Myocardial Bridging as a Common Phenotype of Hypertrophic Cardiomyopathy Has No Effect on Prognosis

BackgroundThe prognostic significance of myocardial bridging in hypertrophic cardiomyopathy (HCM) remains controversial. This investigation sought to evaluate the impact of myocardial bridging on prognosis of patients with HCM.MethodsA total of 298 adult patients (73% male, mean age, 53 ± 12 years) with HCM were retrospectively enrolled at Fuwai Hospital from 1999 to 2011. Myocardial bridging was evaluated by coronary angiography. Follow-up data were collected by telephone interviews and mailed questionnaires.ResultsThirty-four (11%, 34/298) patients were determined with myocardial bridging and the middle of left anterior descending artery was the most frequently involved segment (77%, 26/34). Patients with myocardial bridging were younger than those without bridging (48 ± 9 versus 54 ± 12 years, P = 0.001). During the follow-up of 4.2 ± 2.3 years (range, 0.7-12.2 years), the presence of myocardial bridging was not evidently associated with increased risk for all-cause death (P = 0.54), cardiovascular death (P = 0.60), sudden cardiac death (P = 0.53) and deterioration of heart failure (P = 0.84).ConclusionsMyocardial bridging was a relatively common morphological component of HCM but not a predictor for adverse clinical outcomes.     

Myocardial bridging does not predict sudden death in children with hypertrophic cardiomyopathy but is associated with more severe cardiac disease

OBJECTIVES

We sought to examine the association between systolic compression of sections of epicardial coronary vessels (myocardial bridging) with myocardial perfusion abnormalities and clinical outcome in children with hypertrophic cardiomyopathy (HCM).

BACKGROUND

It has recently been suggested that myocardial bridging is an important cause of myocardial ischemia and sudden death in children with HCM.

METHODS

Angiograms from 57 children with HCM were reviewed for the presence of bridging (50% or more maximum systolic arterial compression). QT interval indices, echocardiographic and cardiac catheterization findings, treadmill exercise tests, exercise thallium scintigraphy, Holter monitoring and electrophysiologic study findings were compared in children with and without bridging. The findings were also related to the presence or absence of compression of septal branches of the left anterior descending artery (LAD).

RESULTS

Bridging was present in 23 (40%) of the children. Multiple coronary arteries were involved in four children. Bridging involved the LAD in 16 of 28 (57%) affected vessels. Myocardial perfusion abnormalities were present in 14 of 30 (47%) children without bridging and in 17 of 22 (94%) children with bridging, P = 0.002. However, bridging was associated with more severe septal hypertrophy (19 ± 8 mm vs. 28 ± 8 mm, p < 0.001), a higher septum:posterior wall thickness ratio (2.7 ± 1.2 vs. 1.8 ± 0.9, p < 0.001), and higher left ventricle (LV) outflow gradient (45 ± 37 mm Hg vs. 16 ± 28 mm Hg, P = 0.002). Compression of septal LAD branches was present in 37 (65%) of the children and was significantly associated with bridging, severity of LV hypertrophy and outflow obstruction. Multivariate analysis demonstrated that LV septal thickness and septal branch compression, and not bridging, were independent predictors of thallium perfusion abnormalities. There was a 90% power at 5% significance to detect an effect of bridging on thallium abnormalities at an odds ratio of 3. Bridging was also not associated with significantly greater symptoms, increased QT and QTc intervals and QTc dispersion, ventricular tachycardia on Holter or induced at EP study, or a worse prognosis.

CONCLUSIONS

Bridging and compression of septal branches of the LAD are common in HCM children and are related to magnitude of LV hypertrophy. Left ventricular hypertrophy and compression of intramyocardial branches of the epicardial coronary arteries may contribute to myocardial perfusion abnormalities. Our findings suggest that bridging does not result in myocardial ischemia and may not cause arrhythmias or sudden death in HCM children.     

Long-term outcome and prognostic determinants in children with hypertrophic cardiomyopathy

Objectives. We sought to determine clinical, angiographic, and echocardiographic predictors of survival in children with isolated hypertrophic cardiomyopathy (HCM) in a large pediatric centre.

Background. Sudden death is a catastrophic outcome of HCM in childhood but has been difficult to predict. Current therapies might provide for improved outcome if factors identifying high risk can be identified.

Methods. Records of 99 patients diagnosed with HCM from 1958 to 1997 at <18 yr were reviewed for clinical, angiographic (n = 62) and echocardiographic (n = 83) predictors of survival outcome. The effects of clinical characteristics on sudden death (including resuscitated sudden death) were individually tested in Cox’s proportionate hazard modeling.

Results. Seventy-one subjects were male. Median age at diagnosis was 5.0 yr with a medical follow-up interval of 4.8 yr. Thirty-seven of 97 patients had a family history of HCM. Ambulatory electrocardiograms (ECG) in 78 patients demonstrated supraventricular tachycardia in 16 and ventricular tachycardia in 21. Death or resuscitated sudden death occurred in 18 patients. Sudden death rate was 2.7%/yr after age 8 yr. Cox’s proportionate survival modeling revealed increased corrected QT interval (QTc) dispersion on ECG (relative risk [RR] 1.61 per 20 ms increment, p < 0.0003), ventricular tachycardia (VT) on ambulatory ECG (RR 3.75, p < 0.006) and myocardial bridging of the LAD coronary (RR 12.0, p < 0.003) to be associated with reduced time to death or resuscitated sudden death.

Conclusions. Detailed assessment of ECGs, ambulatory ECGs, and coronary angiography can assist in identifying which children with HCM are at risk for sudden death.     

Long-term prognosis of patients with myocardial bridge and angiographic milking of the left anterior descending coronary artery

INTRODUCTION: Myocardial bridging with systolic compression (milking) of the left anterior descending coronary artery may be associated with myocardial ischemia. Little information is available about the long-term prognosis of patients with this coronary anomaly. MATERIAL AND METHODS: A review was made of coronary angiographies of patients diagnosed as ischemic heart disease made between 1994 and 1999 in two centers. The long-term follow-up of patients with myocardial bridging and systolic compression of the left anterior descending coronary artery was analyzed. Data were collected by reviewing medical records and completed by telephone interview. RESULTS: Prevalence: 0.72%. Milking was observed in 60 patients, but 25 of them were excluded due to associated hypertrophic cardiomyopathy, severe valvular disease, or coronary artery disease. The clinical follow-up was available for all patients (median: 43 months, range: 12-80 months). Mean age 55.7 years (SD = 11.9). Men 74%. Clinical presentation: angina 26 patients, atypical chest pain with positive non-invasive test 8, acute myocardial infarction 1. During follow-up, 1 patient died of sudden cardiac death. Seven patients continued to present stable angina CCS class I-II, coronary angiography was repeated in 5 patients, and one required percutaneous revascularization for symptoms. In 63% of cases, antianginal drugs were still needed at the end of follow-up period (beta-blockers or calcium antagonists). CONCLUSIONS: Patients with myocardial bridging and systolic compression of the left anterior descending artery have a good long-term prognosis, although more than half of them continue regular treatment with antianginal drugs. In a small percentage of cases percutaneous intervention must be performed and ischemic heart disease may appear in more aggressive forms (acute myocardial infarction or sudden death).     

Toward clinical risk assessment in hypertrophic cardiomyopathy with gadolinium cardiovascular magnetic resonance

OBJECTIVES: We sought to assess whether hyperenhancement by gadolinium cardiovascular magnetic resonance (CMR) occurs in hypertrophic cardiomyopathy (HCM) and correlates with the risk of heart failure and sudden death. BACKGROUND: The myocardial interstitium is abnormal in HCM at post-mortem. Focally increased interstitial myocardial space appears as hyperenhancement with gadolinium CMR. METHODS: In a blinded, prospective study, HCM patients were selected for the presence (n = 23) or absence (n = 30) of an increased clinical risk of sudden death and/or progressive adverse left ventricular (LV) remodeling. Gadolinium-enhanced CMR was performed. RESULTS: Myocardial hyperenhancement was found in 42 patients (79%), affecting 10.9% (range 0% to 48%) of the LV mass. There was a greater extent of hyperenhancement in patients with progressive disease (28.5% vs. 8.7%, p < 0.001) and in patients with two or more risk factors for sudden death (15.7% vs. 8.6%, p = 0.02). Improved discrimination was seen in patients >40 years old (29.6% vs. 6.7%, p < 0.001) for progressive disease and for patients <40 years old for risk factors for sudden death (15.7% vs. 2.1%, p = 0.002). Patients with diffuse rather than confluent enhancement had two or more risk factors for sudden death (87% vs. 33%, p = 0.01). CONCLUSIONS: Gadolinium CMR reveals myocardial hyperenhancement in HCM. The extent of hyperenhancement is associated with progressive ventricular dilation and markers of sudden death.     

Post-anoxic encephalopathy after an episode of aborted sudden cardiac death

INTRODUCTION AND OBJECTIVES: The presence of post-anoxic encephalopathy after an episode of aborted sudden cardiac death is a serious medical and social problem. PATIENTS AND METHOD: Of 193 patients admitted to the coronary unit during a 12-year period with aborted sudden cardiac death, 104 died (54%) and 89 survived the episode (46%). We compared the characteristics and 6-month prognosis between survivors according to the presence or absence of post-anoxic encephalopathy. RESULTS: Of 89 survivors, 38 patients were discharged alive with post-anoxic encephalopathy (42%) and 51 were discharged without neurological disturbances (58%). Patients with post-anoxic encephalopathy were older (65 13.6 vs. 59 12.9 years; p = 0.04). Mean time to care for cardiac arrest was 11.14.9 min in the post-anoxic encephalopathy group, versus 3.43 min (p < 0.01). The first documented rhythm was VF/VT in 57% and asystolia in 29% in the post-anoxic encephalopathy group, vs. 88% and 3% (p = 0.02). More than half (58%) of the patients in the post-anoxic encephalopathy group had coronary artery disease, vs. 49% (p = NS). Slightly more than half (52%) of the patients in the post-anoxic encephalopathy group had infectious complications, vs. 21% (p = 0.01). After 6 months of follow-up, mortality in patients discharged with post-anoxic encephalopathy was 62%, vs. 10% (p < 0.01); 21% of then showed significant functional improvement and 18% remained neurologically stable. CONCLUSIONS: Most patients admitted to a coronary unit with aborted sudden cardiac death died during hospitalization. Almost half of the survivors had post-anoxic encephalopathy at discharge; of these patients, 62% died within the following 6 months, and functional status improved only in a minority of them.     

Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy

OBJECTIVES: This study sought to determine the impact of surgical myectomy on long-term survival in hypertrophic cardiomyopathy (HCM). BACKGROUND: Left ventricular (LV) outflow tract obstruction in HCM increases the likelihood of heart failure and cardiovascular death. Although surgical myectomy is the primary treatment for amelioration of outflow obstruction and advanced drug-refractory heart failure symptoms, its impact on long-term survival remains unresolved. METHODS: Total and HCM-related mortality were compared in three subgroups comprised of 1,337 consecutive HCM patients evaluated from 1983 to 2001: 1) surgical myectomy (n = 289); 2) LV outflow obstruction without operation (n = 228); and 3) nonobstructive (n = 820). Mean follow-up duration was 6 +/- 6 years. RESULTS: Including two operative deaths (procedural mortality, 0.8%), 1-, 5-, and 10-year overall survival after myectomy was 98%, 96%, and 83%, respectively, and did not differ from that of the general U.S. population matched for age and gender (p = 0.2) nor from patients with nonobstructive HCM (p = 0.8). Compared to nonoperated obstructive HCM patients, myectomy patients experienced superior survival free from all-cause mortality (98%, 96%, and 83% vs. 90%, 79%, and 61%, respectively; p < 0.001), HCM-related mortality (99%, 98%, and 95% vs. 94%, 89%, and 73%, respectively; p < 0.001), and sudden cardiac death (100%, 99%, and 99% vs. 97%, 93%, and 89%, respectively; p = 0.003). Multivariate analysis showed myectomy to have a strong, independent association with survival (hazard ratio 0.43; p < 0.001). CONCLUSIONS: Surgical myectomy performed to relieve outflow obstruction and severe symptoms in HCM was associated with long-term survival equivalent to that of the general population, and superior to obstructive HCM without operation. In this retrospective study, septal myectomy seems to reduce mortality risk in severely symptomatic patients with obstructive HCM.     

Prognosis of completely asymptomatic adult patients with hypertrophic cardiomyopathy

Objectives. We investigated the long-term prognosis of completely asymptomatic adult patients with hypertrophic cardiomyopathy (HC). Diagnosis of HC was suspected because of an abnormal electrocardiogram and/or cardiac murmur and confirmed by echocardiography and/or left ventricular angiography, and hemodynamic investigation.Background. Hypertrophic cardiomyopathy shows marked heterogeneity in clinical expression and prognosis. The prognosis of asymptomatic patients with HC has not been fully defined.Methods. Of 128 consecutive adult patients with HC, 58 asymptomatic patients (Group 1, mean age 42.8 years) and 70 symptomatic patients (Group 2, mean age 50.4 years) were studied to assess cardiac mortality. Mean follow-up periods were 11.0 years for Group 1 and 9.1 years for Group 2.Results. At presentation, Group 1 patients were younger and had smaller left atrial dimensions than did Group 2 patients. The annual cardiac mortality rate and the rate for sudden death alone in Group 1 were significantly lower than in Group 2 (0.9% vs. 1.9%, p < 0.05, 0.1% vs. 1.4%, p < 0.05, respectively). Although about one-third of the survivors in Group 1 had cardiac symptoms at their most recent evaluation, only one patient died suddenly compared with eight in Group 2. The annual mortality rate due to heart failure was similar in each group. Only a syncopal episode was associated with both cardiac death and sudden death for both groups combined.Conclusions. The cardiac mortality rate for completely asymptomatic adult patients with HC was very low, significantly lower than that of symptomatic patients, and there was a disproportionately low incidence of sudden death.     

Comprehensive analysis of the beta-myosin heavy chain gene in 389 unrelated patients with hypertrophic cardiomyopathy

OBJECTIVES: We sought to determine the prevalence and phenotype of beta-myosin heavy chain gene MYH7 mutations in a large cohort of unrelated patients with hypertrophic cardiomyopathy (HCM). BACKGROUND: Hypertrophic cardiomyopathy is a heterogeneous cardiac disease. MYH7 mutations are one of the most common genetic causes of HCM and have been associated with severe hypertrophy, young age of diagnosis, and high risk of sudden cardiac death. However, these clinical findings from large, family studies have not been confirmed in a large unrelated cohort. METHODS: Deoxyribonucleic (DNA) samples obtained from 389 HCM outpatients seen at this tertiary referral center were analyzed for mutations, using polymerase chain reaction, denaturing high-performance liquid chromatography, and DNA sequencing for all 38 protein-coding exons of MYH7. Clinical data were extracted from patient records blinded to patient genotype. RESULTS: Fifty-eight patients (15%) harbored 40 different mutations in MYH7. Compared with HCM patients without MYH7 mutations, HCM patients with MYH7 were younger at diagnosis (32.9 vs. 42.7 years, p = 0.0002), had more hypertrophy (left ventricular wall thickness of 24.2 vs. 21.1 mm, p = 0.0009), and more frequently underwent myectomy (60% vs. 38%, p = 0.002). The HCM patients with MYH7 mutations more often had a family history of HCM (43% vs. 29%, p = 0.006), but there was no difference in family history of sudden death (16% vs. 14%, p = NS). CONCLUSIONS: In this setting, HCM patients with MYH7 were diagnosed at a younger age and had more hypertrophy, but they had no greater frequency of sudden death among first-degree relatives. Although these associations may prove useful for targeted gene screening, caution should be exercised in terms of using pathogenic status in risk stratification.     

Long-term prognosis of coronary artery spasm

This study analyses the long-term prognosis of 210 patients with coronary spasm documented at coronary angiography. All patients with a previous history of myocardial infarction or who had undergone coronary angioplasty were excluded. The average follow-up was 55 months and only 11 patients were lost to follow-up. The actuarial survival figures showed the 1 year, 2 year and 5 year survival rates to be 95, 92 and 89 per cent respectively. Extracardiac mortality was mainly related to smoking (lung cancer, laryngeal cancer, etc.) and was higher than cardiac mortality. More than half of the cardiovascular events (sudden death, myocardial infarcts) occurred during the first year of follow-up. Ten patients (4.7%) died suddenly. The predictive factors of this event were: previous syncopal episodes or syncopal angina due to coronary spasm, percritical arrhythmias and the documentation of multiple spasms at coronary angiography. Myocardial infarction was observed in 10.6 per cent of patients. Only those with significant coronary arterial lesions developed this complication. At the end of the follow-up period, 75 per cent of patients were asymptomatic or had only atypical chest pain. No significant differences were observed between the two groups treated medically, by aortocoronary bypass or by the association of coronary bypass and plexectomy with the exception of non-lethal myocardial infarcts being significantly less common in patients treated medically. Therefore, the long-term prognosis of patients with coronary spams is relatively satisfactory.     

Dilated-hypokinetic evolution of hypertrophic cardiomyopathy: prevalence, incidence, risk factors, and prognostic implications in pediatric and adult patients.

OBJECTIVES: This study sought to investigate the incidence, risk factors, and prognosis of dilated-hypokinetic evolution in a large cohort of patients with hypertrophic cardiomyopathy (HCM) followed up at a cardiology center serving both the pediatric and the adult population. BACKGROUND: The available data on this evolution of HCM mainly regards prevalence (rather than incidence) in adults, with very little being known about the pediatric population. METHODS: A total of 222 consecutive HCM patients (65% men, 19% < or =18 years old) were prospectively evaluated for a mean follow-up of 11 +/- 9 years. RESULTS: A diagnosis of dilated-hypokinetic HCM was made in 12 patients at first evaluation (11 without previous septal myectomy surgery; prevalence, 4.9%). Twelve of the 210 patients with classic HCM at first evaluation underwent dilated-hypokinetic evolution (incidence, 5.3/1,000 patient-years). Patients with prevalent/incident dilated-hypokinetic evolution were younger at first evaluation (32 +/- 14 years vs. 41 +/- 21 years, p = 0.04) and more often had a family history of HCM (61% vs. 26%, p = 0.002) or sudden death (43% vs. 19%, p = 0.01) with respect to patients who maintained classic HCM. Moreover, they showed greater interventricular septum (23 +/- 3 mm vs. 19 +/- 6 mm, p = 0.004) and posterior wall (15 +/- 3 mm vs. 13 +/- 4 mm, p = 0.006) thickness. Cardiovascular death-free survival was lower among patients with dilated-hypokinetic HCM (p < 0.04). Cox proportional hazards regression analysis identified left ventricular wall thickness (hazard ratio [HR] = 1.07; 95% confidence interval [CI], 1.01 to 1.14; p = 0.03) and end-diastolic diameter (HR = 1.08; 95% CI 1.04 to 1.11; p = 0.0001) as independent predictors of cardiovascular death. CONCLUSIONS: Dilated-hypokinetic evolution is rare but not exceptional in HCM. Young age at diagnosis, family history of HCM, and greater wall thickness are incremental risk factors for dilated-hypokinetic HCM, which carries an ominous prognosis.     

Severe coronary tortuosity or myocardial bridging in patients with chest pain, normal coronary arteries, and reversible myocardial perfusion defects

We reviewed patients with normal or near-normal coronary angiograms enrolled in the SPAM contrast stress echocardiographic diagnostic study in which 400 patients with chest pain syndrome of suspected cardiac origin with a clinical indication to coronary angiography were enrolled. Patients underwent dipyridamole contrast stress echocardiography (cSE) with sequential analysis of wall motion, myocardial perfusion, and Doppler coronary flow reserve before elective coronary angiography. Ninety-six patients with normal or near-normal epicardial coronary arteries were screened for the presence of 2 prespecified findings: severely tortuous coronary arteries and myocardial bridging. Patients were divided in 2 groups based on the presence (false-positive results, n = 37) or absence (true-negative results, n = 59) of reversible myocardial perfusion defects during cSE and compared for history and clinical and angiographic characteristics. Prevalence of severely tortuous coronary arteries (35% vs 5%, p <0.001) or myocardial bridging (13% vs 2%, p <0.05) was 7 times higher in patients who demonstrated reversible perfusion defects at cSE compared to those without reversible perfusion defects. No significant differences were found between the 2 groups for the main demographic variables and risk factors. Patients in the false-positive group more frequently had a history of effort angina (p <0.001) and ST-segment depression at treadmill electrocardiography (p <0.001). In conclusion, we hypothesize that patients with a positive myocardial perfusion finding at cSE but without obstructive epicardial coronary artery disease have a decreased myocardial blood flow reserve, which may be caused by a spectrum of causes other than obstructive coronary artery disease, among which severely tortuous coronary arteries/myocardial bridging may play a significant role.     

Avoidance of Coronary Angiography in High-Risk Patients With Acute Coronary Syndromes: The ACSIS Registry Findings

Background/purposePatients with acute coronary syndrome (ACS) are at high-risk for recurrent coronary syndromes, heart failure and death. Early coronary intervention combined with medications reduces these risks. The ACS Israeli Survey (ACSIS) is conducted over a 2-month period, every 2–3 years. ACSIS includes all patients discharged with a diagnosis of ACS from the 24 coronary care units and cardiology departments in Israel. We compared clinical profiles and 1-year survival between ACS patients who did and did not undergo coronary angiography.Methods/materialsWe reviewed ACSIS for the period 2002–2013.ResultsThe prognosis of patients who did not undergo coronary angiography during hospitalization (N = 2078) was significantly worse than for patients who underwent angiography (N = 9550). Avoidance of angiography was less common in ST-elevation myocardial infarction (STEMI) patients than in non-STEMI/unstable angina (NSTEMI/UAP) patients (13% vs. 22%, p < 0.001). Among NSTEMI/UAP patients, those who did not undergo angiography were older (mean: 71 vs. 64 years, p < 0.001), had higher incidences of diabetes (47% vs. 38%, p < 0.001), and renal (55% vs. 27%, p < 0.001) and heart failure (35% vs. 13%, p < 0.01) on admission, compared to those who underwent angiography. Even patients that underwent only diagnostic angiography had had a better prognosis than patients who did not undergo angiography. After propensity score matching for the major differences mentioned above, survival was still significantly better for patients who underwent angiography.ConclusionACS patients who did not undergo coronary angiography had higher-risk clinical profiles and worse 1-year survival than ACS patients who underwent angiography. After propensity score matching, the absence of angiography was independently associated with higher mortality.SummaryData over 10 years were reviewed from a national registry of acute coronary syndrome. Patients who did not undergo coronary angiography during hospitalization were older and with more comorbidities than patients who underwent angiography. After propensity score matching, the absence of angiography remained independently associated with 1-year mortality.     

Noncardiac surgery and the risk of death and other cardiovascular events in patients with hypertrophic cardiomyopathy

BACKGROUND: There is a paucity of reports evaluating the perioperative risk of noncardiac surgery in patients with hypertrophic cardiomyopathy (HCM). HYPOTHESIS: The study was undertaken to evaluate the incidence of acute myocardial infarction (MI) and all-cause inhospital mortality following noncardiac surgery in patients with HCM. METHODS: We searched the National Hospital Discharge Survey database for patients with a diagnosis of HCM who had undergone noncardiac surgery. Cases were matched by age, gender, and year of surgery. Death or acute MI were used as endpoints for analysis. RESULTS: From 1996 to 2002, 227 patients with HCM were matched with 554 controls (representing national estimates of 25,874 HCM and 50,326 controls patients). Patients with HCM were more likely than controls to have a history of atrial fibrillation (22.7 vs. 10.6%, p < 0.001) and of congestive heart failure (CHF) (24.2 vs. 14.1%, p < 0.001). The in-hospital incidence of death or MI was higher in patients with HCM than in controls (6.7 vs. 2.5%, p < 0.001 for death and 2.2 vs. 0.3%, p < 0.001 for MI). After correcting for age, gender, race, presence of hypertension, diabetes mellitus, history of coronary artery-disease, history of CHF, atrial fibrillation, and ventricular arrhythmias in a multivariate binary logistic regression model, the presence of HCM increased the odds of death by 61% (odds ratio [OR] = 1.61, 95% confidence interval [CI] 1.46-1.77, p < 0.001), and almost tripled the odds of the combined endpoint of death or MI (OR = 2.82, 95% CI 2.59-3.07, p < 0.001). CONCLUSION: The presence of HCM significantly increases the risk of death and MI associated with noncardiac surgery. Patients with HCM undergoing elective procedures may require more careful preoperative assessment and perioperative monitoring. The impact of the severity of HCM on outcomes of noncardiac surgery needs further study.     

The impact of coronary revascularization on long-term outcomes after surgical repair of abdominal aortic aneurysm]

BACKGROUND: Complications due to undetectable coronary artery disease are the major causes of morbidity and mortality in the surgical treatment of abdominal aortic aneurysm (AAA). The aim of our study was to evaluate the importance of significant coronary artery disease identification and the impact of coronary revascularization on early and late outcomes after surgical repair of AAA. METHODS: Between January 1994 and July 2004, 210 patients (204 males and 6 females, mean age 68 +/- 12 years) were candidates to elective surgical repair of AAA. Coronary angiography was performed in 122 patients (58%) in presence of angina symptoms, previous myocardial infarction, echocardiographic or scinti-scan evidence of myocardial ischemia. Coronary revascularization was performed in 83 patients (39.5%). The population was divided into two groups: coronary artery bypass graft/coronary angioplasty (CABG/PTCA) + AAA group (83 patients submitted to CABG surgery [n = 61], or PTCA [n = 22], for significant coronary artery disease before surgical repair of AAA), AAA group (127 patients without significant coronary artery disease, operated for AAA). Follow-up (90% complete) had a mean duration of 42 +/- 23 months. RESULTS: CABG/PTCA + AAA group compared to AAA group presented major symptoms of angina (p = 0.001), higher incidence of previous myocardial infarction (67 vs 10%, p < 0.0001), lower mean value of left ventricular ejection fraction (50 vs 54%, p = 0.01). Operative mortality was 0.95%, and was not related to any cardiac morbidity: operative mortality was observed in the AAA group (2 patients died of anossic cerebral damage and respiratory failure) and was absent in the CABG/PTCA + AAA group (p = 0.8). The overall 8-year survival in the AAA group and in the CABG/PTCA + AAA group was 80 +/- 11 vs 95 +/- 2.8%, respectively (p = 0.7). Freedom from cardiac late death and freedom from cardiac events (recurrence of angina, myocardial infarction, congestive heart failure) were high in both groups (93 +/- 6.4 vs 97 +/- 2.3%, p = 0.6; and 91 +/- 6.6 vs 89 +/- 6.7%, p = 0.5, respectively). In the CABG/PTCA + AAA group symptoms for angina (p = 0.0002) and dyspnea (p < 0.0001) significantly improved during the follow-up. CONCLUSIONS: Significant coronary artery disease was not negligible (39.5%) in patients candidates to surgical repair of AAA. Identification and correction of coronary artery disease prior to AAA surgery is the most important strategy to reduce the risk of vascular procedure. The beneficial impact of coronary revascularization on early and late outcomes is evident, in terms of satisfactory survival and freedom from cardiac adverse events. Therefore, coronary angiography is strongly suggested to optimize early and long-term results.     

Long-term prognosis in patients with single-vessel or double-vessel coronary artery disease: does successful revascularization achieved by coronary angioplasty improve late outcome?

OBJECTIVES: It is not clear whether revascularization by coronary angioplasty improves long-term prognosis in patients with stable angina, single- or double-vessel coronary artery disease. This study investigated the extent of late revascularization achieved by percutaneous transluminal coronary angioplasty(PTCA) and evaluated the long-term effect of revascularization in patients with coronary artery disease. METHODS: This study reviewed 178 patients with single-vessel or double-vessel disease and significant coronary diameter stenosis(American Heart Association classification, 75% or more stenosis), but excluded 35 patients with failed revascularization of the target vessels because of initial failed angioplasty(n = 14) or restenosis(n = 21). The remaining 143 patients were available for assessment. Revascularization was successful at follow-up angiography after the last angioplasty in 105 patients(Group A). The remaining 38 patients received conservative medical therapy(Group B). Kaplan-Meier survival curves were used to examine absolute survival difference. RESULTS: One hundred forty-three patients(mean age 64 +/- 9 years) were followed-up for 3.8 +/- 1 years. The patients were 70.6% male, 59.4% had myocardial infarction and 76.9% had single-vessel disease. Anatomical complete revascularization in the chronic phase was accomplished in 80 patients with single-vessel disease(97.6%) and 11 patients with double-vessel disease(47.8%). The event-free survival rate was not significantly different between Group A and Group B(88.6% vs 84.2%, p = NS). Cardiac survival rate decreased significantly in Group B compared to Group A(89.5% vs 99.0%, p < 0.01). This difference in survival rate was due to sudden cardiac death in Group B(7.9% vs 0%, p < 0.05). Non-fatal myocardial infarctions occurred in seven patients(6.7%) with revascularization and in one patient(2.6%) with conservative medical therapy, but with no significant difference. Late successful revascularization improved cardiac survival rate in patients with proximal left anterior descending coronary artery involvement or single-vessel disease. CONCLUSIONS: Cardiac events decreased and long-term prognosis appeared to be a good possibility in patients with single- or double-vessel coronary artery disease if late successful revascularization of target vessel was accomplished.     

Myocardial injury in critically ill patients: relation to increased cardiac troponin I and hospital mortality

OBJECTIVE: To examine the relationship between myocardial injury, assessed by cardiac troponin I (cTnI) levels, and outcome in selected critically ill patients without acute coronary syndromes or cardiac dysfunction. DESIGN AND SETTING: Prospective, observational study in the emergency ICU of a university teaching hospital. POPULATION: Over a 6-month period, 217 consecutive patients admitted to the ICU were studied. METHODS AND RESULTS: cTnI assays were performed in all patients on admission to the ICU. The incidence of myocardial injury, defined by cTnI level > 0.1 ng/mL, was 32% (69 of 217 patients). Overall mortality was 27% (58 of 217 patients). Patients with myocardial injury had a mortality rate of 51%, compared with only 16% mortality for those without myocardial injury (p < 0.001). The hospital mortality rate was highest among older patients (71 +/- 14% vs 58.5 +/- 20%, p < 0.0001) and patients with higher simplified acute physiology scale (SAPS) II score (62 +/- 25% vs 37 +/- 17%, p < 0.0001). Mechanical ventilation was associated with higher in-hospital death (50% vs 31%, for patients who died in the hospital vs those who were discharged alive; p = 0.03). Elevated blood levels of cTnI were found to be independently associated with hospital mortality, regardless of the presence of SAPS II score and mechanical ventilation, in the logistic regression analysis (odds ratio, 2.09; 95% confidence interval, 1.06 to 4.11; p = 0.01). CONCLUSIONS: This study demonstrates the high frequency of myocardial injury (32%) in critically ill patients without acute coronary syndromes or cardiac dysfunction on admission to ICU. Myocardial injury is an independent determinant of hospital mortality. Assessment of myocardial injury on admission to ICU would make it possible to identify patients at increased risk of death.     

Does coronary angiography before emergency aortic surgery affect in-hospital mortality?

OBJECTIVES: To study the relationship between coronary angiography and in-hospital mortality in patients undergoing emergency surgery of the aorta without a history of coronary revascularization or coronary angiography before the onset of symptoms. BACKGROUND: In the setting of acute ascending aortic dissection warranting emergency aortic repair, coronary angiography has been considered to be desirable, if not essential. The benefits of defining coronary anatomy have to be weighed against the risks of additional delay before surgical intervention. METHODS: Retrospective analysis of patient charts and the Cardiovascular Information Registry (CVIR) at the Cleveland Clinic Foundation. RESULTS: We studied 122 patients who underwent emergency surgery of the aorta between January 1982 and December 1997. Overall, in-hospital mortality was 18.0%, and there was no significant difference between those who had coronary angiography on the day of surgery compared with those who had not (No: 16%, n = 81 vs. Yes: 22%, n = 41, p = 0.46). Multivariate analysis revealed that a history of myocardial infarction (MI) was the only predictor of in-hospital mortality (relative risk: 4.98 95% confidence interval: 1.48-16.75, p = 0.009); however, coronary angiography had no impact on in-hospital mortality in patients with a history of MI. Furthermore, coronary angiography did not significantly affect the incidence of coronary artery bypass grafting (CABG) during aortic surgery (17% vs. 25%, Yes vs. No). Operative reports revealed that 74% of all CABG procedures were performed because of coronary dissection, and not coronary artery disease. CONCLUSIONS: These data indicate that determination of coronary anatomy may not impact on survival in patients undergoing emergency surgery of the aorta and support the concept that once diagnosed, patients should proceed as quickly as possible to surgery.     

Treatment of obstructive sleep apnea is associated with decreased cardiac death after percutaneous coronary intervention.

OBJECTIVES: Our purpose was to compare outcomes of patients treated for obstructive sleep apnea (OSA) versus patients with untreated OSA, all of whom had undergone percutaneous coronary intervention (PCI). BACKGROUND: Obstructive sleep apnea has been associated with increases in fatal and nonfatal cardiovascular events. It is not known whether treatment of OSA in patients who have had PCI results in a better outcome. METHODS: In a retrospective cohort study, a group of patients with OSA diagnosed with polysomnography between 1992 and 2004 (apnea-hypopnea index > or =15) who subsequently underwent a PCI (n = 371) were stratified according to whether they were treated for OSA (n = 175) or not (n = 196). Main outcome measures were cardiac death, general mortality, major adverse cardiac events (MACE) (severe angina, myocardial infarction, PCI, coronary artery bypass grafting, or death), and major adverse cardiac or cerebrovascular events (MACCE). RESULTS: Patients treated for OSA had a statistically significant decreased number of cardiac deaths on follow-up when compared with untreated OSA patients (3% [95% confidence interval (CI) 0% to 6%] vs. 10% [95% CI 5% to 14%] after 5 years, p = 0.027), as well as a trend toward decreased all-cause mortality (p = 0.058). There was no difference in the number of MACE or MACCE between the 2 groups (p = 0.91 and 0.96, respectively). CONCLUSIONS: Treatment of OSA is associated with a reduction in the number of cardiac deaths, but not in MACE or MACCE, after PCI. Screening for and treating OSA in patients with coronary artery disease who may undergo PCI may result in decreased cardiac death.     

Gender-related differences in the clinical presentation and outcome of hypertrophic cardiomyopathy

OBJECTIVES: The goal of this study was to assess gender-related differences in a multicenter population with hypertrophic cardiomyopathy (HCM). BACKGROUND: Little is known regarding the impact of gender on the heterogeneous clinical profile and clinical course of HCM. METHODS: We studied 969 consecutive HCM patients from Italy and the U.S. followed over 6.2 +/- 6.1 years. RESULTS: Male patients had a 3:2 predominance (59%), similar in Italy and the U.S. (p = 0.24). At initial evaluation, female patients were older and more symptomatic than male patients (47 +/- 23 years vs. 38 +/- 18 years; p < 0.001; mean New York Heart Association [NYHA] functional class 1.8 +/- 0.8 vs. 1.4 +/- 0.6; p < 0.001), and more frequently showed left ventricular outflow obstruction (37% vs. 23%; p < 0.001). Moreover, female patients were less often diagnosed fortuitously by routine medical examination (23% vs. 41% in male patients, p < 0.001). Female gender was independently associated with the risk of symptom progression to NYHA functional classes III/IV or death from heart failure or stroke compared with male gender (independent relative hazard 1.5; p < 0.001), particularly patients > or =50 years of age and with resting outflow obstruction (p < 0.005). Hypertrophic cardiomyopathy-related mortality and risk of sudden death were similar in men and women. CONCLUSIONS: Women with HCM were under-represented, older, and more symptomatic than men, and showed higher risk of progression to advanced heart failure or death, often associated with outflow obstruction. These gender-specific differences suggest that social, endocrine, or genetic factors may affect the diagnosis and clinical course of HCM. A heightened suspicion for HCM in women may allow for timely implementation of treatment strategies, including relief of obstruction and prevention of sudden death or stroke.