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Biomedical subjects

R M Califf

Publications and source records attributed to R M Califf.

At least 523 records · Page 29Linked to original sources
PubMed1986

Medical, psychological and social correlates of work disability among men with coronary artery disease.

This study identifies the medical, psychologic and social factors that independently affect employment in patients with coronary artery disease (CAD). At coronary angiography, extensive clinical, psychological and social profiles were collected on 814 men younger than 60 years with documented CAD. Clinical factors studied included measures of symptom severity, prior myocardial infarction, coronary anatomy and left ventricular function. Psychosocial factors studied included the Minnesota Multiphasic Personality Inventory (MMPI), Zung Depression and Anxiety Scales, a type A structured interview, Jenkins Activity Survey and measures of education and social support. Multiple logistic regression analyses were used to assess the relative strength of the relation between these different factors and the patients' employment status. Many single factors differed between the 204 men (25%) who were disabled and the 610 (75%) who were not. Disabled men were less educated but no different in age, marital status or number of dependents. Disabled men had lower ejection fractions and higher indexes of angina, previous myocardial infarction and coexisting vascular disease. Disabled men also were more depressed and anxious and had lower ego strength and higher hypochondriasis scores on the MMPI, but were no different in type A behavior. By multivariable analysis, the most significant (p less than 0.01) independent predictors of work disability were, in decreasing order of importance, low education level, history of myocardial infarction, high levels of depression and high levels of hypochondriasis. It is concluded that psychological and social factors are strongly related to work status in patients with CAD, and may be more important than medical factors.

Anxiety↗
PubMed1986

A simplified method to predict occurrence of complete heart block during acute myocardial infarction.

Data were analyzed from 698 patients with proved acute myocardial infarction (AMI) to develop a method to predict the occurrence of complete heart block (CHB). The presence of electrocardiographic abnormalities of atrioventricular or intraventricular conduction during hospitalization was determined for each patient. The electrocardiographic risk factors considered were: first-degree atrioventricular block, Mobitz type I atrioventricular block, Mobitz type II atrioventricular block, left anterior hemiblock, left posterior hemiblock, right bundle branch block and left bundle branch block. A CHB risk score was developed that consisted of the sum of each patient's individual risk factors. CHB risk scores of 0, 1, 2 or 3 or more were associated with incidences of CHB of 1.2, 7.8, 25.0 and 36.4%, respectively. When applied to an independent AMI data base, as well as to the summed results of 6 previously reported series that identified predictors of CHB during AMI, a similar incremental risk of CHB as predicted by the risk score method was demonstrated.

Electrocardiography↗
PubMed1986

Predicting outcome in coronary disease. Statistical models versus expert clinicians.

To study the accuracy with which long-term prognosis can be predicted in patients with coronary artery disease, prognostic predictions from a data-based multivariable statistical model were compared with predictions from senior clinical cardiologists. Test samples of 100 patients each were selected from a large series of medically treated patients with significant coronary disease. Using detailed case summaries, five senior cardiologists each predicted one- and three-year survival and infarct-free survival probabilities for 100 patients. Fifty patients appeared in multiple samples for assessing interphysician variability. Cox regression models, developed using patients not in the test samples, predicted corresponding outcome probabilities for each test patient. Overall, model predictions correlated better with actual patient outcomes than did the doctors' predictions. For three-year survival, rank correlations were 0.61 (model) and 0.49 (doctors). For three-year infarct-free survival predictions, correlations with outcome were 0.48 (model) and 0.29 (doctors). Comparisons by individual doctor revealed Cox model three-year survival predictions were better than those of four of five doctors (model predictions added significant [p less than 0.05] prognostic information to the doctor's predictions, whereas the converse was not true). For infarct-free survival, the Cox model was superior to all five doctors. Where predictions were made by multiple doctors, the interphysician variability was substantial. In coronary artery disease, statistical models developed from carefully collected data can provide prognostic predictions that are more accurate than predictions of experienced clinicians made from detailed case summaries.

Coronary Disease↗
PubMed1986

Rate-related left bundle branch block with chest pain and normal coronary arteriograms treated by exercise training.

A clinical observation of chest pain associated with the onset of rate-related left bundle branch block has been described in patients with normal coronary arteriograms. The authors used standard cardiac rehabilitation techniques for exercise training in a 47-year-old woman with these manifestations. Serial treadmill tests revealed that during the course of 3 months of exercise training, the heart rate at onset of LBBB gradually rose from 133 to 175 beats per minute, and she no longer developed symptoms during her routine daily activities or exercises. Exercise training was a successful nonpharmacologic strategy that delayed the onset of rate-related LBBB and chest pain in this patient and avoided the need for beta blocker therapy.

Bundle-Branch Block↗
PubMed1985

Diagnostic and prognostic significance of minimally elevated creatine kinase-MB in suspected acute myocardial infarction.

CK-MB changes were studied using agarose gel electrophoresis in 244 patients admitted to a coronary care unit for suspected acute myocardial infarction (AMI). A range of minimally elevated CK-MB levels, from 1 to 24 IU/liter, was identified as representing uncertain AMI events. Positive AMI events were defined by elevations of 25 IU/liter or more documented in patients with new Q waves or abnormalities in all enzyme and isoenzyme levels. Negative AMI events were defined by elevation of 0 IU/liter, observed in all control subjects. The 1-year cardiac mortality rates in the "positive"-AMI (n = 91) and "uncertain"-AMI (n = 22) groups were identical (22%), and significantly higher than that in the "negative"-AMI group (n = 93) (6%) (p less than 0.05). However, when a larger uncertain-AMI group of 115 patients was compiled by 2 collaborating centers, the 1-year cardiac mortality rate in the 39 patients with chest pain alone was 0%, vs 33% in the 76 patients with accompanying severe medical problems such as cardiac or respiratory failure. Whether minimal CK-MB elevations represent AMI of limited extent is not clear. These elevations occur most often in association with severe medical problems, and in patients without such problems, they may not indicate a poor prognosis.

Adult↗
PubMed1985

Value of radionuclide angiography for predicting specific cardiac events after acute myocardial infarction.

The value of rest and exercise radionuclide angiography (RNA) for predicting specific events including death, recurrent acute myocardial infarction (AMI), coronary care unit readmission for unstable chest pain, and medically refractory angina after AMI was studied in 106 consecutive survivors of AMI. Analysis of the RNA variables using the Cox proportional hazards regression model yielded significant associations of the time to death with ejection fraction at rest and during exercise (X2 = 11.1 and 14.0, respectively). Both variables added significant prognostic information to the clinical assessment (X2 = 4.3 and 5.7, respectively). The change in ejection fraction from rest to exercise predicted the time to coronary artery bypass grafting for medically refractory angina before (X2 = 21.0) and after (X2 = 13.2) adjustment for the clinical descriptors, but did not predict death or other non-fatal events. Significant correlations were found between RNA variables and a variety of clinical descriptors previously reported to have prognostic significance. Clinical and RNA variables that are measures of left ventricular function were predictive of subsequent mortality, whereas those that reflect residual potentially ischemic myocardium were predictive of subsequent nonfatal ischemic events. Rest and exercise RNA after AMI provides significant prognostic information regarding specific events during follow-up independent of that provided by clinical assessment.

Adult↗
PubMed1985

Prognostic significance of precordial ST-segment depression during inferior acute myocardial infarction.

To study the mechanism and prognostic importance of precordial ST-segment depression during inferior acute myocardial infarction, 162 patients admitted during 1969 through 1982 were identified. Patients with ST depression in leads V1, V2 and V3 had significantly larger infarctions as assessed by a QRS scoring system. Hospital mortality was 4% (3 of 75) among patients without ST depression, and 13% (11 of 87) in patients with ST depression. The relation between the amount of ST depression and hospital mortality was significant (p less than 0.001 by logistic regression), and remained significant (p less than 0.003) after adjusting for other potentially prognostic factors. Among patients discharged from the hospital, the 5-year survival was 92% in those without precordial ST depression and 80% in those with precordial ST depression (p = 0.058 by the Cox model). Precordial ST-segment depression on the admission electrocardiogram during an inferior acute myocardial infarction indicates a larger infarction, predicts a higher hospital mortality and suggests a worse long-term prognosis after discharge.

Adult↗
PubMed1985

Prognostic value of a coronary artery jeopardy score.

The prognostic value of a coronary artery jeopardy score was evaluated in 462 consecutive nonsurgically treated patients with significant coronary artery disease, but without significant left main coronary stenosis. The jeopardy score is a simple method for estimating the amount of myocardium at risk on the basis of the particular location of coronary artery stenoses. In patients with a previous myocardial infarction, higher jeopardy scores were associated with a lower left ventricular ejection fraction. When the jeopardy score and the number of diseased vessels were considered individually, each descriptor effectively stratified prognosis. Five year survival was 97% in patients with a jeopardy score of 2 and 95, 85, 78, 75 and 56%, respectively, for patients with a jeopardy score of 4, 6, 8, 10 and 12. In multivariable analysis when only jeopardy score and number of diseased vessels were considered, the jeopardy score contained all of the prognostic information. Thus, the number of diseased vessels added no prognostic information to the jeopardy score. The left ventricular ejection fraction was more closely related to prognosis than was the jeopardy score. When other anatomic factors were examined, the degree of stenosis of each vessel, particularly the left anterior descending coronary artery, was found to add prognostic information to the jeopardy score. Thus, the jeopardy score is a simple method for describing the coronary anatomy. It provides more prognostic information than the number of diseased coronary arteries, but it can be improved by including the degree of stenosis of each vessel and giving additional weight to disease of the left anterior descending coronary artery.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Angiography↗
PubMed1985

Randomized trials of coronary artery bypass surgery: impact on clinical practice at Duke University Medical Center.

Trends in practice patterns at Duke University Medical Center were assessed in patient groups comparable to those enrolled in the three major randomized trials of coronary artery bypass grafting (CABG). In addition, changes in practice patterns that appeared unrelated to the randomized trials were examined. Most patients with 75% or greater left main stenosis have been treated surgically after publication of the Veterans Administration Cooperative Study, but little change was noted in the proportion of patients with 50% left main stenosis who have been treated surgically. A trend towards selection of surgical therapy for patients with three-vessel disease and normal left ventricular function was evident before the publication of the European Coronary Surgery Study, although one-third of patients in this category continue to be treated nonsurgically after publication of the results of the trial. For the past decade, most patients who would have been eligible for the Coronary Artery Surgery Study have been treated nonsurgically. We have also documented trends in practice patterns that are independent of the results of randomized trials. The advent of percutaneous transluminal angioplasty has provided another therapeutic alternative that has been used increasingly. In addition, growing numbers of patients with advanced age, unstable angina, or markedly depressed left ventricular ejection fraction are being evaluated with cardiac catheterization despite the lack of supporting randomized trials. Randomized trials have placed our understanding of the effects of CABG on a sound foundation, but it is evident that clinicians continue to consider many other factors when therapeutic decisions are made.

Academic Medical Centers↗
PubMed1984

"Left main equivalent" coronary artery disease: its clinical presentation and prognostic significance with nonsurgical therapy.

The clinical characteristics and nonsurgical prognosis of 55 patients with "left main (LM) equivalent" coronary artery disease (CAD) were evaluated and defined as: (1) greater than or equal to 75% diameter reduction of the left anterior descending coronary artery (LAD) before the takeoff of any large septal perforator or anterolateral (diagonal) branches; (2) greater than or equal to 75% diameter reduction of the left circumflex artery (LC) before the takeoff of any large marginal branch; and (3) absence of greater than or equal to 50% stenosis of the LM coronary artery. Compared with nonsurgically treated patients with greater than or equal to 75% stenosis of the LM artery, patients with LM equivalent CAD had a shorter duration of symptoms (median of 51 months vs 66 months) and more often had a Q wave on the electrocardiogram (60 vs 39%). Survival in patients with LM equivalent CAD (78% at 1 year and 55% at 5 years) was better than that in patients with LM disease with nonsurgical therapy (65% at 1 year and 40% at 5 years) (p = 0.02), although the rate of freedom from cardiovascular events was not significantly different. Compared with other nonsurgically treated patients with 2- or 3-vessel CAD involving the LAD and LC (28 and 42%, respectively, with progressive angina), patients with LM equivalent CAD had more severe anginal symptoms (55% with progressive angina) and a longer duration of symptoms (medians of 20 months in 2-vessel CAD, 36 months in 3-vessel CAD and 51 months in LM equivalent CAD).(ABSTRACT TRUNCATED AT 250 WORDS)

Constriction, Pathologic↗
PubMed1984

Prognostic indicators from radionuclide angiography in medically treated patients with coronary artery disease.

The purpose of this investigation was to determine which variables obtained when performing radionuclide angiography predict subsequent survival or total events (cardiovascular death or nonfatal myocardial infarction) in stable patients with symptomatic coronary artery disease (CAD). Univariable and multivariable analyses of 6 variables, including ejection fraction (EF) at rest and exercise, change in EF with exercise, development of ischemic chest pain or electrocardiographic changes, left ventricular (LV) wall motion abnormalities and exercise time were examined in 386 patients followed up to 4.5 years. Univariate analyses revealed that the exercise EF was the variable most closely associated with future events (p less than 0.01), followed by EF at rest, wall motion abnormalities and exercise time. Multivariable analyses revealed that once the exercise EF was known, no other radionuclide variables contributed independent information about the likelihood of future events. Multivariable analyses also revealed that the exercise EF describes much of the prognostic information of coronary anatomy. Our findings suggest that the radionuclide angiogram is useful in predicting future events in patients with stable CAD, although examination in conjunction with other clinical descriptors will be necessary to further quantify this contribution.

Cardiac Output↗
PubMed1984

Factors affecting sensitivity and specificity of exercise electrocardiography. Multivariable analysis.

Unlike the predictive value of a diagnostic test, which depends on the prevalence of disease in the population tested, its sensitivity and specificity have been assumed to be constants. This assumption was examined in patients who had both exercise electrocardiography and cardiac catheterization. The effects on sensitivity of factors from clinical history, catheterization, and exercise performance were defined by multivariable logistic regression analysis in 1,401 patients with coronary disease; effects on specificity were defined by a similar analysis in 868 patients without coronary disease. Five factors had significant, independent effects on exercise electrocardiographic sensitivity: maximal exercise heart rate, number of diseased coronary arteries, type of angina, and the patient's age and sex. Only maximal exercise heart rate had a significant, independent effect on exercise electrocardiographic specificity. Thus, the sensitivity and specificity of exercise electrocardiography vary with clinical history, extent of disease, and treadmill performance; the sensitivity and specificity of other diagnostic tests may also vary.

Adult↗
PubMed1984

Prognostic significance of isolated sinus tachycardia during first three days of acute myocardial infarction.

Sinus tachycardia often accompanies other indicators of poor prognosis in acute myocardial infarction. This study was performed to evaluate the prognostic significance of early (Days 1 to 3) in-hospital sinus tachycardia (isolated sinus tachycardia) in the absence of other common indicators of poor prognosis. All patients consecutively admitted directly to the cardiac care unit during a six-year period were evaluated. Patients who had confirmed acute myocardial infarction and no urgent complications during Days 1 to 3 with isolated sinus tachycardia (99 patients) or without isolated sinus tachycardia (159 patients) were included in the study. Both groups were followed for subsequent in-hospital outcome and long-term survival. Univariable and multivariable analysis of historical and demographic characteristics showed no significant differences between the two groups. When clinical descriptors of the infarct were evaluated, the group with isolated sinus tachycardia had a significantly higher mean peak creatine kinase level (p = 0.0007), a larger proportion of anterior infarcts and multiple infarct sites (p less than 0.001) by electrocardiography, a higher incidence of peri-infarction pericarditis (p = 0.007), and a higher incidence of recurrent chest pain (p = 0.03). Twenty-five patients (25 percent) in the group with isolated sinus tachycardia had subsequent urgent complications during the hospitalization compared with 11 patients (7 percent) in the control group (p = 0.00005). In multivariable analysis, isolated sinus tachycardia was an independent predictor of subsequent urgent complications (p = 0.0009) and mortality (p = 0.05).

Age Factors↗
PubMed1984

Accuracy and interobserver variability of coronary cineangiography: a comparison with postmortem evaluation.

The accuracy of interpretation of coronary cineangiography by two independent observers was tested against postmortem findings in 27 patients who died within 6 months of cardiac catheterization. Variations in cineangiographic interpretations between the angiographers were also evaluated. Two patients had normal coronary arteries, while the remaining 25 patients had significant coronary artery disease. Significant stenosis was defined as 75% or greater reduction in luminal diameter. Of 326 coronary segments that could be evaluated postmortem, 15% could not be evaluated cineangiographically. The respective overall accuracy of the two observers was 89 and 88% with an accuracy of 96 and 100% for the left main coronary artery, 91 and 93% for the left anterior descending artery, 84 and 86% for the right coronary artery and 89 and 79% for the left circumflex coronary artery. Cineangiographic assessment of luminal status distal to a significant proximal lesion was possible in more than 70% of major vessels with accuracy levels of 86% for both observers. Of 96 distal vessels inadequately opacified cineangiographically, 49 (52%) were found to be free of significant lesions. Both angiographers agreed in their assessment of 86% of the 340 coronary segments. Interobserver agreement was significantly better for the left main, right and left anterior descending coronary arteries than for the left circumflex coronary artery (p less than 0.05). Accuracy was 93% for 244 segments that were adequately opacified and assessed the same by both angiographers. Cineangiography can thus be used to evaluate coronary anatomy with a high degree of accuracy and minimal interobserver variability.

Autopsy↗