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PubMed2002

Risk group stratification in patients undergoing permanent (125)I prostate brachytherapy as monotherapy.

PURPOSE: Patients undergoing prostate brachytherapy (PB) as monotherapy are often selected on the basis of favorable pretreatment factors. However, intermediate and high-risk prostate cancer patients are commonly offered PB as monotherapy without the addition of external beam radiotherapy (EBRT) or hormonal therapy. This series reports the outcome of patients undergoing PB as monotherapy who were stratified into low, intermediate, and high-risk groups with extended follow-up. METHODS AND MATERIALS: A total of 102 patients with clinically localized prostate cancer underwent PB alone as monotherapy. EBRT or hormonal therapy was not part of their initial treatment. Prostate-specific antigen (PSA) relapse-free survival (PRFS) was determined in accordance with the American Society for Therapeutic Radiology and Oncology consensus statement. Patients were stratified as at favorable risk (Stage T1-2a, pretreatment PSA < or =10.0 ng/mL, and Gleason score < or =6), intermediate risk (one prognostic indicator with a higher value), or unfavorable risk (> or =2 indicators with higher values). The median follow-up period for patients in this series was 7 years (range 2.1-9.7). The median age at treatment was 71 years (range 54-80), and the median prescribed dose of (125)I was 145 Gy. RESULTS: Forty patients experienced a biochemical relapse at a median of 1.9 years (range 0.4-4.2). The 5-year actuarial PRFS rate for patients with favorable, intermediate, and unfavorable risk was 85%, 63%, and 24%, respectively (p <0.0001). All but 1 patient had the relapse within the first 5 years of treatment. When stratifying patients on the basis of their pretreatment PSA level, the 5-year PRFS rate for men with a PSA < or =10 ng/mL vs. >10 ng/mL was 78% vs. 35%, respectively (p = 0.0005). Furthermore, the 5-year PRFS rate for men with a Gleason score of < or =6 vs. > or =7 was 74% vs. 33%, respectively (p = 0.0001). No difference was found between Stage T1-T2a and Stage T2b or higher (64% vs. 54%, respectively; p = 0.353). CONCLUSION: On the basis of risk stratification, PB as monotherapy produces comparable PRFS to EBRT and surgery at 7 years of follow-up. PB as monotherapy is particularly ineffective in patients with unfavorable risk factors, and additional therapy is warranted.

Aged↗
PubMed2001

Stress testing for risk stratification of patients with low to moderate probability of acute cardiac ischemia.

In summary, this article focused on the use of stress testing to risk-stratify patients at the conclusion of their emergency evaluation for ACI. As discussed, those patients in the probably not ACI category require additional risk stratification prior to discharge. It should be kept in mind that patients in this category are heterogeneous, containing subgroups at both higher and lower risk of ACI and cardiac events. The patients with lower pretest probability for ACI may only need exercise testing in the ED. Patients with higher pretest probability should undergo myocardial perfusion or echocardiographic stress testing to maximize diagnostic and prognostic information. Prognostic information is the key to provocative testing in the ED. Prognostic information is the component that will help emergency physicians identify the patients who may be discharged home safely without having to worry about a 6% annual cardiac death rate and a 10% overall death rate over the next 30 months. Stress testing provides this key prognostic data, and it can be obtained in short-stay chest pain observation units in a safe, timely, and cost-effective fashion.

Acute Disease↗
PubMed2000

Exploiting rate-related hysteresis in repolarization alternans to improve risk stratification for ventricular tachycardia.

OBJECTIVES: We sought to study the effect of heart rate acceleration and deceleration on the ability of repolarization alternans (RPA) to stratify ventricular tachycardia (VT) risk. BACKGROUND: Heart rate fluctuations alter arrhythmic propensity, yet it is unclear whether fluctuations, as well as absolute rate, dynamically increase VT risk. We hypothesized that repolarization heterogeneity reflected by RPA would exhibit hysteresis during rising and falling heart rate, which may reflect arrhythmic propensity. METHODS: The RPA magnitude (absolute voltage of alternation [V(alt)] and T-wave alternans ratio [TWAR]) and temporal distribution were determined from the electrocardiogram (ECG) in 60 patients during paced heart rate acceleration from 100 to 150 beats/min, then deceleration to 100 beats/min at electrophysiologic study (EPS). The V(alt) and TWAR thresholds were varied prospectively to generate receiver-operating characteristics (ROC) for the prediction of inducible VT at EPS. RESULTS: Thirty-six patients were induced into VT and 24 were not. Hysteresis of RPA was seen. The V(alt) reached steady-state within 60 beats of each rate transition and was higher in deceleration than in acceleration at matched heart rates. In induced patients, V(alt) rose then fell with heart rate. In noninduced patients, V(alt) was insensitive to acceleration, but rose on initial deceleration. The RPA distributed later within repolarization in induced patients but, on deceleration, moved earlier in both groups. By ROC analysis, V(alt) = 2.6 microV in late repolarization at 120 beats/min provided optimal sensitivity and specificity for VT in acceleration (87.5% and 88.7%, respectively) versus deceleration (80% and 62.5%, respectively; p = 0.004, chi-square test). CONCLUSIONS: 1) Physiologic fluctuations in heart rate may affect the clinical utility of RPA for VT risk stratification; and 2) repolarization dispersion measured by RPA is more exaggerated during deceleration than acceleration at matched heart rates (rate hysteresis).

Adult↗
PubMed2001

When to stress patients after coronary artery bypass surgery? Risk stratification in patients early and late post-CABG using stress myocardial perfusion SPECT: implications of appropriate clinical strategies.

OBJECTIVES: The study compared the prognostic significance of myocardial perfusion single-photon emission computed tomography (SPECT) (MPS) in patients early and late after coronary artery bypass graft surgery (CABG). BACKGROUND: The long-term effectiveness of CABG is limited by graft stenosis. The greatest incidence of graft occlusion occurs between five and eight years after surgery. However, little is known regarding the appropriate time to stress patients post-CABG with respect to risk stratification. METHODS: We identified 1,765 patients, who underwent MPS 7.1 +/- 5.0 years post-CABG. All patients underwent rest T1-201/stress Tc-99m sestamibi MPS and were followed up > or =1 year after testing. Patients with early CABG or PTCA (<60 days after MPS) were censored. The prognostic population consisted of 1,544 patients. A semiquantitative visual analysis employing a 20-segment model was used to define summed stress score (SSS), summed rest score (SRS), summed difference score (SDS), and the number of nonreversible segments (NRS). RESULTS: During follow-up, 53 cardiac deaths (CD) occurred. There was a significant increase in annual CD rates as a function of SSS. A multivariate analysis identified age, ischemia (SDS), and infarct size (NRS) as independent predictors of CD. Nuclear variables added incremental value to prescan information. The annual CD rate was relatively low (1.3%) in patients < or =5 years post-CABG. In this subgroup only age and infarct size (NRS) were predictive of CD. CONCLUSION: MPS is strongly predictive of subsequent CD in post-CABG patients and adds incremental value over clinical and treadmill test information. Our data suggest that symptomatic patients < or =5 years and all patients >5 years post-CABG may benefit from testing.

Aged↗
PubMed2001

Prognostic value of Doppler echocardiographic mitral inflow patterns: implications for risk stratification in patients with chronic congestive heart failure.

OBJECTIVES: This prospective study tested whether transmitral flow patterns add incremental value to peak oxygen consumption (VO2) in determining the prognosis of patients with chronic congestive heart failure (CHF) and systolic dysfunction. BACKGROUND: Peak VO2 is an objective marker of functional capacity and is routinely used as a criterion to identify heart transplant candidates. Diastolic dysfunction limits functional capacity, but its prognostic importance relative to that of peak VO2 is unknown. METHODS: Peak VO2 and mitral inflow velocities were prospectively measured in 311 consecutive patients (mean age 54 years, 84% male) with impaired left ventricular function (ejection fraction <40%; 88 patients with ischemic and 223 with dilated cardiomyopathy) who were evaluated for heart transplant candidacy. RESULTS: During a mean follow-up period of 512 +/- 314 days, 65 patients died and 43 patients underwent heart transplantation. Diastolic filling patterns, peak VO2 and left ventricular end-diastolic diameters were independent predictors of cardiac mortality. In patients with peak VO2 < or = 14 ml/min per kg body weight, the outcome was markedly poorer in the presence of restrictive filling patterns as compared with their absence (two-year survival rate 52% vs. 80%). Similarly, despite peak VO2 levels >14 ml/min per kg, the outcome was less favorable in the presence of restrictive filling patterns (two-year survival rate 80% vs. 94%). A risk-stratification model based on the identified independent noninvasive predictors separated groups into those with high (93%), intermediate (65%) and low (39%) two-year survival rates. CONCLUSIONS: Transmitral flow patterns add incremental value to peak VO2 in determining the prognosis of patients with CHF and impaired systolic function.

Blood Flow Velocity↗
PubMed2001

Long-term risk stratification for survivors of acute coronary syndromes. Results from the Long-term Intervention with Pravastatin in Ischemic Disease (LIPID) Study. LIPID Study Investigators.

OBJECTIVES: We developed a prognostic strategy for quantifying the long-term risk of coronary heart disease (CHD) events in survivors of acute coronary syndromes (ACS). BACKGROUND: Strategies for quantifying long-term risk of CHD events have generally been confined to primary prevention settings. The Long-term Intervention with Pravastatin in Ischemic Disease (LIPID) study, which demonstrated that pravastatin reduces CHD events in ACS survivors with a broad range of cholesterol levels, enabled assessment of long-term prognosis in a secondary prevention setting. METHODS: Based on outcomes in 8,557 patients in the LIPID study, a multivariate risk factor model was developed for prediction of CHD death or nonfatal myocardial infarction. Prognostic indexes were developed based on the model, and low-, medium-, high- and very high-risk groups were defined by categorizing the prognostic indexes. RESULTS: In addition to pravastatin treatment, the independently significant risk factors included: total and high density lipoprotein cholesterol, age, gender, smoking status, qualifying ACS, prior coronary revascularization, diabetes mellitus, hypertension and prior stroke. Pravastatin reduced coronary event rates in each risk level, and the relative risk reduction did not vary significantly between risk levels. The predicted five-year coronary event rates ranged from 5% to 19% for those assigned pravastatin and from 6.4% to 23.6% for those assigned placebo. CONCLUSIONS: Long-term prognosis of ACS survivors varied substantially according to conventional risk factor profile. Pravastatin reduced coronary risk within all risk levels; however, absolute risk remained high in treated patients with unfavorable profiles. Our risk stratification strategy enables identification of ACS survivors who remain at very high risk despite statin therapy.

Aged↗
PubMed2002

Bedside quantification of atherosclerosis severity for cardiovascular risk stratification: a prospective cohort study.

OBJECTIVES: We sought to assess the ability of a new noninvasive method to quantify atherosclerosis severity and to examine its power to predict cardiovascular events. BACKGROUND: Drug prevention of cardiovascular events is effective but costly, leading to a debate about who should receive this treatment. Patient selection is often based on surrogate markers, but quantification of atherosclerosis severity is desirable. METHODS: Atherosclerosis severity was quantified by determination of specific aortic wall elastance in transthoracic echocardiography, applying the biomechanics of pulse wave propagation. After validating the method in 52 patients by measuring aortic plaque burden in transesophageal echo directly, another 336 patients were prospectively studied by monitoring atherosclerotic events at one year and comparing the results with conventional risk stratification. RESULTS: Specific aortic elastance was well correlated with plaque burden (p < 0.0001) and largely independent of confounding variables. Specific aortic elastance predicted the primary end point of "atherosclerotic death, myocardial infarction or stroke" at one year (p < 0.0002). Event rate at one year in the lowest specific elastance tertile was 1.8% (CI 0.0% to 4.3%), in the middle tertile 5.4% (CI 1.1% to 9.7%) and in the highest tertile 12.7% (CI 6.3% to 19%). Secondary end points supported these findings. Stepwise multivariate analysis identified specific aortic elastance, prior atherosclerotic events and left ventricular ejection fraction as independent risk predictors. Specific elastance was of incremental value to clinically identified variables. CONCLUSIONS: Bedside measurement of specific aortic elastance allows assessment of atherosclerosis severity. It predicts the risk for future atherosclerotic events beyond conventional risk factors, promising better targeting of pharmacologic prevention and improved cost effectiveness.

Adult↗
PubMed2002

Contribution of the sST elevation/T-wave normalization in Q-wave leads during routine, pre-discharge treadmill exercise test to patient management and risk stratification after acute myocardial infarction: a 2.5-year follow-up study.

OBJECTIVES: This study investigated whether ST-segment elevation and T-wave normalization (TWN) in Q-wave leads on pre-discharge exercise electrocardiogram (ECG) can contribute to patient management after a recent myocardial infarction (MI). BACKGROUND: The clinical relevance of these exercise ECG changes remains controversial despite accumulating evidence of their association with myocardial viability. Because discrepancies of previous studies may depend on patient selection, the value of these ST/T abnormalities in the thrombolytic era should be better defined. METHODS: One-hundred one patients, age 58 +/- 11 years, with a recent, first Q-wave MI (57% thrombolyzed, ejection fraction 43 +/- 7%) underwent pre-discharge, submaximal treadmill testing followed, in the absence of severe ischemia, by dobutamine stress echocardiography, thallium-201 single photon emission computed tomography, and coronary angiography. RESULTS: ST elevation at peak exercise, but not TWN, was associated with more severe infarctions as indicated by higher peak creatine kinase (p < 0.05) and with a greater number of scarred segments both on echocardiography (p < 0.05) and scintigraphy (p < 0.01). However, the incidence of myocardial viability and ischemia did not differ between groups with or without these ST/T changes. Anterior infarction location and >or=3 echocardiographically scarred segments were among the independent predictors of ST elevation at peak ergometric exercise. During follow-up (31 +/- 13 months), the rate of hard events was low (8%) and similar between the study groups. CONCLUSIONS: In patients after acute Q-wave MI without severe ischemia according to clinical and standard ECG criteria, exercise-induced ST elevation, but not TWN, is associated with larger infarctions. The contribution of these ST/T abnormalities toward identifying patients with myocardial viability or ischemia and determining risk stratification is poor. In-hospital management of such patients based on routine clinical practice is sufficient for selection of a population with a relatively low long-term risk.

Coronary Angiography↗
PubMed2002

Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: implications for risk stratification and treatment.

OBJECTIVES: We sought to determine the incidence of arteriovenous fistulas (AVF), identify risk factors for AVF, and follow up the clinical outcome of femoral AVF. BACKGROUND: Arteriovenous fistulas are a potential harmful complication of cardiac catheterization. Incidence and clinical outcome of iatrogenic AVF are unknown so far, although important for risk stratification and treatment. METHODS: A total of 10,271 consecutive patients undergoing cardiac catheterization were followed up prospectively over a period of three years. Diagnosis of AVF was performed by duplex sonography. RESULTS: The incidence of AVF was 0.86% (n = 88). The following significant and independent risk factors for AVF were identified: high heparin dosage (odds ratio [OR]) = 2.88), coumadin therapy (OR = 2.34), puncture of the left groin (OR = 2.21), arterial hypertension (OR = 1.86), and female gender (OR = 1.84). Within 12 months 38% of all AVF closed spontaneously. No signs of cardiac volume overload or limb damage were observed in patients with persisting AVF. None of the risk factors for AVF influenced the incidence or the rate of AVF closure. Only intensified anticoagulation showed a tendency to extend AVF persistence. CONCLUSIONS: Almost 1% of patients undergoing cardiac catheterization acquire femoral AVF, for which patient- and procedure-related risk factors could be identified. One-third of iatrogenic AVF close spontaneously within one year. Cardiac volume overload and limb damage are highly unlikely with AVF persistence. Thus, a conservative management for at least one year seems to be justified.

Aged↗
PubMed1999

Risk stratification following myocardial infarction in the thrombolytic era: a two-step strategy using noninvasive and invasive methods.

OBJECTIVES: We prospectively performed a two-step risk assessment in patients in the early phase after acute myocardial infarction (MI). BACKGROUND: Noninvasive methods like Holter electrocardiographic monitoring (HM) and determination of the left ventricular ejection fraction (EF) as well as the invasive technique of programmed ventricular stimulation (PVS) have been used to identify patients in the late phase after MI as candidates for prophylactic implantation of a cardioverter/defibrillator. However, it is unclear whether these results can be transferred to patients following acute MI. METHODS: A series of 657 patients with acute MI (< or = 75 years) underwent HM and EF. If one of the two methods yielded abnormal findings (HM > or = 20 ventricular ectopic beats/h/> or =10 ventricular pairs/day/ventricular tachycardia; EF < or = 40%), PVS was done (abnormal PVS: induction of monomorphic ventricular tachycardia, duration >10 s, cycle length > or = 230 ms). RESULTS: Of 657 patients, 304 (46%) had either an abnormal HM or EF. The PVS performed in 146 of 304 patients was abnormal in 22. During a mean follow-up of 37 months, there were 106 (16%) deaths, being sudden in 24 (3.6%), nonsudden cardiac in 45 (6.8%). The incidence of arrhythmic events (sudden cardiac death, symptomatic ventricular tachycardia, cardiac arrest) was 18% (4/22) with an abnormal PVS and only 4% (5/124) with a normal PVS (odds ratio 4.0, p=0.032). CONCLUSIONS: The rate of arrhythmic events is low in post-MI patients in the 1990s. Nevertheless, a two-step risk stratification is helpful in selecting candidates for a defibrillator trial aiming at primary prevention of sudden cardiac death after MI.

Combined Modality Therapy↗
PubMed1999

Risk stratification of emergency department patients with acute coronary syndromes using P-selectin.

OBJECTIVES: We compared the predictive properties of P-selectin to creatine kinase, MB fraction (CK-MB) for detecting acute myocardial infarction (AMI), acute coronary syndromes (ACS) and serious cardiac events upon emergency department (ED) arrival. BACKGROUND: Practioners detecting early diagnosis of ACS have focused on cardiac markers of myocardial injury. Plaque rupture/platelet aggregation precedes myocardial ischemia. Therefore, markers of platelet aggregation may detect ACS earlier than cardiac markers. METHODS: Consecutive patients with potential ACS presenting to an urban university ED were identified by research assistants who screened all ED patients between November 12, 1997 and January 31, 1998. Whole blood was drawn at presentation and 1 h later and rapidly stained and fixed for membrane P-selectin assay and plasma was separated for soluble P-selectin assay. Creatine kinase, MB fraction values were determined using standard immunoassay techniques. Clinical history and hospital course were followed daily. Outcomes were AMI, ACS (AMI and unstable angina) and serious cardiac events. Receiver operator characteristic curves were derived for CK-MB, and soluble and membrane-bound P-selectin to determine the optimal cutoff values. Predictive properties were calculated with 95% confidence intervals. RESULTS: A total of 263 patients were enrolled. They had a mean age of 56.5+/-14 years; 52% were male. There were 22 patients with AMI; 87 patients with ACS and 54 patients with serious cardiac events. Creatine kinase, MB fraction had a higher specificity for detection of AMI, ACS and serious cardiac events than both soluble and membrane-bound P-selectin. At the time of ED presentation, the specificity of CK-MB, and soluble and membrane-bound P-selectin for AMI was 91% versus 76% versus 71%; for ACS, 95% versus 79% versus 71%, and for serious cardiac events, 91% versus 76% versus 72% (p < 0.05). The sensitivities for AMI were 50% versus 45% versus 32%; for ACS, 26% versus 35% versus 30%, and for serious cardiac events, 29% versus 35% versus 36%. CONCLUSIONS: Although theoretically attractive, the use of soluble and membrane-bound P-selectin for risk stratification of chest pain patients at the time of ED presentation does not appear to have any advantages over the use of CK-MB.

Adult↗
PubMed1999

ST-segment monitoring with continuous 12-lead ECG improves early risk stratification in patients with chest pain and ECG nondiagnostic of acute myocardial infarction.

OBJECTIVES: The purpose of this study was to evaluate the prognostic importance of ischemic episodes detected by ST-segment monitoring with continuous 12-lead electrocardiography (ECG) in a nonselected coronary care unit (CCU) population with chest pain and ECG nondiagnostic of acute myocardial infarction (AMI). BACKGROUND: Patients with chest pain and ECG nondiagnostic of AMI constitute a heterogeneous group concerning both diagnosis and prognosis. Continuous 12-lead ECG is a rather new method not thoroughly studied in this population. METHODS: The ST-segment monitoring with continuous 12-lead ECG was performed for 12 h in 630 consecutive patients admitted to CCU due to chest pain and a nondiagnostic ECG, i.e., no ST-segment elevations. An ST-episode was defined as a transient ST-segment depression or elevation of at least 0.10 mV. The median follow-up time was six months. RESULTS: A total of 176 ST-episodes occurred in 100 (15.9%) patients. The median duration and maximal ST-segment deviation in patients with ST-episodes were 80 min and 0.20 mV, respectively. Presence of ST-episodes predicted worse outcome concerning cardiac death and cardiac death or myocardial infarction (MI) (log-rank p < 0.001). At 30 day follow-up procedure, 10% versus 1.5% died from cardiac causes or had an MI in the group with and without ST-episodes, respectively. In a multivariate analysis, only troponin T > or = 0.10 microg/l and the presence of ST-episodes came out as independent predictors of cardiac death or MI. CONCLUSIONS: Continuous 12-lead ECG monitoring provides prognostic information on-line and considerably improves early risk stratification in patients with ECG nondiagnostic of AMI and symptoms suggestive of acute coronary syndrome.

Aged↗
PubMed2003

Cardiac risk stratification in patients undergoing endoluminal graft repair of abdominal aortic aneurysm: a single-institution experience with 365 patients.

OBJECTIVE: Patients undergoing abdominal aortic aneurysm repair have a high incidence of coexisting cardiac disease. The traditional cardiac risk stratification for open abdominal aortic aneurysm surgery may not apply to patients undergoing endoluminal graft exclusion. The purpose of this study was to examine predictive risk factors for perioperative cardiac events. METHODS: As part of multiple prospective endograft trials approved by the US Food and Drug Administration, data for 365 patients who underwent endoluminal graft repair from 1996 to 2001 were collected. Variables included for analysis were age and sex; history of smoking; presence of hypertension, diabetes mellitus, or renal insufficiency; Eagle clinical cardiac risk factors; American Society of Anesthesiologists index; type of anesthesia administered; estimated blood loss; preoperative hemoglobin level; preoperative use of beta-blocker therapy; duration of surgery; need for iliac artery conduit; and concomitant other vascular procedures. Univariate and multivariate logistic regression analysis were used to determine which variables were predictive of an adverse perioperative cardiac event, eg, Q wave and non-Q wave myocardial infarction (MI), congestive heart failure (CHF), severe arrhythmia, and unstable angina. RESULTS: The study cohort included 322 men and 43 women (mean age, 74.2 years). Fifty-two (14.2%) postoperative cardiac events occurred: severe dysrhythmia in 15 patients (4.1%), MI in 14 patients (3.8%), non-Q wave MI in 8 patients (2.2%), CHF in 8 patients (2.2%), and unstable angina in 7 patients (1.9%). Univariate analysis demonstrated that age 70 years or older (P =.034), history of MI (P =.018), angina (P =.004), history of CHF (P <.001), two or more Eagle risk factors (P <.001), and lack of use of preoperative beta-blocker therapy (P =.005) were predictors of perioperative cardiac events. Multivariate analysis identified only age 70 years or older (P =.026), history of MI (P =.024) or CHF (P =.001), and lack of use of preoperative beta-blocker therapy (P =.007) as independent risk factors for an adverse cardiac event. CONCLUSIONS: Age 70 years or older, history of MI or CHF, and lack of use of preoperative beta-blocker therapy are independent risk factors for perioperative cardiac events in patients undergoing endoluminal graft repair.

Adrenergic beta-Antagonists↗
PubMed2001

Risk stratification analysis of operative mortality in heart and thoracic aorta surgery: comparison between Parsonnet and EuroSCORE additive model.

OBJECTIVE: Our purpose was to compare the performance of risk stratification model between Parsonnet and European System for Cardiac Operative Risk Evaluation (EuroSCORE) in our patient database. METHODS: From August 1994 to December 2000, 803 consecutive patients have undergone heart and thoracic aorta surgery using cardiopulmonary bypass and scored according to Parsonnet and EuroSCORE algorithm. The population was divided into five clinically relevant risk categories. We compared correlation of predicted mortality and observed mortality between these two models. Score validity was assessed by calculating the area under the receiver operating characteristic (ROC) curve. RESULTS: Overall hospital mortality was 4.5%. In Parsonnet model, predicted mortality was 2.4% for 0-4% risk, 6.7% for 5-9% risk, 12% for 10-14% risk, 17% for 15-19% risk, 25% for 20% plus risk, and 10.4% for overall patients. Observed mortality was 2.4, 0.4, 5.9, 8.7, 11, and 4.5%, respectively. The thoracic aorta and valve cohort indicated poor correlation between predicted and observed mortality compared to coronary cohort. In the EuroSCORE model, predicted mortality was 1.4% for 0-2% risk, 4.0% for 3-5% risk, 6.7% for 6-8% risk, 9.7% for 9-11% risk, 13% for 12% plus risk, and 5.3% for overall patients. Actual mortality was 0, 1.5, 6.8, 11, 21, and 4.5%, respectively. Each of the thoracic aorta, valve, and coronary cohort indicated good correlation between predicted and observed mortality. Areas under the ROC curves were 0.72 in Parsonnet and 0.82 in EuroSCORE. CONCLUSIONS: The EuroSCORE additive model yielded good predictive value for hospital mortality of Japanese patients undergoing not only cardiac but also thoracic aortic surgery.

Algorithms↗
PubMed2002

Short-term and 5-year outcome after primary isolated coronary artery bypass graft surgery: results of risk stratification in a bilocation center.

OBJECTIVE: We retrospectively investigated the short and mid-term outcome of non-emergent primary isolated coronary artery bypass graft (CABG) surgery in relation to risk stratification in the fully equipped university location (FE) and the low volume, limited facility location (LVLF) of our department. METHODS: Between September 1995 and December 1996, 832 patients were referred to our department to undergo a primary isolated CABG operation. The surgical team selected 482 patients (58%) as being at low-risk. These were treated in the LVLF hospital. The other 350 patients with mixed-risk were treated in the FE hospital. The selection consisted primarily of exclusion of patients with moderate or poor left ventricular function, severe COPD or renal impairment, from surgery in the LVLF location. Finally, the prognostic value of the EuroSCORE and the Parsonnet score was tested on our patient population. RESULTS: Overall in-hospital mortality was 1.6% (13 patients). One patient died in the LVLF group (0.2%) and 12 patients (3.4%) in the FE group. LVLF patients experienced less complications during the hospital period compared to the FE patients (5 versus 21%; P=0.0001). The Parsonnet risk model and the EuroSCORE risk model showed both a good relation with in-hospital mortality. After discharge, an increased risk of late mortality was observed up to 1 year postoperative in the FE group compared to the LVLF group (2.7 versus 0.5%; P=0.01). Risk factors for 5-year mortality were pre-operative renal impairment (blood creatinine >150 micromol/l) (hazard ratio (HR): 2.8; 95% confidence interval (CI): 1.4-5.5), diabetes (HR: 2.1; 95% CI: 1.3-3.5), impaired LVEF (HR: 1.9; 95% CI: 1.2-3.0), COPD (HR: 1.9; 95% CI: 1.1-3.5) and older age (HR: 1.07 per year; 95% CI: 1.01-1.10). Lipid-lowering therapy was a predictor of lower mortality at 5-years (HR: 0.5; 95% CI: 0.4-0.9). CONCLUSION: By careful decision making, selection of low-risk patients for a low volume and limited facility location resulted in excellent in-hospital survival with very low complication rates.

Adult↗
PubMedDate not supplied

Preoperative risk stratification by adenosine thallium 201 single-photon emission computed tomography in patients undergoing vascular surgery.

BACKGROUND: Adenosine perfusion scintigraphy is a powerful technique for diagnosing coronary artery disease and risk stratifying patients with recent myocardial infarction. METHODS AND RESULTS: We investigated the use of adenosine 201Tl tomography to risk stratify 106 patients undergoing vascular arterial reconstruction consisting of lower limb arterial grafting in 44, aortic aneurysmectomy in 36, and carotid endarterectomy in 26 patients. Abnormal tomograms occurred in 57 patients (54%), 47 (82%) of whom had reversible perfusion defects. There were three postoperative deaths, all in the group that underwent aortic aneurysmectomy. Another patient with an aortic aneurysm had unstable angina and one patient who underwent lower limb arterial surgery had pulmonary edema after surgery. No patient without transient defects had an event (negative predictive value 100%). Cardiac events occurred only in patients with transient perfusion defects. However, only 5 of 47 such patients had events (positive predictive value 11%). The perfusion defect size (23% +/- 14% vs 8.9% +/- 135; p = 0.034) and the ischemic fraction (20% +/- 16% vs 5.6% +/- 8.9%; p = 0.009) were 2.5- and 3.5-fold larger, respectively, in patients with than in those without events. A history of diabetes mellitus or previous infarction did not enhance the predictive value of the test. CONCLUSION: Thus absence of reversible hypoperfusion during adenosine scintigraphy ensures virtual absence of postoperative cardiac events. Patients undergoing aortic aneurysmectomy may be targeted preferentially for risk-stratification strategies in the future.

Adenosine↗
PubMed2002

[Biological variables and stratification of patients with inoperable non-small-cell bronchial cancer: recommendations for future trials].

OBJECTIVE: To identify, through a review of the literature, the laboratory variables that would allow a more accurate stratification of unresected non small-cell lung cancer patients who participate in clinical trials. METHOD: Systematic review, without meta-analysis, following the recommendations of the International Federation of Clinical Chemistry and Laboratory Medicine, and taking into account the Consolidated Standards of Reporting Trials statement. RESULTS: Of 1106 publications retrieved, we were able to include only fourteen studies in our review. Available evidence would support the use of several laboratory variables as prognostic covariables to stratify non resected non small-cell lung cancer patients in clinical trials, but blood haemoglobin would be the only one that could be recommended on a routine basis, and only in patients treated with radiotherapy (three studies out of three). The possible consequences in terms of therapeutic decision of haemoglobin measurements remain however to be clarified. CONCLUSION: Until better designed studies are published, a number of arguments would support the pre-treatment measurements of the following variables in patients participating in clinical trials: blood haemoglobin, white blood cell count with differential, serum LDH, albumin, calcium, and NSE. Further studies would also be necessary to support the addition to this list, of other tumour markers (including Cyfra 21-1), and/or measurements during or after treatment.

Biomarkers, Tumor↗
PubMed2026

Visual Detection and Stratification of Pathogenic mtDNA SNV Heteroplasmy by Balancing FnCas12a Signal Output and Allelic Discrimination.

Assessment of pathogenic mitochondrial DNA (mtDNA) single-nucleotide variant (SNV) heteroplasmy is important for molecular diagnostics, yet rapid visual profiling remains analytically challenging because an assay must combine single-nucleotide allelic discrimination, mutant-fraction-associated readout, and suitable target access. Herein, we report VISTA (visual identification and stratification of targeted mtDNA alleles), a broad-PAM FnCas12a assay that rebalances trans-cleavage signal output and mutant-wild-type discrimination for visual mtDNA SNV heteroplasmy analysis. VISTA uses unmodified FnCas12a with relaxed TTN PAM recognition and integrates crRNA spacer-length engineering with PEG8000/acBSA reaction tuning to improve the practical signal-discrimination balance without nuclease engineering. At the m.3243A>G model locus, spacer truncation enhanced mutant-wild-type discrimination, while molecular-dynamics simulations identified spacer-dependent differences between matched and mismatched complexes at the crRNA-DNA interface. The optimized assay resolved defined synthetic m.3243A>G heteroplasmy gradients by fluorescence imaging and was further adapted to lateral-flow detection. In locus-specific analyses of a deidentified collection of 74 peripheral-blood samples, fluorescence and lateral-flow readouts achieved ROC AUC values above 0.9 for mutant-allele classification after target-region amplification. Fluorescence supported heteroplasmy-associated profiling, whereas lateral flow provided a visual, semiquantitative readout for relative ranking based on the T/C ratio rather than absolute heteroplasmy measurement. VISTA therefore provides an accessible dual-readout analytical strategy for visual detection and heteroplasmy-associated profiling by tuning the FnCas12a signal output and allelic discrimination.

DNA, Mitochondrial↗