Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals

Background

Coronary artery disease (CAD) diagnosis by coronary computed tomographic angiography (CCTA) is useful for identification of symptomatic diabetic individuals at heightened risk for death. Whether CCTA-detected CAD enables improved risk assessment of asymptomatic diabetic individuals beyond clinical risk factors and coronary artery calcium scoring (CACS) remains unexplored.

Methods

From a prospective 12-center international registry of 27,125 individuals undergoing CCTA, we identified 400 asymptomatic diabetic individuals without known CAD. Coronary stenosis by CCTA was graded as 0%, 1–49%, 50–69%, and ≥70%. CAD was judged on a per-patient, per-vessel and per-segment basis as maximal stenosis severity, number of vessels with ≥50% stenosis, and coronary segments weighted for stenosis severity (segment stenosis score), respectively. We assessed major adverse cardiovascular events (MACE) – inclusive of mortality, nonfatal myocardial infarction (MI), and late target vessel revascularization ≥90 days (REV) – and evaluated the incremental utility of CCTA for risk prediction, discrimination and reclassification.

Results

Mean age was 60.4 ± 9.9 years; 65.0% were male. At a mean follow-up 2.4 ± 1.1 years, 33 MACE occurred (13 deaths, 8 MI, 12 REV) [8.25%; annualized rate 3.4%]. By univariate analysis, per-patient maximal stenosis [hazards ratio (HR) 2.24 per stenosis grade, 95% confidence interval (CI) 1.61–3.10, p < 0.001], increasing numbers of obstructive vessels (HR 2.30 per vessel, 95% CI 1.75–3.03, p < 0.001) and segment stenosis score (HR 1.14 per segment, 95% CI 1.09–1.19, p < 0.001) were associated with increased MACE. After adjustment for CAD risk factors and CACS, maximal stenosis (HR 1.80 per grade, 95% CI 1.18–2.75, p = 0.006), number of obstructive vessels (HR 1.85 per vessel, 95% CI 1.29–2.65, p < 0.001) and segment stenosis score (HR 1.11 per segment, 95% CI 1.05–1.18, p < 0.001) were associated with increased risk of MACE. Beyond age, gender and CACS (C-index 0.64), CCTA improved discrimination by maximal stenosis, number of obstructive vessels and segment stenosis score (C-index 0.77, 0.77 and 0.78, respectively). Similarly, CCTA findings improved risk reclassification by per-patient maximal stenosis [integrated discrimination improvement (IDI) index 0.03, p = 0.03] and number of obstructive vessels (IDI index 0.06, p = 0.002), and by trend for segment stenosis score (IDI 0.03, p = 0.06).

Conclusion

For asymptomatic diabetic individuals, CCTA measures of CAD severity confer incremental risk prediction, discrimination and reclassification on a per-patient, per-vessel and per-segment basis.     

The Effect of Tai Chi on Psychosocial Well-being: A Systematic Review of Randomized Controlled Trials

ObjectiveThis systematic review aimed to critically appraise published clinical trials designed to assess the effect of Tai Chi on psychosocial well-being.Data SourcesDatabases searched included MEDLINE, CINAHL, EMBASE, HEALT, PsycINFO, CISCOM, the Cochrane Central Register of Controlled Trials of the Cochrane Library, and dissertations and conference proceedings from inception to August 2008.Review MethodsMethodological quality was assessed using a modified Jadad scale. A total of 15 studies met the inclusion criteria (i.e. English publications of randomized controlled trials with Tai Chi as an intervention and psychological well-being as an outcome measure), of which eight were high quality trials. The psychosocial outcomes measured included anxiety (eight studies), depression (eight studies), mood (four studies), stress (two studies), general mental health three studies), anger, positive and negative effect, self-esteem, life satisfaction, social interaction and self-rated health (one study each).ResultsTai Chi intervention was found to have a significant effect in 13 studies, especially in the management of depression and anxiety. Although the results seemed to suggest Tai Chi is effective, they should be interpreted cautiously as the quality of the trials varied substantially. Furthermore, significant findings were shown in only six high quality studies. Moreover, significant between group differences after Tai Chi intervention was demonstrated in only one high quality study (the other three significant results were observed in non-high quality studies). Two high quality studies in fact found no significant Tai Chi effects.ConclusionIt is still premature to make any conclusive remarks on the effect of Tai Chi on psychosocial well-being.     

Guideline on antiplatelet and anticoagulation management in cardiac surgery.

This document presents a professional view of evidence-based recommendations around the issues of antiplatelet and anticoagulation management in cardiac surgery. It was prepared by the Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery (EACTS). We review the following topics: evidence for aspirin, clopidogrel and warfarin cessation prior to cardiac surgery; perioperative interventions to reduce bleeding including the use of aprotinin and tranexamic acid; the use of thromboelastography to guide blood product usage; protamine reversal of heparin; the use of factor VIIa to control severe bleeding; anticoagulation after mechanical, tissue valve replacement and mitral valve repair; the use of antiplatelets and clopidogrel after cardiac surgery to improve graft patency and reduce thromboembolic complications and thromboprophylaxis in the postoperative period. This guideline is subject to continuous informal review, and when new evidence becomes available. The formal review date will be at 5 years from publication (September 2013).     

Irresponsible responsibility

The Medical Association for Prevention of War (UK) submitted the following written statement to the Third Special Session on Disarmament of the United Nations General Assembly, which was held at UN headquarters in New York on 31 May‐25 June 1988.     

The effects of lidocaine and adrenergic agonists on rat sciatic nerve and skeletal muscle blood flow in vivo

It has been proposed that epinephrine prolongs lidocaine nerve blockade duration by exerting a local vasoconstrictive effect on tissues at the injection site, slowing lidocaine's local clearance. However, previous studies have failed to demonstrate consistent effects of lidocaine and epinephrine, injected alone and in combination, on vascular tone or regional blood flow. To reinvestigate this idea, in this study we used the radiolabeled microsphere technique to measure in vivo tissue blood flow before and at several time points after perisciatic nerve and intramasseter muscle injection of lidocaine alone, epinephrine, the selective alpha(1)-adrenergic receptor agonist phenylephrine, or lidocaine combined with these adrenergic receptor agonists. Repeated-measures analyses of variance were used to assess significant changes in blood flow over time. Lidocaine (2, 10, and 20 mg/mL) and epinephrine (10 micro g/mL or 1:100,000) injected alone did not alter blood flow in sciatic nerve, perisciatic muscle, or masseter muscle. Injections of lidocaine (10 mg/mL) combined with epinephrine (10 micro g/mL) did not affect adjacent muscle blood flow but caused a mild reduction in sciatic nerve blood flow, which was significant 30 min after injection. However, phenylephrine (10 micro g/mL), a potent vasoconstrictor, combined with lidocaine (10 mg/mL) significantly reduced blood flow in all three tissues. Our findings suggest that mechanisms other than local vasoconstriction may contribute to the prolongation of lidocaine nerve blocks by epinephrine. IMPLICATIONS: Accepting that the microsphere technique may be limited in its sensitivity to detect small but clinically relevant changes in tissue blood flow, our findings suggest that mechanisms other than local vasoconstriction may contribute to the prolongation of lidocaine nerve blocks by epinephrine.