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PubMed1985

The use of rest and exercise radionuclide ventriculography in risk stratification in patients with suspected coronary artery disease.

The study examined the value of rest and exercise radionuclide ventriculography in risk stratification in patients with suspected coronary artery disease. There were 604 patients, 474 men and 130 women, aged 55 +/- 11 years (mean +/- standard deviation). At a follow-up of 18 +/- 10 months, there were 43 hard cardiac events: 27 patients died of cardiac causes and 16 had nonfatal acute myocardial infarctions. Univariate and multivariate survival analysis of the 10 most important clinical and exercise variables identified the exercise left ventricular ejection fraction as the most important predictor of death and total cardiac events (chi 2 = 18.1 and 29.6, respectively). The exercise heart rate was a significant, independent, but much weaker predictor of cardiac death and total events (chi 2 = 8.4 and 3.9, respectively), while exercise tolerance was a significant independent predictor of cardiac death only (chi 2 = 6.4). Actuarial life table analysis showed that the risk for future cardiac events increased in stepwise fashion as the exercise ejection fraction decreased. Thus, the exercise left ventricular ejection fraction is a useful prognosticator in patients with suspected coronary artery disease. This finding has important implications in patient management.

Actuarial Analysis↗
PubMed1998

Dobutamine stress echocardiography for preoperative cardiac risk stratification in patients undergoing orthotopic liver transplantation.

This study attempts to evaluate the efficacy of dobutamine stress echocardiography for preoperative cardiac risk stratification in patients undergoing orthotopic liver transplantation. Two hundred twenty consecutively submitted patients were evaluated in preparation for orthotopic liver transplantation. Dobutamine stress echocardiography was performed in 80 patients with known or suspected coronary artery disease. Follow-up information was available in 40 patients in the form of cardiac catheterization and/or outcome from liver transplantation to validate the dobutamine stress echo findings. The prevalence of coronary artery disease in this cohort was 5% and was closely associated with the presence of diabetes mellitus. Dobutamine stress echocardiography, when interpreted as abnormal in the presence of wall motion abnormalities only, is associated with a sensitivity, specificity, and positive and negative predictive value of 100%. Dobutamine stress echocardiography is highly efficacious and should be the screening study of choice to detect coronary artery disease in patients undergoing orthotopic liver transplantation.

Adult↗
PubMed2001

Combination of Goldman risk and initial cardiac troponin I for emergency department chest pain patient risk stratification.

BACKGROUND: Accurate identification of low-risk emergency department (ED) chest pain patients who may be safe for discharge has not been well defined. Goldman criteria have reliably risk-stratified patients but have not identified any subset safe for ED release. Cardiac troponin I (cTnI) values have also been shown to risk-stratify patients but have not identified a subset safe for ED release. OBJECTIVE: To test the hypothesis that ED chest pain patients with a Goldman risk of < or =4% and a single negative cTnI (< or =0.3 ng/mL) at the time of ED presentation would be safe for discharge [<1% risk for death, acute myocardial infarction (AMI), revascularization]. METHODS: A prospective cohort study was performed in which consecutive ED chest pain patients were enrolled from July 1999 to November 2000. Data collected included patient demographics, medical and cardiac history, electrocardiogram, and creatine kinase-MB and cTnI. Goldman risk stratification score was calculated while patients were still in the ED. Hospital course was followed daily. Telephone follow-up occurred at 30 days. The main outcome was death, AMI, or revascularization (percutaneous transluminal coronary angioplasty/stents/coronary artery bypass grafting) within 30 days. RESULTS: Of 2,322 patients evaluated, 998 had both a Goldman risk < or =4% and a cTnI < or =0.3 ng/mL. During the initial hospitalization, 37 patients met the composite endpoint (3.7%): 6 deaths (0.7%), 17 AMIs (1.7%), 18 revascularizations (1.8%). Between the time of hospital discharge and 30-day follow-up, 15 patients met the composite endpoint: 4 deaths (0.4%), 6 AMIs (0.6%), and 5 revascularizations (0.5%). Overall, 49 patients met the composite endpoint (4.9%; 95% CI = 3.6% to 6.2%): 10 deaths (1.0%; 95% CI = 0.4% to 1.6%); 23 AMIs (2.3%; 95% CI = 1.4% to 3.2%), and 23 revascularizations (2.3%; 95% CI = 1.4% to 3.2%) within 30 days of presentation. CONCLUSIONS: The combination of two risk stratification modalities for ED chest pain patients (Goldman risk < or =4% and cTnI < or =0.3 ng/mL) did not identify a subgroup of chest pain patients at <1% risk for death, AMI, or revascularization within 30 days.

Aged↗
PubMed1989

Long-term survival and risk stratification in patients with angina at rest undergoing medical treatment.

In order to determine those factors which influence long-term prognosis in patients with angina at rest associated with transient ST-segment changes, 217 patients undergoing medical treatment were followed for a mean of 39 months. All patients underwent coronary arteriography. Univariate analysis identified 12 variables significantly related to prognosis. These were disease of the left main coronary artery; the number of diseased vessels; left ventricular end-diastolic pressure; ejection fraction; baseline electrocardiogram; presence of prior myocardial infarction; ST-segment depression and ventricular arrhythmias during pain; disease of the proximal anterior descending coronary artery; crescendo angina; hypertension; and age. Use of the Cox regression model for survival analysis revealed only 3 variables which were independent predictors of prognosis. They were disease of the left main coronary artery; the number of diseased vessels and left ventricular end-diastolic pressure. The model allowed stratification of patients into 3 groups. Survival at 3 years was 98% in the low risk group; 82% in the intermediate risk group; and 58% in the high risk group. These data indicate that disease of the left main coronary artery, the number of diseased vessels and left ventricular end-diastolic pressure are the independent predictors of prognosis in angina at rest. These variables may allow stratification of patients into groups having different long-term survivals.

Adult↗
PubMed2004

Natriuretic peptides for risk stratification of patients with acute coronary syndromes.

Natriuretic peptides (BNP and NT-proBNP) have been shown to be useful tools for risk stratification of patients with acute myocardial ischemia encompassing the whole spectrum of acute coronary syndromes (ACS), particularly for prediction of mortality. Both BNP and NT-proBNP possess several characteristics of the ideal biomarker, showing independent and incremental prognostic value above traditional clinical, electrocardiographic, and biochemical (particularly troponin) risk indicators. Specifically, in ACS patients, BNP and NT-proBNP have powerful prognostic value both in patients without a history of previous heart failure or without clinical or instrumental signs of left ventricular dysfunction on admission or during hospital stay. They can also be easily and rapidly measured in an emergency context. We have performed a meta-analysis of available studies concerning the prognostic value of natriuretic peptides. Our results show that the prognostic value of natriuretic peptides is similar: (1) both at short- and long-term; (2) when natriuretic peptides are measured at first patient contact or during hospital stay; (3) for BNP or NT-proBNP; and (4) in patients with ST elevation myocardial infarction or no ST elevation ACS. These data suggest that natriuretic peptide measurement should be integrated into routine evaluation of patients with an ACS.

Angina, Unstable↗
PubMed2005

Stress echocardiography is superior to exercise ECG in the risk stratification of patients presenting with acute chest pain with negative Troponin.

OBJECTIVE: To compare exercise electrocardiography (ExECG) and stress echocardiography (SE) in the risk stratification of patients presenting to hospital with cardiac-sounding chest pain, non-diagnostic ECGs and negative cardiac Troponin. METHODS: Patients presenting with acute chest pain were prospectively randomised to early ExECG or SE. A post-test likelihood of CAD was determined by the pre-test likelihood and the result of the stress test. Patients with a low post-test likelihood of CAD were discharged; those with a high post-test probability were considered for coronary angiography. All others were managed according to standard hospital protocols. RESULTS: A total of 302 patients underwent either ExECG or SE. SE identified significantly more patients with a low post-test probability of CAD (80% vs 31%, p<0.0001) and significantly fewer patients with an intermediate post-test likelihood of CAD compared to ExECG (3% vs 47%; p<0.0001). Significantly fewer patients undergoing SE were referred for further tests to exclude or refute the diagnosis of CAD (16% vs 52%; p<0.0001). In total, 36 (12%) had flow limiting CAD demonstrated by coronary angiography. Significant CAD was seen in fewer patients with a positive ExECG than with a positive SE (56% vs 84% (p=0.12)). Event rates were low for both modalities in patients with low post-test probability (3.5% for SE vs 5.1% for ExECG; p=ns) though the number of patients identified as low risk was higher if SE was performed. CONCLUSION: Despite negative cardiac Troponin, 12% of patients with acute chest pain had significant CAD. SE is superior to ExECG in discriminating between those patients with a low and intermediate risk of CAD and correctly identified patients with significant CAD, as well as conferring an excellent prognosis in those considered low risk. SE significantly reduces the requirement for further tests to diagnose CAD compared to ExECG.

Analysis of Variance↗
PubMed1993

Stratification of patients according to prior cardiopulmonary disease and probability assessment based on the number of mismatched segmental equivalent perfusion defects. Approaches to strengthen the diagnostic value of ventilation/perfusion lung scans in acute pulmonary embolism.

A categorical diagnosis of "high probability" or "intermediate probability" encompasses a spectrum of diagnostic probabilities of pulmonary embolism (PE) that is not communicated to the referring physician. The diagnostic value of ventilation/perfusion lung scans, in the present investigation, was strengthened by use of a table to determine the likelihood of PE in individual patients on the basis of the observed number of mismatched segmental equivalent perfusion defects. In addition, we tested the hypothesis that stratification of patients according to the presence or absence of prior cardiopulmonary disease may enhance the ventilation/perfusion scan assessment of the probability of PE among both of these clinical categories of patients. Data were derived from the collaborative study of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). Ventilation/perfusion lung scans were evaluated in 378 patients with acute PE and 672 patients in whom suspected PE was excluded. Among patients with no prior cardiopulmonary disease, > or = 1.0 mismatched segmental equivalents was indicative of PE in 102 of 118 (86 percent) vs 113 of 155 (73 percent) among patients with prior cardiopulmonary disease (p < 0.02). Among patients with prior cardiopulmonary disease, > or = 2 mismatched segmental equivalents were required to indicate > or = 80 percent probability of PE. Stratification on the basis of the presence or absence of prior cardiopulmonary disease, therefore, enhanced the ability of ventilation/perfusion scan readers to assign an accurate positive predictive value and specificity to individual patients based on the observed number of mismatched segmental equivalent defects. Among patients with no prior cardiopulmonary disease, fewer mismatched segmental equivalent defects were required to indicate a high probability of PE than were required by PIOPED criteria. The findings from some of these patients, by PIOPED criteria, would have indicated intermediate probability. Some indeterminate probability readings, therefore, will be eliminated among patients stratified with no prior cardiopulmonary disease.

Acute Disease↗
PubMed1998

Value of pharmacologic stress echocardiography in risk stratification of patients with single-vessel disease: a report from the Echo-Persantine and Echo-Dobutamine International Cooperative Studies.

OBJECTIVES: This study sought to verify the effectiveness of pharmacologic stress echocardiography in risk stratification of patients with single-vessel disease. BACKGROUND: Noninvasive prognostic assessment of single-vessel disease is an unresolved issue to date. METHODS: The study evaluated prospectively collected data from 754 patients with angiographic single-vessel disease who underwent either dipyridamole (n = 576) or dobutamine (n = 178) stress echocardiography. Invasive treatment (coronary revascularization within 3 months of stress testing) was performed in 260 patients and medical treatment in 494. RESULTS: Echocardiographic positivity was observed in 421 patients (56%). Patients treated invasively had a higher incidence of stress test positivity (69% vs. 49%, p < 0.001) and left anterior descending coronary artery involvement (60% vs. 46%, p < 0.001) than patients maintained with medical therapy. During a mean follow-up of 37 months, 54 hard cardiac events occurred (14 deaths, 40 nonfatal infarctions): 37 in medically and 17 in invasively treated patients (7.5% vs. 6.5%, p = NS). On Cox analysis, a positive result on stress testing was the only independent prognostic predictor in medically treated patients (relative risk 2.92, 95% confidence interval 1.29 to 6.59). The 4-year infarction-free survival rate was higher for a negative than a positive stress test result in medically (93.9% vs. 87.3%, p = 0.009) but not invasively treated patients (92.7% vs. 97.1%, p = 0.545). Moreover, a significantly higher 4-year infarction-free survival rate was found in invasively versus medically treated patients with a positive (p = 0.012), but not in those with a negative, stress test result (p = 0.853). CONCLUSIONS: Pharmacologic stress echocardiography is effective in risk stratification of single-vessel disease and can accurately discriminate patients in whom coronary revascularization can have the maximal beneficial effect. These findings have a potential favorable impact on the cost-effectiveness of invasive procedures.

Coronary Artery Bypass↗
PubMed2005

High-sensitivity C-reactive protein: potential adjunct for risk stratification in patients with stable congestive heart failure.

AIMS: To determine the potential adjunct of high-sensitivity (hs) C-reactive protein for risk stratification in patients with stable congestive heart failure (CHF). METHODS AND RESULTS: We studied 546 consecutive patients clinically stable with an ejection fraction <45% who were referred to our centre for evaluation of left ventricular dysfunction. hs C-reactive protein levels were determined on blood samples obtained on entry into the study. Clinical follow-up (median 972 days) was obtained for 545 patients. Cardiovascular mortality was significantly increased (P=0.001) in patients with hs C-reactive protein >3 mg/L. By multivariable analysis, including clinical, biological, and echocardiographic variables, hs C-reactive protein >3 mg/L was an independent predictor of cardiovascular mortality [HR=1.78 (1.17-2.72); P=0.008]; the strongest predictive parameter in this model was B-type natriuretic peptide (BNP) (P=0.005). When peak VO(2) was included into the model, hs C-reactive protein >3 mg/L remained an independent predictor of cardiovascular mortality [HR=1.55 (1.02-2.38); P=0.04]; the strongest predictive parameter in this model was peak VO(2) (P<0.0001). In patients with ischaemic CHF, cardiovascular mortality was significantly increased in patients with hs C-reactive protein >3 mg/L (P=0.001), whereas in patients with non-ischaemic CHF, hs C-reactive protein >3 mg/L was not associated with cardiovascular mortality (P=0.098). By multivariable analysis, hs C-reactive protein >3 mg/L was an independent predictor of cardiovascular mortality in ischaemic patients [HR=2.16 (1.23-3.78)] but not in non-ischaemic patients [HR=1.05 (0.52-2.11)]. CONCLUSION: Cardiovascular mortality is increased in CHF patients with hs C-reactive protein >3 mg/L. The impact of hs C-reactive protein is independent of usual prognostic parameters, in particular BNP and peak VO(2). The interest of hs C-reactive protein determination appears to be especially marked in patients with ischaemic cardiomyopathy.

C-Reactive Protein↗
PubMed1994

Risk stratification in patients with chest pain.

The evaluation of patients with chest pain and suspected coronary disease remains a challenge for primary care physicians. In this article, three major points are emphasized. First, making full use of the data collected during the initial encounter prior to performance of an exercise test is helpful in formulating assessments of both the likelihood of significant coronary disease and of the short-term risk of a major cardiac event. Second, exercise testing is helpful for intermediate-likelihood patients because positive tests in low-likelihood patients cannot "rule in" disease, and negative tests in high-likelihood patients cannot "rule out" disease. Finally, exercise testing in risk stratification of the patient with suspected coronary artery disease is valuable in identifying low-risk patients in whom further testing, including catheterization, may be safely deferred.

Chest Pain↗
PubMed2001

Exercise echocardiography for the prognostic stratification of patients with low pretest probability of coronary artery disease.

PURPOSE: The aim of this study was to determine whether exercise echocardiography provides incremental data for risk stratification of patients with a low pretest probability of coronary artery disease. PATIENTS AND METHODS: The study included patients referred for exercise echocardiography whose probability of coronary artery disease was 25% or less. We calculated an exercise wall motion score index (on a 1-5 scale), an indicator of the extent and severity of exercise-induced abnormalities. The primary outcomes of the study were subsequent cardiac events (cardiac death and nonfatal myocardial infarction). RESULTS: We studied 571 men and 1047 women; their mean (+/- SD) age was 55 +/- 13 years. During a median follow-up of 3 years, there were 19 cardiac events (6 cardiac deaths and 13 nonfatal myocardial infarctions); an additional 37 patients underwent coronary revascularization. In a multivariate analysis of clinical, exercise electrocardiographic, and echocardiographic parameters, exercise wall motion score index (hazard ratio [HR] = 2.1 per 0.5 units; 95% confidence interval [CI]: 1.3 to 3.4), and age (HR = 2.0 per decade; 95% CI: 1.2-2.8) were independently associated with the risk of cardiac events. Although exercise echocardiographic variables contributed significantly (P = 0.01) to a model of the risk of adverse events, only 9 (47%) of the 19 patients with cardiac events were identified by an abnormal exercise echocardiogram. CONCLUSION: Among patients with low pretest probability of coronary artery disease by clinical criteria, exercise echocardiography identifies some, but not all, patients at risk of future events. Because of the low event rate, routine application of exercise echocardiography in a patient with a low pretest probability does not appear to be cost-effective and therefore cannot be recommended.

Adult↗
PubMed2006

QT dispersion and heart rate variability in sudden death risk stratification in patients with ischemic heart disease.

The aim of the article is to review the literature data about the significance and problems of the QT dispersion and heart rate variability in sudden death risk stratification in patients with coronary heart disease. QT dispersion is defined as the difference between the longest and the shortest QT intervals as measured in the 12-lead electrocardiogram. A direct relationship between the prolongation of QT dispersion and myocardial ischemia has been reported by several authors. Our previous study showed that QT dispersion assessed immediately after bicycle exercise test was significantly higher in patients with coronary stenoses of > 50% as compared to the patients without coronary artery disease. Despite some controversial data, several studies showed that QT dispersion is a significant predictor of cardiovascular mortality. Heart rate variability representing a relationship between the autonomic nervous system and cardiovascular mortality, including sudden cardiac death, is one of the most promising markers. The predictive value of heart rate variability is independent of other factors established for postinfarction risk stratification, such as depressed left ventricular ejection fraction, increased ventricular ectopic activity, and presence of late potentials. For prediction of all-cause mortality, the value of heart rate variability is similar to that of left ventricular ejection fraction, but heart rate variability is superior to left ventricular ejection fraction in predicting arrhythmic events (sudden cardiac death and ventricular tachycardia).

Cardiotonic Agents↗
PubMed2006

Additive role of plasma von Willebrand factor levels to clinical factors for risk stratification of patients with atrial fibrillation.

BACKGROUND AND PURPOSE: To aid decisions for thromboprophylaxis in atrial fibrillation (AF), several risk stratification schemes that predict stroke risk according to clinical and echocardiographic features have been published. von Willebrand factor (vWf) is a plasma markers of endothelial damage/dysfunction and is associated with the risk of stroke and vascular events in AF patients. This study determined the additive role of plasma vWf levels to clinical factors for risk stratification in patients with AF. METHODS: We classified 994 AF patients who were enrolled in the SPAF III trial as being at low, moderate, or high risk of stroke and thromboembolism according to the Birmingham and CHADS(2) risk stratification schemes. vWf levels were classified as elevated when >or=158 IU /dL. Rates of ischemic stroke and vascular events within each clinical risk stratum with and without plasma vWf levels were compared. RESULTS: The accuracy of both clinical risk stratification schemes was similar for predicting event rates (Birmingham: ischemic strokes, 0.642; vascular events, 0.670; CHADS(2): ischemic strokes, 0.672; vascular events, 0.672). Subsequent addition of categorized vWf levels to both clinical risk stratification schemes further refined risk stratification for stroke and vascular events. When added to the Birmingham and CHADS(2) clinical risk stratification, high vWf levels were independently associated with a risk of vascular events (hazard ratio, 2.05; 95% confidence interval, 1.30 to 3.22 and 2.01, 1.27 to 3.18 with Birmingham and CHADS(2), respectively) but not ischemic stroke. CONCLUSIONS: When added to clinical risk stratification schemes (Birmingham; CHADS(2)), plasma vWf levels refined clinical risk stratification for stroke and vascular events among AF patients. vWf levels may aid decisions about thromboprophylaxis, particularly among AF patients at moderate risk.

Aged↗
PubMed2004

Prognostic stratification of patients with right bundle branch block using dobutamine stress echocardiography.

The presence of a right bundle branch block (RBBB) is associated with increased mortality. We studied the role of dobutamine stress echocardiography for the prognostic stratification of patients with RBBB. The presence of an abnormal dobutamine stress echocardiography was the strongest predictor of cardiac events and provided incremental prognostic information to clinical and stress test data.

Aged↗
PubMed2006

Unanswered questions for management of acute coronary syndrome: risk stratification of patients with minimal disease or normal findings on coronary angiography.

BACKGROUND: The prognostic implication of chest pain associated with normal or near-normal findings on angiography is still unknown. We explored outcomes and methods of risk stratification in patients with nonobstructive coronary artery disease in the setting of non-ST-segment elevation acute coronary syndromes. METHODS: Data were pooled from 3 Thrombolysis in Myocardial Infarction (TIMI) trials (TIMI 11B, TIMI 16, and TIMI 22). Angiographic data were available on 7656 patients with non-ST-segment elevation acute coronary syndromes. The primary end point of this analysis was the composite of the rates of death, myocardial infarction, unstable angina requiring rehospitalization, revascularization, and stroke at 1-year follow-up. Outcomes were evaluated by mean of the TIMI risk score for developing at least 1 component of the primary end point. RESULTS: Angiographic findings showed that 710 (9.1%) of 7656 patients had nonobstructive coronary artery disease; 48.7% of these had normal coronary arteries (0% stenosis), and 51.3% had mild coronary artery disease (>0% to <50% stenosis). A primary end-point event occurred in 101 patients (12.1%). It is noteworthy that a 2% event rate of deaths and myocardial infarctions had occurred in these patients at the 1-year follow-up. Event rates of death and myocardial infarction increased significantly as the TIMI risk score increased from 0.6% for a score of 1 to 4.0% for a score greater than 4. CONCLUSIONS: Patients with non-ST-segment elevation acute coronary syndromes with nonobstructive coronary artery disease detected by angiography have a substantial risk of subsequent coronary events within 1 year. The risk is not univariately high, and the TIMI risk score helps to reveal patients at high risk.

Angina, Unstable↗
PubMed2001

[Arrhythmia risk stratification in patients with heart failure. Foreword].

The challenge of preventing arrhythmic sudden death is one of the major issues of today's treatment of heart failure. To pursue this aim, an accurate selection of candidates for sudden death has to be routinely carried out, while a maximized and individualized drug treatment has to be extensively administered in all high-risk selected patients. However, in clinical practice there is no agreement on the selection criteria of sudden death risk, particularly in patients with advanced heart failure. Furthermore, the real impact of each category of drugs in reducing the risk of sudden death in heart failure patients is still under debate. As far as non-pharmacological options are concerned, implantable cardioverter-defibrillators (ICD) have been demonstrated to be the most effective therapy in patients with prior cardiac arrest due to ventricular fibrillation or poorly tolerated ventricular tachycardia. Low left ventricular ejection fraction, unsustained ventricular tachycardia and inducibility at electrophysiological study also may identify high-risk patients requiring ICD implantation. However, such a stratification seems to be effective in ischemic more than in non-ischemic patients, while generally the primary prevention of sudden death is still restricted to a minority of patients. Biventricular pacing has been proven to be effective in optimizing left ventricular function in more than 50% of left bundle branch block and advanced heart failure patients, while further studies are needed to evaluate the real impact of cardiac resynchronization therapy on hard endpoints, such as survival and long-term clinical outcome. Therefore, the selection criteria of "responders" to this novel non-pharmacological therapy still have to be defined. There is convincing evidence in the literature that tailored drug therapy can be highly effective in preventing heart failure progression as well as in reducing total and sudden mortality. Nevertheless, prevention of sudden death is still a debated point in heart failure treatment. For this reason, we aimed to provide heart failure specialists with updated reviews on this topic, such as those published in this issue of the Italian Heart Journal Supplement. Therefore, we are proud to present all the authors who contributed with the high quality of their articles to this editorial effort. Obviously, we have to thank the authors, but we also have to address the readers, thanking them in advance for their interest in such an initiative.

Arrhythmias, Cardiac↗
PubMed2002

Usefulness of fractional flow reserve for risk stratification of patients with multivessel coronary artery disease and an intermediate stenosis.

Intracoronary-derived, pressure-based fractional flow reserve (FFR) is important for clinical decision-making in patients with 1-vessel coronary artery disease (CAD). In the present study, we investigated the prognostic value of FFR in patients with intermediate stenoses and multivessel CAD. Therefore, we analyzed 107 patients with stable angina pectoris who underwent myocardial perfusion scintigraphy and showed no perfusion defects in the region of the intermediate lesion. At angiography, FFR was determined distal to the intermediate lesion. FFR was abnormal (i.e., <0.75) in 15 of 107 stenoses (14%). Angioplasty of the intermediate stenosis was deferred based on the absence of a perfusion defect. Patients were followed for 1 year to document major cardiac events related to the intermediate lesion. At 1-year follow-up, a total of 12 (11%: no deaths, 3 myocardial infarctions, 2 coronary bypass operations, 7 coronary angioplasties) events occurred in the entire group that were related to the intermediate lesion. The event rate was significantly higher when angioplasty was deferred despite FFR <0.75 compared with the group with FFR > or = 0.75 (4 of 15 [27%] vs 8 of 92 [9%]; p <0.041). The relative risk of FFR for predicting cardiac events (mainly revascularization procedures) was 3.1 (95% confidence interval 1.1 to 8.9; p <0.05). In conclusion, deferral of angioplasty of intermediate coronary narrowings is safe based on FFR > or = 0.75 in this patient cohort; this coincides with previous reports in patients with 1-vessel CAD. Furthermore, these results suggest that FFR is more useful than single-photon emission computed tomography for clinical decision-making and risk stratification in patients with multivessel CAD.

Adult↗
PubMed2002

Independent value of tissue harmonic echocardiography for risk stratification in patients with non-ST-segment elevation acute chest pain.

BACKGROUND: Clinical factors, electrocardiography, and cardiac troponins provide a satisfactory, although not ideal, means for risk-stratifying patients with non-ST-segment elevation acute chest pain. Tissue harmonic echocardiography enables improved assessment of wall motion abnormalities compared with fundamental echocardiography and may be a useful adjunct for the detection of myocardial ischemia and infarction. We aimed to determine the value of tissue harmonic echocardiography in relation to electrocardiographic and biochemical factors for risk stratification of these patients. RESULTS: Eighty patients with non-ST-segment elevation chest pain were studied using tissue harmonic echocardiography and troponin-T and -I. Fifty-five (69%) patients had abnormal electrocardiograms and 47 (59%) patients had abnormal echocardiograms. Thirteen patients (17%) had elevated troponin-T levels and 17 (21%) had elevated levels of troponin-I. Twelve patients (15%) had a myocardial infarction as the presenting event and, of the remaining 68 patients, 24 sustained an adverse cardiac event during the follow-up period (3 cardiac deaths, 4 nonfatal myocardial infarctions, 17 revascularization procedures). Troponin-T (98%), troponin-I (97%), and echocardiography (97%) all had similar negative predictive values for myocardial infarction as the presenting event, but troponin-T was the only independent predictor of this endpoint (relative risk 230, 95% CI 22-2427). An abnormal echocardiogram was the only independent predictor of subsequent events. The independent predictors of all events were age, troponin-T, and echocardiography. CONCLUSION: Tissue harmonic echocardiography provides independent information for risk stratification of patients with non-ST-segment elevation acute chest pain.

Aged↗