Significance of graft occlusion and coronary atherosclerosis 5 years after coronary artery bypass grafting. A quantitative angiographic study with serial exercise testing

OBJECTIVE: To evaluate the relative importance of graft occlusions and progression of atherosclerosis in coronary arteries as causes of the occurrence of angina pectoris and impairment of physical performance 5 years after coronary artery bypass surgery. DESIGN: A 5-year follow-up study. SETTING: University hospital in south-western Finland. SUBJECTS: Altogether, 174 consecutive electively operated bypass patients. MAIN OUTCOME MEASURES: Serial clinical evaluation and bicycle exercise tests (pre-operatively, at 6 months, and at 1 and 5 years). Quantitative coronary angiography pre-operatively and 5 years after the surgery. RESULTS: Subjects with patent grafts had fewer angina pectoris symptoms at the 5-year follow-up (24 vs. 52%, P = 0.001) and were treated less frequently with long-acting nitrates (3 vs. 15%, P = 0.037) than subjects with graft occlusions. Fewer of them were in classes II-III of the functional classification of the Canadian Cardiovascular Society (39 vs. 74%, P = 0.001). The exercise test was interrupted less often because of chest pain (23 vs. 41%, P = 0.03) and improvement in exercise test variables during the follow-up period was significantly greater in subjects with patent grafts (P<0.002). Amongst patients without graft occlusions, those with new > or =50% diameter stenoses in coronary arteries were more often in functional classes II-III (59 vs. 32%, P = 0.03) than those without new stenoses, but the groups were similar with respect to angina pectoris and exercise tests variables. In patients with graft occlusions, those with and without new > or =50% diameter stenoses were similar with respect to functional class, angina pectoris and exercise test variables. CONCLUSIONS: Angina pectoris and impairment of physical capacity 5 years after coronary artery bypass grafting are mainly due to occlusion of bypass grafts and not to progression of atherosclerosis in coronary arteries.     

Current review of exercise testing: application and interpretation

Exercise testing has changed dramatically in scope over the past 50 years. While initially used to assess functional capacity, it is now also utilized to detect the presence and severity of coronary artery disease (CAD), to evaluate postmyocardial infarction patients at risk for future cardiac events, to screen certain asymptomatic populations for CAD, and to evaluate dysrhythmias, peripheral vascular disease, and lung disease. Dynamic exercise in continuous multistage protocols is most popularly employed because of the more easily measured workload. The safety of exercise testing, its contraindications and termination end points are summarized. The sensitivity of exercise testing ranges between 60 and 70% while specificity has been reported between 85 and 90%. Both sensitivity and specificity are enhanced through use of radionuclide exercise thallium imaging and ventricular angiography.     

Prognostic significance of silent myocardial ischaemia during maximal exercise testing after a first acute myocardial infarction

Clinical, exercise, and angiographic variables, and long-termfollow-up were compared in patients, who, during maximal Bruceexercise testing after a first acute myocardial infarction (AMI),had positive responses to exercise testing (n = 116, 38% of303) with (n % 23, group I) or without (n = 93, group II) angina.Group I patients more often (52 vs 19%, P < 0.001) had ahistory of pre-infarction angina. Group II had a greater proportion(75 vs 52%, P < 0.05) of inferior wall AMI, whereas groupI had a greater proportion (30 vs 19%, P < 0.01) of non-Qwave AMI. Total exercise duration was significantly (P <0.01) longer in group II (7.6 ± 3.2 vs 5.5 ± 3.1min). Maximal exercise heart rate (144 ± 22 vs 133 ±21, beats . min^–1 P < 0.05 was also higher in groupII. A greater proportion of group II patients (37 vs 9%, P <0.05) had single-vessel disease, whereas multivessel diseasewas more common (91 vs 63% P < 0.03) in group I. Left ventricularfunction was similar in both groups. During follow-up (48 ±22 months) the incidence of cardiac death (group I, 3.3%, groupII, 4.8%), of recurrent infarction (group I, 4.8%, group II3.3%), and of revascularization procedures (group I, 28.5%,group II, 19.8%) were similar in both groups. Although asymptomaticexercise-induced ischaemia was associated with better exerciseperformance and less extensive coronary disease than symptomaticischaemia, it had the same long-term prognostic implications.     

Additional value of thallium-201 SPECT to a conventional exercise test for the identification of severe coronary lesions after an episode of unstable coronary artery disease

The additional value of thallium-201 SPECT to a conventional exercise test for the identification of patients with severe coronary lesions was evaluated in 170 men, one month after an episode of unstable coronary artery disease. Severe coronary lesions at coronary angiography — defined as three vessel disease, left main stenosis or proximal left anterior descending artery stenosis as part of two vessel disease — were observed in 45.9%. In the SPECT image, the left ventricular myocardium was divided into nine segments and each segment was classified as either normal (=0), reduced uptake (=1) or uptake defect (=2). The sum of gradings in all segments post-exercise was denoted SPECT score. The patients were divided into nine different groups regarding ST-depression during exercise (no ST-depression, ST-depression in 1–2 leads or 3 leads) and SPECT score (no SPECT score, 1–3 scores or 4 scores). Severe coronary lesions were, in 68% identified by SPECT score 4 and in 65% by ST-depression in 1 lead at exercise test. The specificity for identification of severe coronary lesions was, for both tests, 65%. SPECT score 4 and/or ST-depression in 3 leads identified 82% of the patients with severe coronary lesions with a specificity of 63%. Furthermore, SPECT score 3 identified more patients with isolated proximal left anterior descending artery stenosis than ST-depression alone at exercise test.     

Ambulatory ST-recording has no additional value to exercise test for identification of severe coronary lesions after an episode of unstable coronary artery disease in men

One month after an episode of unstable coronary artery disease, 95 male patients performed coronary angiography, 48 hours ambulatory ST-recording and also an exercise test. ST-depression occurred in 29.5% during the ST-recording and in 44.2% during the exercise test (p<0.05). In patients with ST-depression at ambulatory monitoring, 79% demonstrated the same finding at the exercise test. A high risk response at the exercise test — defined as either ST-depression in 3 leads, ST-depression in 1–2 leads with a maximal work load below the 60th percentile or a maximal work load below the 30th percentile regardless of the ECG reaction — occurred in 56.8%. Severe coronary lesions — defined as three vessel disease, left main stenosis or proximal left anterior descending artery stenosis as part of two vessel disease — was observed in 46.3%. Patents with a high risk exercise test response and patients with ST-depression during ST-recording had severe coronary lesions in 67% and 64% respectively. However, a high risk exercise test response occurred in 82%, while ST-depression at ambulatory monitoring was observed only in 41% of the patients with severe coronary lesions (p < 0.001). Thus, ambulatory ST-recording one month after an episode of unstable coronary artery disease in men adds no further information to a symptom limited exercise test in order to identify patients with severe coronary lesions.     

Persistence of improved exercise tolerance and degree of revascularization after coronary bypass surgery. A prospective randomized study.

Exercise tolerance was repeatedly determined over a 2-year period in a series of 100 patients with coronary heart disease randomly allocated for medical therapy and coronary bypass surgery. The surgical group had a consistently better exercise tolerance than the medical group during the whole follow-up. Completeness of the revascularization, assessed by repeated graft and native vessel angiography, resulted in a marked improvement whereas incompletely revascularized patients exhibited only a marginal improvement which, nevertheless, to some degree exceeded the result of medical management alone. It is concluded that coronary bypass surgery and medical therapy, when indicated, result in markedly better exercise tolerance than medical management alone. This improvement persists up two years after the operation and is largely dependent on the completeness of the revascularization.     

Early exercise testing after coronary care for suspected unstable coronary artery disease -- safety and diagnostic value

The safety of and the diagnostic information provided by a predischargeexercise test performed 2-7 days after admission to the coronarycare unit (CCU) was evaluated in 400 patients less than 65 yearsof age with suspected unstable coronary artery disease, i.e.probable or definite non-transmural myocardial infarction, progressiveangina pectoris or recurring chest pain of recent onset (‘newchest pain’). No serious complications occurred. Signsof ischaemia during exercise tests were more common in olderthan in younger men and more often found in subjects with thanwithout pathological findings in resting ECGs in the CCU. Above45 years of age, more than half of the men with progressiveangina or non-transmural MI had SI depression 2 mm and/or limitingchest pain, whereas men less than 45 years of age had a 10–25%incidence of corresponding findings in the test. In women above55 years with progressive angina or non-transmural MI, 30–35%had ST depression and/or limiting chest pain at the test while20–30% of women below 55 years of age had similar findingsat the test. Beta-adrenoceptor blockade was used by half ofthe patients but did not seem to conceal signs of severe ischaemia.Thus a predischarge exercise test can be performed safely inpatients with suspected unstable coronary artery disease inorder to support or reduce the suspicion of severe disease.     

Age-related differences in the use of guideline-recommended medical and interventional therapies for acute coronary syndromes: a cohort study

OBJECTIVES: To compare the use of guideline-recommended medical and interventional therapies in older and younger patients with acute coronary syndromes (ACSs).
DESIGN: Prospective cohort study.
SETTING: Fifty-five hospitals in Switzerland.
PARTICIPANTS: Eleven thousand nine hundred thirty-two patients with ACS enrolled between March 1, 2001, and June 30, 2006. ACS definition included ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina pectoris (UA).
MEASUREMENTS: Use of medical and interventional therapies was determined after exclusion of patients with contraindications and after adjustment for comorbidities. Multivariate logistic regression models were used to calculate odds ratios (ORs) per year increase in age.
RESULTS: Elderly patients were less likely to receive acetylsalicylic acid (OR=0.976, 95% confidence interval (CI)=0.969–0.980) or beta-blockers (OR=0.985, 95% CI=0.981–0.989). No age-dependent difference was found for heparin use. Elderly patients with STEMI were less likely to receive percutaneous coronary intervention (PCI) or thrombolysis (OR=0.955, 95% CI=0.949–0.961). Elderly patients with NSTEMI or UA less often underwent PCI (OR=0.943, 95% CI=0.937–0.949).
CONCLUSION: Elderly patients across the whole spectrum of ACS were less likely to receive guideline-recommended therapies, even after adequate adjustment for comorbidities. Prognosis of elderly patients with ACS may be improved by increasing adherence to guideline-recommended medical and interventional therapies.     

活动平板试验对冠心病诊断及介入疗效的评价作用

目的探讨活动平板试验对冠心病诊断及介入疗效评价的作用。方法对比分析213例疑诊或临床诊断冠心病患者的运动平板试验和选择性冠状动脉造影结果，并对其中49例接受介入治疗的病例对比分析治疗前后的运动平板试验结果。结果以选择性冠状动脉造影结果为标准，活动平板试验敏感性为66．7％，特异性为87．6％，阳性预测值为77．8％，阴性预测值为80．1％。冠心病介入治疗后活动平板试验的阳性率降低（P〈0．01），总运动代谢当量和运动开始至达到阳性诊断标准的时间较冠心病介入治疗前增加（P均〈0．05）。结论简便、易行及无创的活动平板试验是诊断冠心病的重要手段，并为客观评价冠心病介入治疗效果提供依据。     

Prognostic value of predischarge radionuclide ventriculography at rest and exercise after acute myocardial infarction treated with thrombolytic therapy or primary coronary angioplasty

Background: Previous studies have demonstrated the prognostic value of radionuclide ventriculography at rest and exercise in patients post myocardial infarction (MI). The number of studies in patients treated with modern reperfusion techniques, including thrombolysis or primary angioplasty, however, is limited. Hypothesis: The aim of this study was to evaluate the prognostic significance of predischarge radionuclide ventriculography at rest and exercise in patients with acute MI treated with thrombolysis or primary angioplasty. Methods: A total of 272 consecutive patients with acute MI who were randomized to thrombolysis or primary coronary angioplasty underwent predischarge resting and exercise radionuclide ventriculography. Left ventricular ejection fraction at rest, decrease in ejection fraction during exercise >5 units below the resting value, angina pectoris, ST-segment depression, and exercise test ineligibility were related to subsequent cardiac events (cardiac death, nonfatal reinfarction) during follow-up. Results: During a mean follow-up of 30 ± 10 months, cardiac death occurred in 11 (4%) patients and nonfatal reinfarction in 14 (5%) patients. Resting left ventricular ejection fraction was the major risk factor for cardiac death. In patients with an ejection fraction <40%, cardiac death occurred in 16% compared with 2% in those with an ejection fraction ≥ 40% (p = 0.0004). In addition, cardiac death tended to be higher in patients ineligible than in those eligible for exercise testing (11 vs. 3%, p = 0.08). None of the other exercise variables (decrease in ejection fraction during exercise >5 units below the resting value, angina pectoris or ST-segment depression) were predictive for cardiac death. When all exercise test variables in each patient were combined and expressed as a risk score, a low risk (n = 185) and a higher risk (n = 87) group of patients could be identified, with cardiac death occurring in 1 and 10%, respectively. As the predictive accuracy of a negative test was high, radionuclide ventriculography was of particular value in identifying patients at low risk for cardiac death. Radionuclide ventriculography was not able to predict recurrent nonfatal MI. Conclusion: In patients with MI treated with thrombolysis or primary angioplasty, radionuclide ventriculography may be helpful in identifying patients at low risk for subsequent cardiac death. In this respect, left ventricular ejection fraction at rest was the major determinant. Variables reflecting residual myocardial ischemia were of limited prognostic value. Identification of a large number of patients at low risk allows selective use of medical resources during follow-up in this subgroup and has significant implications for the cost effectiveness of reperfusion therapies.     

Trends in percutaneous versus surgical revascularization of unprotected left main coronary stenosis in the drug-eluting stent era: a report from the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR).

OBJECTIVES: We sought to determine how practice patterns for unprotected left main stenosis have changed with the advent of drug-eluting stents (DES). BACKGROUND: Percutaneous coronary intervention (PCI) of unprotected left main coronary stenosis has been controversial. METHODS: We analyzed data submitted to the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) between January 1, 2002 and December 31, 2004 from 1,276,582 cardiac catheterizations at 417 institutions. Of these, 53,548 (4.2%) had left main stenosis >50% and no prior CABG. After excluding the unrevascularized, the patient sample (N = 32,562) was analyzed for PCI vs. CABG. Data was stratified by year/quarter, bare metal stent vs. DES, elective vs. urgent/emergent situations, LVEF < or > or =40%, and %left main and RCA stenosis. RESULTS: Of unprotected left main revascularizations from 2002 to 2004, PCI increased from 17.0% to 21.9%, while CABG decreased from 83.0% to 78.1% (P < 0.0001). In 2002, bare metal stents were used for all PCIs; in 2004, bare metal stent use was only 25.5%, while DES use was 74.5% (P < 0.0001). Of elective procedures, PCI rose from 19.1% to 27.5% while CABG fell from 80.9% to 72.5% (P < 0.0001). Similar trends, all significant, were seen in every clinical situation. CONCLUSIONS: In the era of DES, the rate of PCI for unprotected left main stenosis has risen, while CABG has declined. These findings are seen across varying clinical situations, including elective procedures. DES have rapidly and largely replaced bare metal stents for PCI of unprotected left mains. However, PCI is still chosen less frequently than CABG for unprotected left main revascularization.     

Prognostic value of exercise testing in a cohort of patients followed for 15 years after acute myocardial infarction.

AIMS: To study the long-term prognostic information obtained from an exercise test following an acute myocardial infarction. METHODS: Between 1979 and 1983, 1773 consecutive patients were admitted to Glostrup County Hospital with an acute myocardial infarction. Of 1430 patients who were alive after 3 weeks, 718 performed an exercise test. Survival data were available after 15 years for all patients. RESULTS: Participation in an exercise test was associated with a risk reduction of death of 56% (95% confidence interval, 49--65%) when adjusting for known differences between the groups. Among patients who performed the test, most indicators of ischaemia were without prognostic information. Exercise tolerance, expressed in metabolic equivalents, was the best predictor of future mortality (relative risk 0.86 for an increase of one metabolic equivalent (0.80--0.92)). Only ST-segment depression of 2 mm or more could identify a population with an increased risk of death (relative risk 1.45 (1.08--1.95)). CONCLUSION: Patients who perform an exercise test after acute myocardial infarction are a low risk population compared to those who do not perform it. The detection of ischaemia during the test is of marginal prognostic value. Exercise capacity is the most powerful predictor of death that can be obtained from the test.     

Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and substance use outcomes after residential treatment for drug dependence: a 5-year follow-up study

AIMS: This study investigates the relationship between frequency of attendance at Narcotics Anonymous and Alcoholics Anonymous (NA/AA) meetings and substance use outcomes after residential treatment of drug dependence. It was predicted that post-treatment NA/AA attendance would be related to improved substance use outcomes. METHODS: Using a longitudinal, prospective cohort design, interviews were conducted with drug-dependent clients (n = 142) at intake to residential treatment, and at 1 year, 2 years and 4-5 years follow-up. Data were collected by structured interviews. All follow-up interviews were carried out by independent professional interviewers. FINDINGS: Abstinence from opiates was increased throughout the 5-year follow-up period compared to pre-treatment levels. Clients who attended NA/AA after treatment were more likely to be abstinent from opiates at follow-up. Abstinence from stimulants increased at follow-up but (except at 1-year follow-up) no additional benefit was found for NA/AA attendance. There was no overall change in alcohol abstinence after treatment but clients who attended NA/AA were more likely to be abstinent from alcohol at all follow-up points. More frequent NA/AA attenders were more likely to be abstinent from opiates and alcohol when compared both to non-attenders and to infrequent (less than weekly) attenders. CONCLUSIONS: NA/AA can support and supplement residential addiction treatment as an aftercare resource. In view of the generally poor alcohol use outcomes achieved by drug-dependent patients after treatment, the improved alcohol outcomes of NA/AA attenders suggests that the effectiveness of existing treatment services may be improved by initiatives that lead to increased involvement and engagement with such groups.     

一站式复合再血管化与经皮冠状动脉介入术治疗冠状动脉多支病变中期造影随访研究

目的 通过冠状动脉造影比较＂一站式＂复合再血管化技术（Hybrid技术）与经皮冠状动脉介入术（PCI）治疗冠状动脉多支病变的靶血管及旁路通畅率.方法 2007年6月至2009年12月我院实施＂一站式＂复合再血管化104例,冠状动脉介入治疗7165例.研究病例分为两组,Hybrid组和PCI组.入选标准：①合并前降支（LAD）病变的冠状动脉多支病变患者;②随访期间无胸痛等不适主诉、无心血管不良事件、无住院治疗、症状药物控制良好的患者;③外科术者和介入术者均为经验丰富的医生.按照上述标准,电话随访同意接受造影复查的患者Hybrid组102例,PCI组157例.2010年10月至2011年12月,50例Hybrid患者完成造影复查;采用倾向性评分1∶1匹配的统计方法抽取PCI组患者50例,完成冠状动脉造影检查.研究终点是两组患者冠状动脉造影随访的靶血管通畅率及二次血运重建率.结果 Hybrid组和PCI组各50例,随访时间分别为（18.0±8.0）个月和（19.3±9.1）个月.两组患者基线特征差异无统计学意义.Hybrid组LIMA-LAD旁路通畅率显著高于PCI组LAD靶血管通畅率（98%比80%,P＝0.004）;Hybrid组的LIMA旁路二次血运重建率显著低于PCI组LAD靶血管二次血运重建率（2%比20%,P＝0.008）.结论 ＂一站式＂复合再血管化技术使冠状动脉多支病变能获得良好的中期靶血管通畅率,其LIMA-LAD旁路通畅率显著优于PCI技术前降支药物洗脱支架通畅率.     

Consideration of a new definition of clinically relevant myocardial infarction after coronary revascularization: An expert consensus document from the society for cardiovascular angiography and interventions (SCAI)

Numerous definitions have been proposed for the diagnosis of myocardial infarction (MI) after coronary revascularization. The universal definition for MI designates post procedural biomarker thresholds for defining percutaneous coronary intervention (PCI)‐related MI (type 4a) and coronary artery bypass grafting (CABG)‐related MI (type 5) which are of uncertain prognostic importance. In addition, for both MI types cTn is recommended as the biomarker of choice, the prognostic significance of which is less well validated than CK‐MB. Widespread adoption of a MI definition not clearly linked to subsequent adverse events such as mortality or heart failure may have serious consequences for the appropriate assessment of devices and therapies, may affect clinical care pathways, and may result in misinterpretation of physician competence. Rather than employing an MI definition sensitive for small degrees of myonecrosis (the occurrence of which, based on contemporary large‐scale studies, are unlikely to have important clinical consequences), it is instead recommended that a threshold level of biomarker elevation which has been strongly linked to subsequent adverse events in clinical studies be used to define a “clinically relevant MI.” The present document introduces a new definition for "clinically relevant MI" after coronary revascularization (PCI or CABG) which is applicable for use in clinical trials, patient care, and quality outcomes assessment. © 2013 Wiley Periodicals, Inc.