Biomedical subjects

Eric Boersma

Publications and source records attributed to Eric Boersma.

At least 37 records · Page 2Linked to original sources

PubMed2006

Patients using statin treatment within 24 h after admission for ST-elevation acute coronary syndromes had lower mortality than non-users: a report from the first Euro Heart Survey on acute coronary syndromes.

AIMS: Statins provide effective secondary prevention in cardiovascular disease. However, it remains uncertain how soon statins should be started after an acute coronary syndrome (ACS). Recently published trials suggest starting before discharge. We hypothesize that statins should be initiated without delay. METHODS AND RESULTS: Data from a large cohort of 10,484 consecutive patients with an ACS were analysed. Of this cohort, 1426 first-time statin receivers and survivors of the first 24 h were compared with 6771 first-day survivors not receiving statin therapy. A propensity score for the likelihood of receiving statin therapy within 24 h was developed and used with other established risk factors in a multivariable analysis. There was a significantly reduced all-cause 7-day mortality in patients receiving early statin therapy [0.4 vs. 2.6%, unadjusted hazard ratio (HR) 0.16, 95% confidence interval (CI) 0.08-0.37, adjusted HR 0.34, 95% CI 0.15-0.79]. Statistical significance was observed in patients presenting with STE-ACS (adjusted HR 0.17, 95% CI 0.04-0.70) and not in NSTE-ACS patients. However, no statistical evidence of heterogeneity in treatment effect was observed between these groups. CONCLUSION: These data suggest that very early statin therapy is associated with reduced mortality in patients presenting with STE-ACS; however, these findings have to be confirmed by prospective, randomized controlled trials before firm treatment recommendations can be given.

Aged↗

PubMed2006

High-dose beta-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients.

BACKGROUND: Adverse perioperative cardiac events occur frequently despite the use of beta (beta)-blockers. We examined whether higher doses of beta-blockers and tight heart rate control were associated with reduced perioperative myocardial ischemia and troponin T release and improved long-term outcome. METHODS AND RESULTS: In an observational cohort study, 272 vascular surgery patients were preoperatively screened for cardiac risk factors and beta-blocker dose. Beta-blocker dose was converted to a percentage of maximum recommended therapeutic dose. Heart rate and ischemic episodes were recorded by continuous 12-lead electrocardiography, starting 1 day before to 2 days after surgery. Serial troponin T levels were measured after surgery. All-cause mortality was noted during follow-up. Myocardial ischemia was detected in 85 of 272 (31%) patients and troponin T release in 44 of 272 (16.2%). Long-term mortality occurred in 66 of 272 (24.2%) patients. In multivariate analysis, higher beta-blocker doses (per 10% increase) were significantly associated with a lower incidence of myocardial ischemia (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.51 to 0.75), troponin T release (HR, 0.63; 95% CI, 0.49 to 0.80), and long-term mortality (HR, 0.86; 95% CI, 0.76 to 0.97). Higher heart rates during electrocardiographic monitoring (per 10-bpm increase) were significantly associated with an increased incidence of myocardial ischemia (HR, 2.49; 95% CI, 1.79 to 3.48), troponin T release (HR, 1.53; 95% CI, 1.16 to 2.03), and long-term mortality (HR, 1.42; 95% CI, 1.14 to 1.76). CONCLUSIONS: This study showed that higher doses of beta-blockers and tight heart rate control are associated with reduced perioperative myocardial ischemia and troponin T release and improved long-term outcome in vascular surgery patients.

Adrenergic beta-Antagonists↗

PubMed2006

The impact of guideline compliant medical therapy on clinical outcome in patients with stable angina: findings from the Euro Heart Survey of stable angina.

AIMS: The European Society of Cardiology published guidelines for the management of stable angina in 1997, with the objective of promoting an evidence-based approach to the condition. This study focuses on the impact of guideline compliant medical treatment on clinical outcome in patients with stable angina. METHODS AND RESULTS: The Euro Heart Survey of Stable Angina is a multicentre prospective observational study conducted between 2002 and 2003. Patients with a clinical diagnosis of stable angina by a cardiologist were enrolled and follow-up was conducted at 1 year. The primary outcome of interest was death or myocardial infarction (MI). The increasing intensity of guideline compliant medical therapy was quantified by means of a simple treatment score based on the use of guideline advocated therapies: antiplatelets, statins, and beta-blockers. A total of 3779 patients were included in the initial survey. Increasing intensity of guideline compliant therapy at initial assessment was associated with a reduction in death and MI during follow-up in patients with angina and confirmed coronary disease (HR 0.68; 95% CI 0.49-0.95 per unit increase in treatment score). All cardiovascular events were also significantly reduced in this subgroup (HR 0.82; 95% CI 0.69-0.97). The benefits of guideline compliant therapy were only observed in patients with objective evidence of coronary disease. CONCLUSION: Guideline compliant medical therapy improves clinical outcome in patients with stable angina and objective evidence of coronary disease.

Analysis of Variance↗

PubMed2006

Association of plasma N-terminal pro-B-type natriuretic peptide with postoperative cardiac events in patients undergoing surgery for abdominal aortic aneurysm or leg bypass.

Postoperative cardiac events are related to myocardial ischemia and reduced left ventricular function. The utility of N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP) for preoperative cardiac risk evaluation has not been evaluated. The objective of this study was to assess whether plasma NT-pro-BNP predicts postoperative cardiac events in patients who undergo major vascular surgery in addition to clinical and dobutamine stress echocardiographic data. One hundred seventy consecutive patients scheduled for major noncardiac vascular surgery were prospectively evaluated by dobutamine stress echocardiographic and NT-pro-BNP measurements. Multivariable logistic regression analysis was performed to evaluate the predictors of cardiac death and nonfatal myocardial infarction during a follow-up of 30-days. Receiver-operating characteristic analysis was performed to determine the optimal cut-off value of NT-pro-BNP to predict outcome. Patients' mean age was 59 +/- 13 years, and 71% were men. The median NT-pro-BNP level was 110 pg/ml (interquartile range 42 to 389). Cardiac events occurred in 2 of 144 patients (1.4%) with NT-pro-BNP <533 pg/ml (i.e., the optimal cut-off value to predict cardiac events) and in 11 of 26 patients (42%) with NT-pro-BNP >or=533 pg/ml (unadjusted odds ratio 52, 95% confidence interval 11 to 256, p <0.0001). After adjustment for cardiac risk factors and dobutamine stress echocardiographic results, NT-pro-BNP remained significantly associated with cardiac events (adjusted odds ratio 17, 95% confidence interval 3 to 106, p = 0.002). In conclusion, in patients scheduled for major vascular surgery, elevated plasma NT-pro-BNP levels are independently associated with an increased risk for postoperative cardiac events. Further studies in a larger number of patients are required to confirm these findings.

Analysis of Variance↗

PubMed2006

Influence of cardiac risk factors and medication on length of hospitalization in patients undergoing major vascular surgery.

Major vascular surgery is associated with a long in-hospital length of stay (LOS). Cardiac risk factors identify patients with an increased risk. Recent studies have associated statin, aspirin, and beta-blocker therapies with improved postoperative outcome. However, the effect of all these factors on LOS has not been defined. Our aims were to determine the effect of cardiac risk factors and (preventive) statin, aspirin, and beta-blocker therapy on LOS and to deduce from these factors a model that predicts LOS. In total, 2,374 patients from 1990 to 2004 were enrolled. Mean LOS was 18 +/- 9 days. Cardiac risk factors that were significantly associated with LOS in the multivariable analysis were age, previous heart failure, hypertension, diabetes mellitus, renal failure, and chronic obstructive pulmonary disease. Statin and aspirin use was associated with a shorter LOS. Beta blockers shortened LOS only in patients with underlying coronary artery disease. Together, these factors explained 14.1% of the variance in LOS. In conclusion, in-hospital LOS in patients who undergo major vascular surgery can be predicted more accurately by clinical cardiac risk factors. A significant decrease in in-hospital LOS was achieved with statin, aspirin, and beta-blocker therapies.

Adolescent↗

PubMed2006

Effects of statins on renal function after aortic cross clamping during major vascular surgery.

Ischemic reperfusion injury is an important cause of renal dysfunction after major vascular surgery and increases postoperative morbidity and mortality. The aim of the present study was to assess the effect of statins on renal function in patients at high risk for renal dysfunction, that is, those who underwent suprarenal aortic cross clamping-declamping. Seventy-seven patients (28 statin users, 57 men; mean age 69 +/- 8 years) with normal preoperative renal function requiring suprarenal aortic cross clamping-declamping during vascular surgery from 1995 to 2005 were studied. Creatinine levels were obtained before surgery and on days 1, 2, 3, 7, and 30 after surgery. An analysis-of-variance model for repeated measurements was applied to compare creatinine levels between statin users and nonusers, with adjustment for clamping time and blood loss. There were no differences in baseline clinical characteristics, preoperative creatinine levels (0.93 vs 0.96 mg/dl, p = 0.59), and glomerular filtration rate (79 vs 73 ml/min, p = 0.1). Postoperative creatinine levels during the 30 days after surgery were significantly lower in statin users than in nonusers (analysis-of-variance p <0.01, 1.17 vs 1.98 mg/dl). Postoperative hemodialysis was required (temporarily) in 7 patients (9.1%), all statin nonusers. These findings suggest an association between statin use and preserved renal function after suprarenal aortic clamping.

Aged↗

PubMed2006

The long-term prognostic value of the resting and postexercise ankle-brachial index.

BACKGROUND: Peripheral arterial disease is associated with a high incidence of cardiovascular mortality. Peripheral arterial disease can be detected by using the ankle-brachial index (ABI). This study assessed the prognostic value of the postexercise ABI in addition to the resting ABI on long-term mortality in patients with suspected peripheral arterial disease. METHODS: In this prospective cohort study of 3209 patients (mean +/- SD age, 63 +/- 12 years; 71.1% male), resting and postexercise ABI values were measured and a reduction of postexercise ABI over baseline resting readings was calculated. The mean follow-up was 8 years (interquartile range, 4-11 years). RESULTS: During follow-up, 1321 patients (41.2%) died. After adjusting for clinical risk factors, lower resting ABI values (hazard ratio per 0.10 lower ABI, 1.08; 95% confidence interval [CI], 1.06-1.10), lower postexercise ABI values (hazard ratio per 0.10 lower ABI, 1.09; 95% CI, 1.08-1.11), and higher reductions of ABI values over baseline readings (hazard ratio per 10% lower ABI, 1.12; 95% CI, 1.09-1.14) were significantly associated with a higher incidence of mortality. In patients with a normal resting ABI (n = 789), a reduction of the postexercise ABI by 6% to 24%, 25% to 55%, and greater than 55% was associated with a 1.6-fold (95% CI, 1.2-2.2), 3.5-fold (95% CI, 2.4-5.0), and 4.8-fold (95% CI, 2.5-9.1) increased risk of mortality, respectively. CONCLUSIONS: Resting and postexercise ABI values are strong and independent predictors of mortality. A reduction of postexercise ABI over baseline readings can identify additional patients (who have normal ABI values at rest) at increased risk of subsequent mortality.

Ankle↗

PubMed2006

Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients.

AIMS: Although outcomes after acute myocardial infarction (AMI) seemed to be superior with primary percutaneous coronary intervention (PPCI) relative to fibrinolysis (FL), the extent to which treatment delay modulates this treatment effect is unclear. METHODS AND RESULTS: Twenty-five randomized trials (n = 7743) testing the efficacy of PPCI vs. FL were identified in journal articles and abstract listings published between 1990 and 2002. Of these, individual patient data from 22 trials (n = 6763) were pooled, and multi-level logistic regression assessed the relationship among treatment, treatment delay, and 30-day mortality. Treatment delay was divided into 'presentation delay' [symptom onset to randomization; FL: median 143 (IQR: 91-225) min; PPCI: 140 (91-220) min] and hospital-specific 'PCI-related delay' [median time from randomization to PPCI minus median time to FL per hospital; median 55 (IQR: 37-74) min]. PPCI was associated with a significant 37% reduction in 30-day mortality [adjusted OR, 0.63; 95% CI (0.42-0.84)]. Although, there was no heterogeneity in the treatment effect by presentation delay (pBreslow-Day = 0.88), the absolute mortality reduction by PPCI widened over time (1.3% 0-1 h to 4.2% >6 h after symptom onset). When the PCI-related delay was <35 min, the relative (67 vs. 28% pBreslow-Day = 0.004) and absolute (5.4 vs. 2.0%) mortality reduction was significantly higher than those with longer delays. CONCLUSION: PPCI was associated with significantly lower 30-day mortality relative to FL, regardless of treatment delay. Although logistic and economic constraints challenge the feasibility of 'PPCI-for-all', the benefit of timely treatment underscores the importance of a comprehensive, unified approach to delivery of cardiac care in all AMI patients.

Aged↗

PubMed2006

Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery.

Electrocardiography is commonly performed as part of preoperative cardiovascular risk assessment in patients undergoing noncardiac surgery. However, the prognostic value of such electrocardiography is still not clear. This study retrospectively studied 23,036 patients who underwent 28,457 surgical procedures at Erasmus Medical Center from 1991 to 2000. Patients were screened before surgery by type of surgery, cardiovascular risk factors (history of coronary heart disease, heart failure, diabetes mellitus, renal dysfunction, and stroke), and preoperative electrocardiography. Electrocardiographic (ECG) results showing atrial fibrillation, left or right bundle branch block, left ventricular hypertrophy, premature ventricular complexes, pacemaker rhythm, or Q-wave or ST-segment changes were classified as abnormal. Multivariate logistic regression was applied to evaluate the relation between ECG abnormalities and cardiovascular death. In-hospital cardiovascular death was observed in 199 of 28,457 patients (0.7%). Patients with abnormal ECG findings had a greater incidence of cardiovascular death than those with normal ECG results (1.8% vs 0.3%; adjusted odds ratio 4.5, 95% confidence interval 3.3 to 6.0). Adding ECG data to clinical risk factors and the type of surgery resulted in an improved C index for the prediction of cardiovascular death (0.79 vs 0.72). However, in patients who underwent low-risk or low- to intermediate-risk surgery, the absolute difference in the incidence of cardiovascular death between those with and without ECG abnormalities was only 0.5%. In conclusion, preoperative electrocardiography provides prognostic information in addition to clinical characteristics and the type of surgery. However, the usefulness of its routine use in lower risk surgery is questionable.

Aged↗

PubMed2006

Cardioprotective medication is associated with improved survival in patients with peripheral arterial disease.

OBJECTIVES: We sought to investigate the effect of cardiac medication on long-term mortality in patients with peripheral arterial disease (PAD). BACKGROUND: Peripheral arterial disease is associated with increased cardiovascular morbidity and mortality. Treatment guidelines recommend aggressive management of risk factors and lifestyle modifications. However, the potential benefit of cardiac medication in patients with PAD remains ill defined. METHODS: In this prospective observational cohort study, 2,420 consecutive patients (age, 64 +/- 11 years, 72% men) with PAD (ankle-brachial index < or =0.90) were screened for clinical risk factors and cardiac medication. Follow-up end point was death from any cause. Propensity scores for statins, beta-blockers, aspirin, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, diuretics, nitrates, coumarins, and digoxin were calculated. Cox regression models were used to analyze the relation between cardiac medication and long-term mortality. RESULTS: Medical history included diabetes mellitus in 436 patients (18%), hypercholesterolemia in 581 (24%), smoking in 837 (35%), hypertension in 1,162 (48%), coronary artery disease in 1,065 (44%), and a history of heart failure in 214 (9%). Mean ankle-brachial index was 0.58 (+/-0.18). During a median follow-up of eight years, 1,067 patients (44%) died. After adjustment for risk factors and propensity scores, statins (hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.36 to 0.58), beta-blockers (HR 0.68, 95% CI 0.58 to 0.80), aspirins (HR 0.72, 95% CI 0.61 to 0.84), and ACE inhibitors (HR 0.80, 95% CI 0.69 to 0.94) were significantly associated with a reduced risk of long-term mortality. CONCLUSIONS: On the basis of this observational longitudinal study, statins, beta-blockers, aspirins, and ACE inhibitors are associated with a reduction in long-term mortality in patients with PAD.

Atherosclerosis↗

PubMed2006

Treatment benefit by perindopril in patients with stable coronary artery disease at different levels of risk.

AIMS: Patients with stable coronary artery disease (CAD) are at increased risk. Estimation of individual risk is difficult. We developed a cardiovascular risk model based on the EUROPA study population and investigated whether benefit of long-term administration of the angiotensin-converting enzyme (ACE)-inhibitor perindopril was modified by risk level. METHODS AND RESULTS: A total of 12 218 patients with stable CAD were treated with 8 mg perindopril or placebo. Baseline patient characteristics were assessed for association with 1091 cardiovascular deaths or non-fatal myocardial infarction (MI). Risk factors were age over 65 years, male gender [hazard ratio (HR) 1.2], previous MI (HR 1.5), previous stroke and/or peripheral vascular disease (HR 1.7), diabetes, smoking, angina (all HR 1.5), and high serum cholesterol and systolic blood pressure. Treatment benefit by perindopril was consistent among high, intermediate, and low risk patients (HRs 0.88, 0.68, and 0.83, respectively). Risk reduction was thus not modified by absolute risk level. CONCLUSION: Risk factors such as age, male gender, smoking, total cholesterol, and blood pressure continue to play an important role once clinical sequellae of coronary heart disease have developed. Patients at moderate-to-high risk because of uncontrolled risk factors and those with other indications for ACE-inhibitors have the most to gain from ACE-inhibition.

Adult↗

PubMed2006

Incidence of recognized and unrecognized myocardial infarction in men and women aged 55 and older: the Rotterdam Study.

AIMS: Contemporary data on the incidence of unrecognized myocardial infarction (MI) among subjects aged 55 and older are limited. METHODS AND RESULTS: We studied the incidence of recognized and unrecognized MI in the Rotterdam Study, a population-based cohort of men and women aged 55 and older. The baseline examination was performed during 1990-93, with follow-up examinations during 1994-95, and 1997-2000. Baseline and follow-up 12-lead ECGs were analysed by the Modular ECG Analysis System. The 5148 participants who had no evidence of prevalent infarction were the subjects for analysis. Incident recognized infarction was defined as the occurrence of a fatal or non-fatal event coded as I21 according to the International Classification of Diseases, 10th edition. A repeat ECG was available in 4187 subjects. An unrecognized infarction was considered to have occurred if there was electrocardiographic evidence in the absence of a clinically recognized event. During a median follow-up of 6.4 years, 141 incident recognized infarctions occurred and the incidence rate of this event was 5.0 per 1000 person years. The incidence was higher in men (8.4) than in women (3.1). The incidence rate of unrecognized infarction was 3.8 per 1000 person years. Men (4.2) and women (3.6) had approximately similar incidence. Hence, the proportion of unrecognized infarction was lower in men (33%) than in women (54%). This difference in proportion of unrecognized infarctions was independent of age. CONCLUSION: A high proportion of incident MIs remains clinically unrecognized. As a history of MI is associated with an increased risk of repeat cardiovascular complications, our data suggest a need for periodical electrocardiographic screening to recognize (prevalent) infarctions and to install effective preventive treatment in those aged 55 and older.

Aged↗

PubMed2006

Effect of posterolateral scar tissue on clinical and echocardiographic improvement after cardiac resynchronization therapy.

BACKGROUND: Currently, one third of patients treated with cardiac resynchronization therapy (CRT) do not respond. Nonresponse to CRT may be explained by the presence of scar tissue in the posterolateral left ventricular (LV) segments, which may result in ineffective LV pacing and inadequate LV resynchronization. In the present study, the relationship between transmural posterolateral scar tissue and response to CRT was evaluated. METHODS AND RESULTS: Forty consecutive patients with end-stage heart failure (NYHA class III/IV), LV ejection fraction < or =35%, QRS duration >120 ms, left bundle-branch block, and chronic coronary artery disease were included. The localization and transmurality of scar tissue were evaluated with contrast-enhanced MRI. Next, LV dyssynchrony was assessed at baseline and immediately after implantation with tissue Doppler imaging. Clinical parameters, LV volumes, and LV ejection fraction were assessed at baseline and at a 6-month follow-up. Fourteen patients (35%) had a transmural (>50% of LV wall thickness) posterolateral scar. In contrast to patients without posterolateral scar tissue, these patients showed a low response rate (14% versus 81%; P<0.05) and did not show improvement in clinical or echocardiographic parameters. In addition, LV dyssynchrony remained unchanged after CRT implantation (84+/-46 versus 78+/-41 ms; P=NS). Patients without posterolateral scar tissue and severe baseline dyssynchrony (> or =65 ms) showed an excellent response rate of 95% compared with patients with a posterolateral scar and/or absent LV dyssynchrony (11%). CONCLUSIONS: CRT does not reduce LV dyssynchrony in patients with transmural scar tissue in the posterolateral LV segments, resulting in clinical and echocardiographic nonresponse to CRT.

Aged↗

PubMed2006

Gender differences in the management and clinical outcome of stable angina.

BACKGROUND: We sought to examine the impact of gender on the investigation and subsequent management of stable angina and to assess gender differences in clinical outcome at 1 year. METHODS AND RESULTS: The Euro Heart Survey of Stable Angina enrolled patients with a clinical diagnosis of stable angina on initial assessment by a cardiologist. Baseline clinical details and cardiac investigations planned or performed within a 4-week period of the assessment were recorded, and follow-up data were collected at 1 year. A total of 3779 patients were included in the survey; 42% were female. Women were less likely to undergo an exercise ECG (odds ratio, 0.81; 95% CI, 0.69 to 0.95) and less likely to be referred for coronary angiography (odds ratio, 0.59; 95% CI, 0.48 to 0.72). Antiplatelet and statin therapies were used significantly less in women than in men, both at initial assessment and at 1 year, even in those in whom coronary disease had been confirmed. Women with confirmed coronary disease were less likely to be revascularized than their male counterparts and were twice as likely to suffer death or nonfatal myocardial infarction during the 1-year follow-up period (hazard ratio, 2.09; 95% CI, 1.13 to 3.85), even after multivariable adjustment for age, abnormal ventricular function, severity of coronary disease, and diabetes. CONCLUSIONS: Significant gender bias has been identified in the use of investigations and evidence-based medical therapy in stable angina. Women were also less likely to be revascularized. The observed bias is of particular concern in light of the adverse prognosis observed among women with stable angina and confirmed coronary disease.

Aged↗

PubMed2006

Patients enrolled in coronary intervention trials are not representative of patients in clinical practice: results from the Euro Heart Survey on Coronary Revascularization.

AIMS: Revascularization in patients with coronary artery disease changed over the last two decades, favouring the number of patients treated by means of percutaneous coronary interventions (PCI) when compared with coronary artery bypass grafting (CABG). Many randomized controlled trials (RCTs) have been performed to compare these two competing revascularization techniques. Because of the strict enrolment criteria of RCTs in which highly selected patients are recruited, the applicability of the results may be limited in clinical practice. The current study evaluates to what extent patients in clinical practice were similar to those who participated in RCTs comparing PCI with CABG. METHODS AND RESULTS: Clinical characteristics and 1-year outcome of 4713 patients enrolled in the Euro Heart Survey on Coronary Revascularization were compared with 8647 patients who participated in 14 major RCTs, comparing PCI with CABG. In addition, we analysed which proportion of survey patients would have disqualified for trial participation (n=3033, 64%), aiming at identifying differences between trial-eligible and trial-ineligible survey patients. In general, important differences were observed between trial participants and survey patients. Patients in clinical practice were older, more often had comorbid conditions, single-vessel disease, and left main stem stenosis when compared with trial participants. Almost identical differences were observed between trial-eligible and trial-ineligible survey patients. In clinical practice, PCI was the treatment of choice, even in patients who were trial-ineligible (46% PCI, 26% CABG, 28% medical). PCI remained the preferred treatment option in patients with multi-vessel disease (57% in trial-eligible and 40% in trial-ineligible patients, respectively, P<0.001); yet, the risk profile of patients treated by PCI was better than that for patients treated either by CABG or by medical therapy. In the RCTs, there was no mortality difference between PCI and CABG. In clinical practice, however, we observed 1-year unadjusted survival benefit for PCI vs. CABG (2.9 vs. 5.4%, P<0.001). Survival benefit was only observed in trial-ineligible patients (3.3 vs. 6.2%, P<0.001). CONCLUSION: Many patients in clinical practice were not represented in RCTs. Moreover, only 36% of these patients were considered eligible for participating in a trial comparing PCI with CABG. We demonstrated that RCTs included younger patients with a better cardiovascular risk profile when compared with patients in everyday clinical practice. This study highlights the disparity between patients in clinical practice and patients in whom the studies that provide the evidence for treatment guidelines are performed.

Aged↗

PubMed2006

Elevated placental growth factor levels are associated with adverse outcomes at four-year follow-up in patients with acute coronary syndromes.

OBJECTIVES: This study sought to evaluate the predictive value of baseline placental growth factor (PlGF) for long-term cardiovascular events in acute coronary syndromes (ACS). BACKGROUND: A biomarker of vascular inflammation, PlGF is identified as a powerful predictor for short-term outcome in patients with ACS. METHODS: In 544 patients who were enrolled in the placebo arm of the c7E3 Fab Anti Platelet Therapy in Unstable REfractory angina (CAPTURE) trial, PlGF levels were determined as well as markers of myocardial necrosis (troponin T [TnT]), general inflammation (high-sensitivity C-reactive protein [hsCRP]), and platelet activation (soluble CD40 ligand [sCD40L]). Cox proportional hazard regression analyses were applied to evaluate the relationship between biomarkers and the occurrence of all-cause death or non-fatal myocardial infarction during a median follow-up period of four years. RESULTS: Patients with PlGF levels in the fourth and fifth quintile (>27 ng/l) had higher mortality than those with lower levels (10.8% vs. 3.2%; hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.6 to 7.1), as well as a higher incidence of the composite end point of death or myocardial infarction (27.6% vs. 11.3% events; HR, 2.6; 95% CI, 1.7 to 3.9). The relationship between PlGF and the composite end point remained significant after adjustment for TnT, sCD40L, and hsCRP (adjusted HR, 3.3; 95% CI, 2.0 to 5.4). CONCLUSIONS: In patients with ACS, elevated plasma levels of PlGF are associated with adverse cardiac outcomes during long-term follow-up. These data suggest that PlGF as a more specific marker of vascular inflammation should be considered for risk stratification of patients with ACS rather than general markers of inflammation.

Abciximab↗

PubMed2006

Predicting prognosis in stable angina--results from the Euro heart survey of stable angina: prospective observational study.

OBJECTIVES: To investigate the prognosis associated with stable angina in a contemporary population as seen in clinical practice, to identify the key prognostic features, and from this to construct a simple score to assist risk prediction. DESIGN: Prospective observational cohort study. SETTING: Pan-European survey in 156 outpatient cardiology clinics. PARTICIPANTS: 3031 patients were included on the basis of a new clinical diagnosis by a cardiologist of stable angina with follow-up at one year. MAIN OUTCOME MEASURE: Death or non-fatal myocardial infarction. RESULTS: The rate of death and non-fatal myocardial infarction in the first year was 2.3 per 100 patient years; the rate was 3.9 per 100 patient years in the subgroup (n = 994) with angiographic confirmation of coronary disease. The clinical and investigative factors most predictive of adverse outcome were comorbidity, diabetes, shorter duration of symptoms, increasing severity of symptoms, abnormal ventricular function, resting electrocardiogaphic changes, or not having any stress test done. Results of non-invasive stress tests did not significantly predict outcome in the population who had tests done. A score was constructed using the parameters predictive of outcome to estimate the probability of death or myocardial infarction within one year of presentation with stable angina. CONCLUSIONS: A score based on the presence of simple, objective clinical and investigative variables makes it possible to discriminate effectively between very low risk and very high risk patients and to estimate the probability of death or non-fatal myocardial infarction over one year.

Angina Pectoris↗

PubMed2006

Outcomes of patients in clinical trials with ST-segment elevation myocardial infarction among countries with different gross national incomes.

AIMS: To evaluate whether there is an association between 30-day mortality in patients with ST-segment elevation myocardial infarction (STEMI) included in clinical trials and country gross national income (GNI). METHODS AND RESULTS: A retrospective analysis of the databases of five randomized trials including 50 310 patients with STEMI (COBALT 7169, GIK-2 2931, HERO-2 17,089, ASSENT-2 17,005, and ASSENT-3 6116 patients) from 53 countries was performed. Countries were divided into three groups according to their GNI based on the World Bank data: low (less than 2900 US dollars), medium (between 2900 US dollars and 9000 US dollars), and high GNI (more than 9000 US dollars per capita). Baseline characteristics, in-hospital management variables, and 30-day outcomes were evaluated. A previously defined logistic regression model was used to adjust for differences in baseline characteristics and to predict mortality. The observed mortality was higher than the predicted mortality in the low (12.1 vs. 11.8%) and in the medium income groups (9.4 vs. 7.9%), whereas it was lower in the high income group (4.9 vs. 5.6%). CONCLUSION: An inverse relationship between mortality and GNI was observed in STEMI clinical trials. Most of the variability in mortality can be explained by differences in baseline characteristics; however, after adjustment, lower income countries have higher mortality than the expected.

Female↗