirin before PCI. Blood samples were taken 24 h after the loading doses of clopidogrel and aspirin. Platelet aggregation was measured using light transmittance aggregometry (LTA) and thrombelastography (TEG). Clopidogrel resistance was defined as more than 50% adenosine diphosphate (ADP) induced platelet aggregation as measured by TEG. Results Platelet aggregation inhibition rate by ADP was significantly lower in patients with MS as measured both by TEG (55% ± 31% vs. 68% ± 32%; P < 0.001) and LTA (29% ± 23% vs. 42% ± 29%; P < 0.001). In the multivariate analysis, elderly [OR (95% CI): 1.483 (1.047–6.248); P = 0.002], obesity [OR (95% CI): 3.608 (1.241–10.488); P = 0.018], high fasting plasma glucose level [OR (95% CI): 2.717 (1.176–6.277); P = 0.019] and hyperuricemia [OR (95% CI): 2.583 (1.095–6.094); P = 0.030] were all statistically risk factors for clopidogrel resistance. CAD patients with diabetes and obesity were more likely to have clopidogrel resistance than the CAD patients without diabetes and obesity [75% (61/81) vs. 43% (67/156); P < 0.001]. Conclusions CAD patients with MS appeared to have poorer antiplatelet response to clopidogrel compared to those without MS. Obesity, diabetes and hyperuricemia were all significantly associated with clopidogrel resistance.     

Association of cardiac events with coronary artery disease detected by 64-slice or greater coronary CT angiography: A systematic review and meta-analysis

Background

The value of ≥ 64-slice coronary CT angiography (CCTA) to determine odds of cardiac death or non-fatal myocardial infarction (MI) needs further clarification.

Methods

We performed a systematic review and meta-analysis using publications reporting events/severity of coronary artery disease (CAD) in patients with suspected CAD undergoing CCTA. Patients were divided into: no CAD, non-obstructive CAD (maximal stenosis < 50%), and obstructive CAD (≥ 50% stenosis). Odds ratios with 95% confidence intervals were calculated using a fixed or random effects model. Heterogeneity was assessed using the I² index.

Results

We included thirty-two studies comprising 41,960 patients with 363 all-cause deaths (15.0%), 114 cardiac deaths (4.7%), 342 MI (14.2%), 69 unstable angina (2.8%), and 1527 late revascularizations (63.2%) over 1.96 (SD 0.77) years of follow-up. Cardiac death or MI occurred in 0.04% without, 1.29% with non-obstructive, and 6.53% with obstructive CAD. OR for cardiac death or MI was: 14.92 (95% CI, 6.78 to 32.85) for obstructive CAD, 6.41 (95% CI, 2.44 to 16.84) for non-obstructive CAD versus no CAD, and 3.19 (95% CI, 2.29 to 4.45) for non-obstructive versus obstructive CAD and 6.56 (95% CI, 3.07 to 14.02) for no versus any CAD. Similar trends were noted for all-cause mortality and composite major adverse cardiovascular events.

Conclusions

Increasing CAD severity detected by CCTA is associated with cardiac death or MI, all-cause mortality, and composite major adverse cardiovascular events. Absence of CAD is associated with very low odds of major adverse events, but non-obstructive disease significantly increases odds of cardiac adverse events in this follow-up period.     

Coronary Atherosclerotic Precursors of Acute Coronary Syndromes

Background

The association of atherosclerotic features with first acute coronary syndromes (ACS) has not accounted for plaque burden.

Risk factors of ventilator-associated pneumonia in pediatric intensive care unit: a systematic review and meta-analysis

Objective

To identify risk factors of ventilator-associated pneumonia (VAP) in pediatric intensive care unit (PICU).

Methods

PubMed, Ovid, Web of Science, the Cochrane Library and references of retrieved articles were searched without language limitation. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by using both the Mantel-Haenszel fixed-effect and the DerSimonian-Laird random-effects models.

Results

Out of the 205 initially retrieved articles, 9 papers were included. All 4,564 patients were enrolled, including 213 patients with VAP and 4,351 patients without VAP. Among fourteen risk factors, six factors had statistical significances. Risk factors of VAP and its value of OR were as follows: genetic syndrome (OR =2.04; 95% CI: 1.08-3.86), steroids (OR =1.87; 95% CI: 1.07-3.27), reintubation or self-extubation (OR =3.16; 95% CI: 2.10-4.74), bloodstream infection (OR =4.42; 95% CI: 2.12-9.22), prior antibiotic therapy (OR =2.89; 95% CI: 1.41-5.94), bronchoscopy (OR =4.48; 95% CI: 2.31-8.71).

Conclusions

Special methods of preventions should be taken in the light of risk factors of VAP in PICU so as to decrease the rate.KEY WORDS : Risk factors, ventilator-associated pneumonia (VAP), pediatric intensive care unit (PICU), meta-analysis     

Traditional Cardiovascular Risk Factors and the Presence of Obstructive Coronary Artery Disease in Men and Women

Background

Extensive research has demonstrated the importance of traditional cardiovascular risk factors in predicting acute coronary events. Our main objective was to evaluate the relationship between traditional risk factors and the presence of obstructive coronary artery disease (CAD), and to explore potential differences in men vs women.

Methods

An observational study was conducted in a population-based cohort of stable patients who underwent cardiac catheterization in Ontario, Canada. We examined the relationship of diabetes, hypertension, hyperlipidemia, and smoking with the presence of obstructive CAD in men and women using multivariable logistic regression models.

Results

Of the 46,490 patients who were included in our study, 61.2% were men and 38.8% were women. We found that 97% of patients with obstructive CAD had at least 1 conventional cardiovascular risk factor. The adjusted odds ratios (ORs) for obstructive CAD in women with diabetes (OR, 1.51), hypertension (OR, 1.38), and smoking (OR, 1.39) were statistically significantly greater than in men (OR, 1.20 for diabetes; OR, 1.08 for hypertension; OR, 1.14 for smoking; P < 0.001). The sex difference was even greater for patients with multiple risk factors. For example, the association with obstructive CAD in women with 4 cardiac risk factors (OR, 4.30; 95% confidence interval, 3.49-5.28) was almost doubled compared with men (OR, 2.26; 95%confidence interval, 1.99-2.57; P < 0.001).

Conclusions

Almost all patients with stable CAD undergoing cardiac catheterization had at least 1 traditional cardiac risk factor. Importantly, the association between multiple cardiac risk factors and the presence of obstructive CAD is substantially stronger in women than men.     

Cost-Effectiveness of Different Diagnostic Strategies in Suspected Stable Coronary Artery Disease in Portugal

Background

Cost-effectiveness is an increasingly important factor in the choice of a test or therapy.

Objective

To assess the cost-effectiveness of various methods routinely used for the diagnosis of stable coronary disease in Portugal.

Methods

Seven diagnostic strategies were assessed. The cost-effectiveness of each strategy was defined as the cost per correct diagnosis (inclusion or exclusion of obstructive coronary artery disease) in a symptomatic patient. The cost and effectiveness of each method were assessed using Bayesian inference and decision-making tree analyses, with the pretest likelihood of disease ranging from 10% to 90%.

Results

The cost-effectiveness of diagnostic strategies was strongly dependent on the pretest likelihood of disease. In patients with a pretest likelihood of disease of ≤50%, the diagnostic algorithms, which include cardiac computed tomography angiography, were the most cost-effective. In these patients, depending on the pretest likelihood of disease and the willingness to pay for an additional correct diagnosis, computed tomography angiography may be used as a frontline test or reserved for patients with positive/inconclusive ergometric test results or a calcium score of >0. In patients with a pretest likelihood of disease of ≥ 60%, up-front invasive coronary angiography appears to be the most cost-effective strategy.

Conclusions

Diagnostic algorithms that include cardiac computed tomography angiography are the most cost-effective in symptomatic patients with suspected stable coronary artery disease and a pretest likelihood of disease of ≤50%. In high-risk patients (pretest likelihood of disease ≥ 60%), up-front invasive coronary angiography appears to be the most cost-effective strategy. In all pretest likelihoods of disease, strategies based on ischemia appear to be more expensive and less effective compared with those based on anatomical tests.     

Efficacy and safety of moxifloxacin in acute exacerbations of chronic bronchitis and COPD: a systematic review and meta-analysis

Purpose

To evaluate the efficacy and safety of moxifloxacin in acute exacerbations of chronic bronchitis (AECB) and chronic obstructive pulmonary disease (AECOPD).

Methods

We searched PubMed, EMBASE, and the Web of Science for relevant studies. Two reviewers extracted data and reviewed the quality of the studies independently. The primary outcome was clinical success at early follow-up. Study-level data were pooled using a random-effects model when I² was >50% or a fixed-effects model when I² was <50%.

Results

Eleven randomized controlled studies were considered. There was no difference between moxifloxacin and comparator agents with regard to treatment success in intention-to-treat (ITT) [odds ratio (OR) =1.18, 95% confidence interval (CI) 0.98-1.42], clinically evaluable (CE) (OR 1.13, 95% CI, 0.93-1.37) patients, or adverse effects in general (OR 1.00, 95% CI, 0.86-1.17). Moxifloxacin was associated with better microbiological success (OR 1.45; 95% CI, 1.14-1.85).

Conclusions

Moxifloxacin was as clinically equivalent and bacteriologically superior to the antibiotic regimens routinely used in patients with AECB and AECOPD. Moxifloxacin therapy may be a promising and safe alternative to empirical treatment for AECB and AECOPD.KEYWORDS : Moxifloxacin, chronic bronchitis, chronic obstructive pulmonary disease (COPD), meta-analysis, systematic review     

Pathogen burden, cytomegalovirus infection and inflammatory markers in the risk of premature coronary artery disease in individuals of Indian origin

BACKGROUND:

Coronary artery disease (CAD) occurs at an earlier age in South Asians compared with other ethnic groups. Infection and inflammation show a positive association with the disease.

OBJECTIVE:

To investigate the association of infection and inflammatory markers with premature CAD in the Indian Atherosclerosis Research Study population.

METHODS:

Antibody titres for Chlamydia pneumoniae, cytomegalovirus (CMV), Helicobacter pylori, herpes simplex virus and levels of interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP), fibrinogen and secretory phospholipase A2, were measured in 866 individuals (433 CAD patients and matched controls). All individuals were followed-up for recurrent cardiac events for four years. ANOVA was used to study the association of infection and inflammation with CAD.

RESULTS:

The present study found that the odds of CAD occurrence was 2.42 (95% CI 1.26 to 4.64; P<0.008), with all four infections and increased in the presence of hsCRP (OR 4.67 [95% CI 1.43 to 15.25]); P=0.011). Only anti-CMV antibody levels were a significant risk factor for CAD occurrence (OR 2.23 [95% CI 1.20 to 4.15]; P=0.011) and recurrent cardiac events (OR 1.94 [95% CI 0.85 to 4.45]; P=0.015). Mean values of the inflammatory biomarkers IL-6 (P=0.035), fibrinogen (P=0.014), hsCRP (P=0.010) and secretory phospholipase A2 (P=0.002) increased with CMV antibody levels. Incorporating hsCRP and IL-6 in the risk prediction models significantly increased the OR to 2.56 (95% CI 1.16 to 5.63; P=0.019) with a c statistic of 0.826.

CONCLUSIONS:

Pathogen burden, especially CMV infection in combination with inflammatory markers, is a significant predictor of CAD risk in the young Indian population.     

Clinical Risk Factors for Upper Gastrointestinal Bleeding after Percutaneous Coronary Intervention: A Single-Center Study

Background/Aims

Percutaneous coronary intervention (PCI) is often performed therapeutically, and antithrombotic treatment is required for at least 12 months after stent implantation. However, the development of post-PCI upper gastrointestinal bleeding (UGIB) increases morbidity and mortality. We investigated the incidence and risk factors for UGIB in Korean patients within 1 year after PCI.

Methods

The medical records of 3,541 patients who had undergone PCI between January 2006 and June 2012 were retrospectively reviewed. We identified 40 cases of UGIB. We analyzed the incidence and clinical risk factors associated with UGIB occurring within 1 year after PCI by comparing the results for each case to matched controls. The propensity score matching method using age and sex was utilized.

Results

UGIB occurred in 40 patients (1.1%). Two independent risk factors for UGIB were a history of peptic ulcer disease (odds ratio [OR], 12.68; 95% confidence interval [CI], 2.70 to 59.66; p=0.001) and the use of anticoagulants (OR, 7.76; 95% CI, 2.10 to 28.66; p=0.002).

Conclusions

UGIB after PCI occurred at a rate of 1.1% in the study population. Clinicians must remain vigilant for the possibility of UGIB after PCI and should consider performing timely endoscopy in patients who have undergone PCI and are suspected of having an UGIB.     

Bone mineral density and coronary atherosclerosis

Background

The association between low bone mineral density (BMD) and atherosclerosis is still unknown. In this study BMD assessed in patients with and without coronary artery atherosclerosis is determined by angiography.

Methods

A total number of 123 consecutive patients referred for coronary angiography were evaluated by dual X-ray absorptiometry. Obstructive CAD was diagnosed when ⩾50% of lumen was narrowed. Conventional atherosclerosis risk factors were also assessed.

Results

The mean age of the patients was 59 ± 8 years. There was frequency of 48.7% male. The prevalence of diabetes was 31.2%, hypertension 57%, dyslipoproteinaemia 51%, vitamin D deficiency 50% and history of smoking 80.8%. Coronary angiography was normal in 15 patients (12.6%) while 67 patients (55.5%) had obstructive CAD. DXA scan showed 25 patients (21%) with normal BMD, 39 patients (32.7%) with osteopenia, and 55 others (46.2%) with osteoporosis. Lower BMD results were significantly associated with older age and lower BMI but it was not associated significantly with diabetes, hypertension, lipids levels or smoking. Moreover the prevalence of obstructive CAD and minimal CAD differed between groups with normal and low bone density but this was not significant (p = 0.67 and 0.52, respectively). The mean T score comparison between patients with and without CAD was also not different.

Conclusions

In patients with and without obstructive CAD the prevalence of low BMD results are not different.     

Predictors for contrast media-induced nephropathy and long-term survival: prospectively assessed data from the randomized controlled Dialysis-Versus-Diuresis (DVD) trial

BACKGROUND:

Among the numerous studies concerning contrast media-induced nephropathy (CIN), there was no prospective trial that provided data on the long-term outcomes.

OBJECTIVES:

To prospectively assess predictors of CIN and long-term outcomes of affected patients.

METHODS:

Four hundred twelve consecutive patients with serum creatinine levels of 115 μmol/L to 309 μmol/L (1.3 mg/dL to 3.5 mg/dL) undergoing elective coronary angiography were included. Patients were randomly assigned to periprocedural hydration alone, hydration plus onetime hemodialysis or hydration plus N-acetylcysteine.

RESULTS:

Multivariate logistic regression identified the following as predictors of CIN within 72 h (equivalent to an increase in creatinine 44.2 μmol/L [0.5 mg/dL] or more) : prophylactic postprocedural hemodialysis (OR 2.86, 95% CI 1.07 to 7.69), use of angiotensin-converting enzyme inhibitors (OR 6.16, 95% CI 2.01 to 18.93), baseline glomerular filtration rate (OR 0.94, 95% CI 0.90 to 0.98) and the amount of contrast media given (OR 1.01, 95% CI 1.00 to 1.01). With regard to long-term outcome (mean follow-up 649 days), multivariate Cox regression models found elevated creatinine levels at 30 days (hazard rate ratio [HRR] 5.48, 95% CI 2.85 to 10.53), but not CIN within 72 h (HRR 1.12, 95% CI 0.63 to 2.02), to be associated with increased mortality. In addition, independent predictors for death during follow-up included left ventricular ejection fraction lower than 35% (HRR 4.01, 95% CI 2.22 to 7.26), serum phosphate (HRR 1.64, 95% CI 1.10 to 2.43) and hemoglobin (HRR 0.80, 95% CI 0.67 to 0.96).

CONCLUSION:

From the present prospective trial, performance of post-procedural hemodialysis, use of angiotensin-converting enzyme inhibitors, reduced baseline glomerular filtration rate and amount of contrast media were independent predictors of CIN within 72 h after catheterization. Assessing renal function after 30 days, rather than within 72 h, seemed to be more predictive for patients’ long-term survival.     

Assessment of the Relationship between Non-Alcoholic Fatty Liver Disease and CAD using MSCT

Background

Some risk factors for atherosclerosis are followed by non-alcoholic fatty liver disease (NAFLD). We wanted to use Multislice computed tomography (MSCT) as technique for searching relationship between NAFLD and coronary artery disease (CAD).

Objective

The relationship between NAFLD and CAD was investigated using MSCT.

Methods

A total of 372 individuals with or without cardiac symptoms who had undergone MSCT angiography were included in the study. The patients were divided into two groups according to the presence of NAFLD. Coronary artery segments were visually evaluated via MSCT angiography. Based on the coronary artery stenosis degree, those with no or minimal plaques were considered normal, whereas those who had stenosis of less than 50% and at least one plaque were considered to have non-obstructive coronary artery disease (non-obsCAD). The patients who had at least one plaque and coronary artery stenosis of 50% or more were considered to have obstructive coronary artery disease (obsCAD). NAFLD was determined according to the MSCT protocol, using the liver density.

Results

According to the liver density, the number of patients with non-alcoholic fatty liver disease (group 1) was 204 (149 males, 54.8%) and with normal liver (group 2) was 168 (95 males, 45.2%). There were 50 (24.5%) non-obsCAD and 57 (27.9%) obsCAD cases in Group 1, and 39 (23.2%) non-obsCAD and 23 (13.7%) obsCAD cases in Group 2.

Conclusions

The present study using MSCT demonstrated that the frequency of coronary artery disease in patients with NAFDL was significantly higher than that of patients without NAFDL.     

Hematological parameters and coronary collateral circulation in patients with stable coronary artery disease

BACKGROUND:

Although hematological parameters have been associated with prognosis in patients with various cardiovascular diseases, their relationship with coronary collateral (CC) circulation in patients with stable coronary artery disease (CAD) is unknown.

OBJECTIVE:

To investigate the relationship between hematological parameters and CC vessel development in patients with stable CAD.

METHODS:

A total of 96 patients who underwent coronary angiography were retrospectively enrolled. All study participants had at least one occluded major coronary artery. Development of CCs was classified using the method of Rentrop. Rentrop grades of 0 and 1 indicate poor CCs, whereas grades 2 and 3 indicate good CCs. Hematological parameters, including mean platelet volume (MPV) and neutrophil/lymphocyte (N/L) ratio, were measured. Multivariate logistic regression analysis was performed to identify independent variables.

RESULTS:

The MPV and N/L ratio were significantly higher in the poor CC group compared with the good CC group. Negative correlations were found in the analyses comparing Rentrop score with MPV and N/L ratio (r=−0.274; P=0.012 and r=−0.339; P=0.001, respectively). In multivariate analysis, the N/L ratio was independently related to CC circulation (OR 0.762 [95% CI 0.587 to 0.988]; P=0.04).

CONCLUSION:

The results suggest that N/L ratio and MPV are associated with poor CCs, and a high N/L ratio is a significant predictor of poor CC development in patients with stable CAD.     

Stress Echocardiography and Major Cardiac Events in Patients with Normal Exercise Test

Background

Exercise test (ET) is the preferred initial noninvasive test for the diagnosis and risk stratification of coronary artery disease (CAD), however, its lower sensitivity may fail to identify patients at greater risk of adverse events.

Objective

To assess the value of stress echocardiography (SE) for predicting all-cause mortality and major cardiac events (MACE) in patients with intermediate pretest probability of CAD and a normal ET.

Methods

397 patients with intermediate CAD pretest probability, estimated by the Morise score, and normal ET who underwent SE were studied. The patients were divided into two groups according to the absence (G1) or presence (G2) of myocardial ischemia on SE .End points evaluated were all-cause mortality and MACE, defined as cardiac death and nonfatal acute myocardial infarction (AMI).

Results

G1 group was comprised of 329 (82.8%) patients. The mean age of the patients was 57.37 ± 11 years and 44.1% were male. During a mean follow-up of 75.94 ± 17.24 months, 13 patients died, three of them due to cardiac causes, and 13 patients suffered nonfatal AMI. Myocardial ischemia remained an independent predictor of MACE (HR 2.49; [CI] 95% 1.74-3.58). The independent predictors for all-cause mortality were male gender (HR 9.83; [CI] 95% 2.15-44.97) and age over 60 years (HR 4.57; [CI] 95% 1.39-15.23).

Conclusion

Positive SE for myocardial ischemia is a predictor of MACE in the studied sample, which helps to identify a subgroup of patients at higher risk of events despite having normal ET.     

The role of red blood cell distribution width in mortality and cardiovascular risk among patients with coronary artery diseases: a systematic review and meta-analysis

Background

Red cell distribution width (RDW) might be a novel biomarker that reflects multiple physiological impairments related to atherosclerosis and coronary artery diseases (CAD). We conducted this systematic review and meta-analysis to evaluate the association of RDW between all-cause mortality and fatal/non-fatal cardiovascular disease (CVD) events in CAD patients.

Methods

Relevant studies were searched and identified in the MEDLINE and EMBASE databases. English-language prospective studies that reported risk estimates for RDW and mortality/CVD events were included. Data were extracted regarding the characteristics and clinical outcomes, and a quality assessment was conducted. Results were extracted for the highest versus lowest RDW level, and meta-analyses were carried out using random effects models.

Results

We identified 22 studies enrolling 80,216 participants. The study duration ranged between 1 month and 23 years. Of the 15 studies that were included in the meta-analysis, higher RDW indicated a significant increased risk for all-cause mortality in CAD patients: pooled risk ratio (RR) 2.20 (95% CI, 1.42-3.39; P<0.0004). The results for fatal, non-fatal and fatal/non-fatal events were: pooled RR 1.80 (95% CI, 1.35-2.41; P<0.0001), RR 1.86 (95% CI, 1.50-2.31; P<0.00001) and RR 2.13 (95% CI, 1.20-3.77; P=0.01). Heterogeneity was moderately present; however, sensitivity analyses for follow-up duration, CAD subtype, or RDW as dichotomous values showed similar results.

Conclusions

The meta-analysis indicates that higher RDW levels are associated with increased risk of mortality and CVD events in patients with established CAD.