64-multislice detector computed tomography coronary angiography as potential alternative to conventional coronary angiography: a systematic review and meta-analysis.

AIMS: To evaluate the diagnostic accuracy of 64-slice multi-detector computed tomography coronary angiography (64-SCTA) compared with the standard reference conventional coronary angiography (CCA). METHODS AND RESULTS: Based on a systematic search, 27 studies including 1740 patients were eligible for meta-analyses. Nineteen studies examined native coronary arteries (n = 1,251), four studies examined coronary artery by-pass grafts (CABG) (n = 271), and five studies examined coronary stents (n = 270). Overall 18 920 segments were assessable and 810 (4%) were unassessable. The prevalence of native coronary artery stenosis in per-segment (19 studies) and per-patients (13 studies) populations were 19 and 57.5% respectively. Accuracy tests with 95% confidence intervals comparing 64-SCTA vs. CCA showed that sensitivity, specificity, positive predictive and negative predictive values for native coronary arteries were 86(85-87), 96(95.5-96.5), 83, and 96.5% by per-segment analysis; 97.5(96-99), 91(87.5-94), 93, and 96.5% by per-patient analysis; 98.5(96-99.5), 96(93.5-97.5), 92 and 99% for CABGs; 80(70-88.5), 95(92-97), 80, and 95% for stent restenosis; and 87(86.5-88), 96(95.5-96.5), 83.5, and 97% by overall per-segment analysis. CONCLUSION: The high diagnostic accuracy of 64-SCTA validates this non-invasive technique as a potential alternative to CCA in carefully selected populations suspected for coronary stenosis.     

A meta-analysis of the effect of angiotensin-converting enzyme inhibitors on functional capacity in patients with symptomatic left ventricular systolic dysfunction

AIM: To determine by meta-analysis whether angiotensin-converting enzyme (ACE) inhibitors improve exercise tolerance in patients with symptomatic left ventricular systolic dysfunction (LVSD). METHODS AND RESULTS: After literature search 13 multi-centre double blind parallel group trials that evaluated the effect of ACE inhibitors vs. placebo on exercise duration were selected. Ninety-four percent of patients were in New York Heart Association class II-IV. The studies were combined using the Cochrane meta-analysis program (Review manager version 4.1). Analyses according to treatment period, exercise protocols and publication periods were performed. Treatment with ACE inhibitor over 4-12 weeks resulted in a beneficial effect on exercise duration (P=0.003 and P=0.0008 for 4- and 12-weeks treatment, respectively), but the magnitude of improvements did not exceed 30 s corresponding to only 5% compared with placebo. CONCLUSION: In addition to the pronounced effect on mortality and morbidity in patients with symptomatic LVSD, ACE inhibitors have improving effect on functional capacity measured as exercise tolerance time.     

Nationwide trends in the prescription of beta-blockers and angiotensin-converting enzyme inhibitors after myocardial infarction in Denmark, 1995–2002

Objectives To study the use of beta-blockers and angiotensin-converting enzyme (ACE) inhibitors after acute myocardial infarction (AMI) in Denmark from 1995 to 2002.

Design Information about patients with first AMI aged ≥30 years and the dispensing of beta-blockers and ACE inhibitors from pharmacies within 30 d from discharge was obtained from the National Patient Registry and the Danish Registry of Medicinal Product Statistics.

Results Beta-blocker use increased from 38.1% of patients in 1995 to 67.9% in 2002 (OR=3.85, CI: 3.58–4.13). Women, elderly patients and patients taking loop-diuretics and antidiabetic drugs received beta-blockers less frequently, but patients taking loop-diuretics or antidiabetic drugs had the greatest increase. ACE inhibitor use increased from 24.5 to 35.5% (OR=1.86, CI: 1.72–2.01). Women, patients aged <60 years or ≥80 years and patients not taking loop-diuretics received ACE inhibitors less frequently, but patients not taking loop-diuretics had the greatest increase.

Conclusions Beta-blocker use increased markedly post-AMI from 1995 to 2002, whereas ACE inhibitor use increased modestly. The results suggested undertreatment of women, elderly patients and people with diabetes.     

Apolipoprotein E Genotype and Cognitive Dysfunction after Noncardiac Surgery

Background: Apolipoprotein E is important in recovery after neuronal damage. The [epsilon]4 allele of the apolipoprotein E gene has been shown as a risk factor for Alzheimer disease, poor outcome after cerebral injury, and accelerated cognitive decline with normal aging. The authors hypothesized that patients with the [epsilon]4 allele would have an increased risk of postoperative cognitive dysfunction (POCD) after noncardiac surgery.

Methods: In a multicenter study, a total of 976 patients aged 40 yr and older undergoing noncardiac surgery were tested preoperatively and 1 week and 3 months after surgery with a neuropsychological test battery comprising seven subtests. POCD was defined as a decline in test performance of more than 2 SD from the expected. Apolipoprotein E genotypes were determined by blood sample analysis at a central laboratory. Multivariate logistic regression analysis with POCD as the dependent variable assessed presence of the [epsilon]4 allele (yes/no) and other possible risk factors.

Results: The [epsilon]4 allele was found in 272 patients. One week after surgery, the incidence of POCD was 11.7% in patients with the [epsilon]4 allele and 9.9% in patients without the [epsilon]4 allele (P = 0.41). Three months later, POCD was found in 10.3% of patients with the [epsilon]4 allele and in 8.4% of patients without the [epsilon]4 allele (P = 0.40). Multivariate logistic regression analysis did not identify the [epsilon]4 allele as a risk factor at 1 week (P = 0.33) or 3 months (P = 0.57).     

The validity of the diagnosis of acute myocardial infarction in routine statistics: a comparison of mortality and hospital discharge data with the Danish MONICA registry

We analyzed the validity of the diagnosis of acute myocardial infarction (MI) in national registries by individual record linkage with the Danish MONICA registry. MI events were identified by record linkage between The National Hospital Registry and The National Death Registry. The sensitivity and specificity were estimated based on three different definitions of an MI event. For events with MI as the primary diagnosis or underlying cause of death the predictive value was 93.6% and sensitivity 77.6% when compared to DANMONICA definite or possible MI. Compared to DANMONICA, definite MI the predictive value was 75.0% and the sensitivity 92.8%. When secondary diagnosis and contributory cause of death were included, the sensitivity increased and the predictive value decreased only slightly. The combination of the national registries was found to be a valid and powerful tool for monitoring the population incidence of MI.     

Heart rate versus heart rate variability in risk prediction after myocardial infarction

INTRODUCTION: The aim of this study was to evaluate and compare heart rate and heart rate variability (HRV) in risk prediction after acute myocardial infarction (MI) and to evaluate the effect of beta-blocker treatment on the prognostic performance of heart rate and HRV. METHODS AND RESULTS: Three hundred sixty-six patients underwent 24-hour Holter recording 1 to 6 days after an MI. HRV was expressed as the standard deviation of all normal-to-normal intervals. Left ventricular systolic function was evaluated using the wall motion index. Half of the patients were taking a beta-blocker at the time of Holter recording. Mean follow-up was 44 months (median 34) after MI. By the end of follow-up, 82 patients had died. Mortality at 1 and 3 years was 12.5% and 22.6%, respectively. HRV, heart rate, wall motion index, number of ventricular premature beats per hour, and ventricular tachycardia were all significantly (P < 0.05) associated with mortality in univariate analysis, independent of beta-blocker therapy. In multivariate Cox analysis, only heart rate, wall motion index, number of ventricular premature beats per hour, and age had independent prognostic value (P < 0.001). In any model, including heart rate, HRV had no predictive value. CONCLUSION: The prognostic information of HRV is contained completely in heart rate, which carries prognostic information further than that of HRV. This result was independent of beta-blocker treatment.     

Hospital variation in mortality after first acute myocardial infarction in Denmark from 1995 to 2002: lower short-term and 1-year mortality in high-volume and specialized hospitals

BACKGROUND: This study used linked data from the National Hospital Registry to determine the factors that contribute to differences between hospitals in all-cause mortality after first acute myocardial infarction (AMI) between 1995 and 2002. METHODS: The study included 64,321 patients with their first admission for AMI between 1995 and 2002 and surviving the day of admission. Multilevel logistic regression was used to determine the relationships between regional and hospital characteristics and 28-day and 365-day mortality after adjusting for individual characteristics, period, and medical history. RESULTS: Tertiary cardiac care centers (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.67-0.96) and main regional hospitals (OR, 0.90; 95% CI, 0.80-0.99) had improved 28-day mortality compared with local hospitals. A 2-fold increase in annual total MI volume decreased 28-day mortality (OR, 0.91; 95% CI, 0.87-0.94) and 365-day mortality (OR, 0.95; 95% CI, 0.91-0.98). Differences between hospitals were more substantial for short-term mortality, such that patients were about twice as likely to die within 28 days in hospitals with the worst performance versus those with the best performance. Higher regional AMI incidence was associated with lower mortality before 2000; this disappeared after 2000. Other regional contextual characteristics had very modest effects on mortality. CONCLUSIONS: Type of hospital, and especially total MI volume at the hospital level, were significantly associated with mortality after AMI. Individual hospitals varied substantially in both short- and long-term mortality.     

Cerebral blood flow and cognitive dysfunction after coronary surgery

BACKGROUND: Postoperative cognitive dysfunction after cardiac surgery has been attributed both to embolic events and periods with reduced cerebral perfusion. We investigated whether cognitive dysfunction after coronary surgery is associated with changes in regional cerebral blood flow (CBF) using single photon emission computed tomography. METHODS: Before surgery and at discharge, 15 coronary surgery patients were studied. Global and regional CBF were measured using a brain-dedicated single photon emission computed tomography scanner, and neuropsychological testing with seven subtests was performed. Postoperative cognitive dysfunction was defined as a Z score above 2. Normative single photon emission computed tomography data were available from 26 healthy age-matched controls. RESULTS: Preoperative global CBF was significantly lower in patients compared with controls (53.7 versus 46.1 mL/100 g/min, p = 0.006). After surgery, global CBF significantly decreased in the patient group (46.1 versus 38.6 mL/100 g/min, p = 0.0001). No significant differences were detected in regional CBF. Cognitive dysfunction was identified in 4 of the 15 patients (26.7%, 95% CI 7.8% to 55.1%). No correlation was found between the neuropsychological Z score and global or regional CBF. CONCLUSIONS: The significant decrease in CBF after coronary surgery was uniformly distributed and was not correlated to postoperative cognitive dysfunction.     

Significant Decline in Case Fatality after Acute Myocardial Infarction in Denmark--a Population-based Study from 1994 to 2001

Objective: We evaluated trends in in-hospital case fatality after acute myocardial infarction (AMI) in Denmark and analysed changes in the hospitalization rate for AMI. Design: National population-based registries were used to identify patients ( &#83 30 years) who were admitted for their first AMI from 1994 to 2001. Results: The annual relative decline in case-fatality rate was constant at 10.5% (95% confidence interval (CI) 9.5-11.5%). The decline was similar for both genders at all ages. The hospitalization rate decreased from 1994 to 1999 at an annual average of 4.3% (95% CI 3.4-5.1%). In 2000 and 2001 the average annual increase was 7-8%. Conclusion: The case-fatality rate after AMI declined significantly in Denmark, similar to other Western countries, but the level is still higher than that of the USA. The increasing hospitalization rate coincided with changes in risk factors in the general population. However, the influence of introducing troponins in the diagnosis of AMI and diagnosis-related grouping may in particular account for the increased hospitalization rate.