Risk stratification and prognosis of patients with known or suspected coronary artery disease by use of supine bicycle exercise stress echocardiography.

BACKGROUND: The aim of this study was to assess the long-term predictive values of supine bicycle exercise stress echocardiography (ESE), and the ESE additional role compared to other traditional clinical and rest echocardiographic variables, in 607 patients with low, intermediate and high pretest risk of cardiac events. METHODS: Clinical status and long-term outcome were assessed for a mean period of 46 months (range 12-60 months). ESE was performed for the diagnosis of suspected coronary artery disease (CAD) in 267 patients (43.9%), and for risk stratification of known CAD in 340 patients (56.1%). At baseline, the mean value of wall motion score index (WMSI) was 1.22 +/- 0.36, and the mean left ventricular ejection fraction was 58.5 +/- 10.9%. RESULTS: ESE was positive for ischemia in 210 patients (34.9%), while ECG was suggestive for ischemia in 157 patients (25.8%). During the test only 97 patients (15.9%) experienced angina. At peak effort, the mean WMSI was 1.38 +/- 0.46. A low workload was achieved by 158 patients (26.1%). During the follow-up period there were 222 events, including 82 hard events (36.9%), 48 deaths (21.6%) and 34 acute non-fatal myocardial infarction (15.3%). At stepwise multivariate model, cigarette smoking (p < 0.01), peak WMSI (p < 0.001), ESE positive for ischemia (p < 0.001) and low workload (p < 0.01) were the only independent predictors of cardiac death, while positive ESE, peak WMSI, angina during the test and hypercholesterolemia were the only independent determinants of hard cardiac events. The cumulative 5-year mean survival rate according to ESE response was 95.9% in patients with negative ESE, and 83.7% in patients with positive ESE (log rank 13.6; p < 0.00001). CONCLUSIONS: ESE yields prognostic information in known or suspected CAD, especially in patients with intermediate pretest risk level. The combined evaluation of clinical variables and other ESE variables, such as peak WMSI and exercise capacity, may further select patients at greatest risk of cardiac death in the overall population.     

Is haemodynamic depression during carotid stenting a predictor of peri-procedural complications?

OBJECTIVE: The clinical significance of Haemodynamic Depression (HD) during carotid stenting (CAS) remains unclear. The aim of this study was to analyze the frequency and predictors of HD during CAS in a single centre experience. METHODS: A prospective protocol for CAS was applied in a 15-month interval. Patients with restenosis, on betablockers, or with arrhythmias were excluded. A standardized dose of atropine (0.4mg) was given prior to stent deployment. Changes in heart rate, blood pressure, and neurological status were monitored and recorded. HD was defined as systolic pressure <90mmHg and/or heart rate <50 beats/min. Fifteen potential predictors of HD (age, gender, hypertension, smoking, diabetes, coronary artery disease, previous myocardial infarction, symptoms, degree of carotid stenosis contralateral CEA or CAS, calcified/hyperechoic plaque, plaque length, stent oversizing and type of stent) were tested in multivariate analysis. RESULTS: Two hundred and twenty three consecutive patients were enrolled. HD occurred in 98 cases (44%): in 68 cases HD required additional pharmacological support. At 30 days, any stroke rate was 3.1% (3 major and 4 minor), TIA rate 1.8%, myocardial infarction rate 0.4%. No deaths were recorded. No difference in complication rates were found in patients with or without HD. From regression analysis only the presence of calcified plaque (HR 9.5; 95% CI 5.0 to 18.2; p<0.0001) and the plaque length (HR 1.77; 95% CI 1.03 to 3.06; p=0.038) were associated significantly with HD. CONCLUSIONS: HD during CAS is a common, relatively benign event, without increased risk of peri-operative complications. Careful pharmacological treatment is necessary to decrease HD and the potential complications, especially in patients with more severe calcified lesions. These results require confirmation in a separate, larger cohort.     

Acute therapy and prevention of stroke in spontaneous carotid dissection

No randomized and controlled study has evaluated acute stroke therapy and antithrombotic agents for stroke prevention in patients with spontaneous cervical artery dissection (CAD). CAD was not a contraindication for including cases with acute ischemic stroke in trials evaluating systemic fibrinolysis with recombinant tissue plasminogen activator (rt-PA). Small case series have reported successful systemic and local intra-arterial thrombolysis without clinical signs of rupture of the dissected vessel. Thus, thrombolysis seems to be a therapeutic option in acute CAD causing ischemic stroke, although it remains unclear whether rt-PA increases the obstruction of the dissected vessel by enlarging the wall hematoma or diminishes the obstruction by enhancing the recanalization of the thrombus adhering to the dissection. Meta-analyses have shown no benefit of anticoagulation compared to aspirin in stroke prevention of patients with CAD. It is also unclear, whether long-term antithrombotic therapy is necessary. Many centers and ours maintain the antithrombotic therapy for 3 to 6 months. Dissections of the internal carotid artery (ICAD) have a benign long-term prognosis with low stroke rates that are not related to the persistence of severe carotid stenosis or occlusion. These results suggest that surgical or endovascular therapy of ICA stenosis or occlusion related to ICAD should only be taken into consideration in the very rare patients with stroke recurrence in spite of an optimal medical treatment. Cervical aneurysms caused by CAD have an excellent long-term outcome with a low stroke risk, and no vessel rupture has been reported. Thus, surgical or endovascular therapy should be restricted to the very rare cases developing ischemic symptoms in the vascular territory supplied by the dissected aneurysm in spite of antithrombotic therapy.     

The prognostic value of early left ventricular longitudinal systolic dysfunction in asymptomatic subjects with cardiovascular risk factors

Background:

Early diagnosis of left ventricular (LV) dysfunction represents a major challenge in asymptomatic subjects with cardiovascular (CV) risk factors. Tissue Doppler imaging (TDI) has emerged as an important tool with clinical relevance in several cardiac diseases.

Hypothesis:

To evaluate the prognostic ability of TDI in detecting early longitudinal ventricular dysfunction in a large group of asymptomatic subjects with CV risk factors (RsF), normal LV systolic function, and normal diastolic function.

Methods:

A total of 554 subjects (mean age 55 ± 13 years, 39% men) formed our study population: controls, 144 healthy subjects; group 1, 163 subjects with 1 CV RsF; group 2, 147 subjects with 2 CV RsF; group 3, 100 subjects with ≥3 CV RsF. All subjects underwent a comprehensive standard echo‐Doppler evaluation, including posterior wall TDI study. Follow‐up data were available in all the studied samples (mean 28 ± 16 mo).

Results:

Upon follow‐up, 18 individuals (3.2%) developed a first overt CV event. The presence of a peak systolic velocity <7.5 cm/second showed a significant additional predictive value compared with the presence of CV RsF (P<0.001).

Conclusions:

Tissue Doppler imaging is able to identify early longitudinal LV systolic abnormalities in the presence of apparently normal systolic and diastolic function. It demonstrated a significant additional prognostic value compared with the simple presence of coexisting CV RsF. These findings could be clinically relevant in identifying asymptomatic subjects with CV RsF who need early, tailored preventive treatment. © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.